Guiding Goal-Directed Therapy

Goal-directed therapy in cardiovascular surgery: A case series study

Hemodynamic and intravascular volume monitoring has been utilized and significantly improved thanks to the technology revolution. Goal-Directed Therapy (GDT) derived from this advanced monitoring is beneficial for complex surgeries, and it shifted the medical approaches from static therapy to more personalized functional treatments. Conventional monitoring methods such as blood pressure, heart rate, urinary output, and central venous pressure are commonly used. However, studies have shown these routine parameters often cannot precisely estimate the quality of tissue perfusion. Tissue hypoperfusion and hypoxia play a crucial role in initiating a systemic inflammatory response after prolonged surgeries, resulting in unstable hemodynamic condition of the patients. Several studies reported the importance of GDT in non-cardiac surgeries and there are few reports on cardiac surgeries. However, tissue perfusion and fluid management are more critical in complex and prolonged cardiovascular surgeries to avoid complications such as low cardiac output syndrome and renal or pulmonary dysfunction. Different advanced hemodynamic monitorings have been utilized perioperatively in cardiac surgery to help decision-making on inotrope and fluid management. In this article we present 5 cases of usefulness hemodynamic monitoring in patients who underwent cardiovascular surgeries.

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.

Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications

Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics - from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient's optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.

Goal-Directed Therapy for Cardiac Surgery

Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.

Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review

BACKGROUND

Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate.

MAIN TEXT

The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications.

CONCLUSIONS

The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.

Goal directed hemodynamic therapy based in esophageal Doppler flow parameters: A systematic review, meta-analysis and trial sequential analysis

BACKGROUND

Numerous studies have compared perioperative esophageal doppler monitoring (EDM) guided intravascular volume replacement strategies with conventional clinical volume replacement in surgical patients. The use of the EDM within hemodynamic algorithms is called 'goal directed hemodynamic therapy' (GDHT).

METHODS

Meta-analysis of the effects of EDM guided GDHT in adult non-cardiac surgery on postoperative complications and mortality using PRISMA methodology. A systematic search was performed in Medline, PubMed, EMBASE, and the Cochrane Library (last update, March 2015).

INCLUSION CRITERIA

Randomized clinical trials (RCTs) in which perioperative GDHT was compared to other fluid management.

PRIMARY OUTCOMES

Overall complications.

SECONDARY OUTCOMES

Mortality; number of patients with complications; cardiac, renal and infectious complications; incidence of ileus. Studies were subjected to quantifiable analysis, pre-defined subgroup analysis (stratified by surgery, type of comparator and risk); pre-defined sensitivity analysis and trial sequential analysis (TSA).

RESULTS

Fifty six RCTs were initially identified, 15 fulfilling the inclusion criteria, including 1,368 patients. A significant reduction was observed in overall complications associated with GDHT compared to other fluid therapy (RR=0.75; 95%CI: 0.63-0.89; P=0.0009) in colorectal, urological and high-risk surgery compared to conventional fluid therapy. No differences were found in secondary outcomes, neither in other subgroups. The impact on preventing the development of complications in patients using EDM is high, causing a relative risk reduction (RRR) of 50% for a number needed to treat (NNT)=6.

CONCLUSIONS

GDHT guided by EDM decreases postoperative complications, especially in patients undergoing colorectal surgery and high-risk surgery. However, no differences versus restrictive fluid therapy and in intermediate-risk patients were found.

Using cardiac output monitoring to guide perioperative haemodynamic therapy

PURPOSE OF REVIEW

The aim of this study was to review recent advances and evidence for the use of cardiac output monitors to guide perioperative haemodynamic therapy.

RECENT FINDINGS

There are multiple different cardiac output monitoring devices available for clinical use which are coupled with many different intervention protocols to manipulate perioperative haemodynamics. There is little evidence to demonstrate superiority of any one device. Previous small studies and meta-analyses have suggested that perioperative haemodynamic therapy guided by cardiac output monitoring improves outcomes after major surgery. Despite relatively low-quality evidence several national bodies have recommended 'perioperative goal-directed therapy' (GDT) as a standard of care.Recent larger trials of GDT have mostly failed to prove a benefit of GDT and one explanation for this is the increased quality of usual care that may be occurring because of initiatives such as enhanced recovery after surgery and the WHO Safer Surgery programmes.

SUMMARY

Perioperative GDT remains an exciting intervention to reduce significant morbidity following major surgery; however, it is not yet a proven standard of care. Further large pragmatic trials are required to demonstrate its effectiveness particularly in the era of enhanced recovery after surgery programmes.