Peri-operative cardiovascular optimization

[Perioperative fluid management: an analysis of the present situation]

Optimal perioperative fluid management is still controversial. Besides well known perioperative hypovolaemia, hypervolaemia has an influence on perioperative morbidity and mortality, particularly with regard to the patient's medical history, a reduced cardiac and pulmonal function and the operation itself. The concepts of preoperative, intraoperative and postoperative fluid administration are neither adequately validated, nor sufficiently integrated into a perioperative concept. At the present, moderate fluid administration to improve preoperative and postoperative outcome is safe in minor or medium surgical procedures. High-risk surgical patients benefit from a time-oriented or/and goal-oriented monitored fluid therapy. In the past only little attention has been concentrated on postoperative fluid management, but may be stimulated by the new concepts of fast track surgery.

A survey of pre-operative optimisation of high-risk surgical patients undergoing major elective surgery

Pre-operative optimisation of high-risk patients undergoing major elective surgery has been shown to decrease peri-operative morbidity and mortality. It is also cost effective because of the resulting decrease in postoperative complications. A questionnaire was sent to 170 intensive care and high dependency units in Britain in order to quantify the number of units practising pre-operative optimisation. There was a 91% response rate. Of the respondents familiar with the evidence advocating pre-operative optimisation, 91% believe pre-operative optimisation improves outcome but only 62% admit patients for such preparation. Moreover, only eight units (6%) admit more than 25% of eligible patients. The reasons given for not admitting such patients pre-operatively are a lack of manpower, beds or both. This survey demonstrates the need for greater investment of resources into intensive care and high dependency units, so that clinicians can deliver high-quality evidence-based healthcare in accordance with the principles of clinical governance.