Abstract
Purpose
Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy.
Principal findings
The focus of many devices used for advanced hemodynamic monitoring is on providing measurements of cardiac output, while other, more recent, devices include estimates of fluid responsiveness based on dynamic indices that better predict an individual’s response to a fluid bolus. Currently available technologies include the pulmonary artery catheter, esophageal Doppler, arterial waveform analysis, photoplethysmography, venous oxygen saturation, as well as bioimpedance and bioreactance. The underlying mechanistic principles for each device are presented as well as their performance in clinical trials relevant for goal-directed therapy in ERAS.
Conclusions
The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.
Résumé
Objectif
La réanimation liquidienne ciblée fait partie intégrale de nombreux protocoles de récupération rapide après une chirurgie (RRAC ou ERAS: Enhanced Recovery After Surgery) utilisés à l’heure actuelle. Le clinicien en périopératoire est confronté à une myriade de dispositifs promettant de fournir des données physiologiques pertinentes pour mieux guider la réanimation liquidienne. L’objectif de cet exposé de synthèse est de fournir une information concise permettant au clinicien de prendre une décision éclairée sur le choix d’un dispositif devant guider la réanimation liquidienne ciblée.
Constatations principales
L’objectif de nombreux dispositifs utilisés pour le monitorage avancé de l’hémodynamie consiste à fournir des mesures de débit cardiaque tandis que d’autres, plus récents, incluent une estimation de la réponse liquidienne en fonction d’indices dynamiques qui prédisent mieux la réponse individuelle à un bolus liquidien. Les technologies actuellement disponibles incluent le cathétérisme de l’artère pulmonaire, le Doppler œsophagien, l’analyse de la courbe artérielle, la photopléthysmographie, la saturation veineuse en oxygène, ainsi que la bioimpédance et la bioréactance. Les principes mécanistes sous-jacents de chaque dispositif sont présentés, ainsi que leurs performances au cours d’essais cliniques pertinents pour la réanimation liquidienne ciblée dans le cadre de la RRAC.
Conclusions
Les protocoles RRAC impliquent habituellement un schéma thérapeutique multiaxes pour faciliter la récupération rapide après chirurgie. L’optimisation périopératoire de la réanimation liquidienne est un élément clé de ces efforts. Bien qu’il n’y ait pas de technologies dénuées de limites, l’essentiel des publications actuellement disponibles suggère que le Doppler œsophagien et l’analyse des courbes artérielles sont les choix les plus souhaitables pour guider l’administration de liquides. Leur performance dépend, en partie, de l’interprétation des modifications dynamiques résultant de la fluctuation de la pression intrathoracique observée au cours de la ventilation mécanique. Les schémas évolutifs de pratique, tels que la ventilation à petit volume courant ainsi que la nécessité de guider la thérapie liquidienne chez des patients respirant spontanément, nécessiteront des études complémentaires.
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In the late 1990s, surgeons and anesthesiologists began a critical assessment of the individual components of the perioperative experience in an effort to reduce the time required to recover from surgery.1 Working together, these physicians challenged the traditional practices of their respective specialties and began to develop comprehensive perioperative protocols based on best available evidence. The results of this undertaking are the Enhanced Recovery After Surgery (ERAS) protocols we know today (Table 1).2-14
All ERAS protocols typically share the following features:
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1)
The patient plays a prominent role in their own care and recovery.
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2)
Patients are no longer inappropriately fasted before surgery.
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3)
Multimodal analgesia is utilized in order to minimize intraoperative and postoperative systemic opioid use.
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4)
Ambulation is initiated on the day of surgery.
While independent examination of the relative value of these four components is difficult, it seems that intraoperative fluid administration has a substantial impact on perioperative outcomes.15-17 Many, but not all, ERAS protocols utilize goal-directed therapy (GDT) to guide intraoperative fluid administration.
In two meta-analyses, an attempt was made to assess the utility of GDT and/or fluid optimization protocols for the management of patients in the perioperative period (although not specifically limited to ERAS protocols). Gurgel et al. examined 32 randomized controlled trials encompassing 5,056 patients and found a significant reduction in mortality (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.55 to 0.82; P < 0.001) in the high-risk (expected mortality > 20%) group.18 Hamilton et al. examined 29 randomized controlled trials encompassing 4,085 patients and found a significant reduction in mortality (OR 0.48; 95% CI: 0.33 to 0.78; P < 0.001) and surgical complications (OR 0.43; 95% CI: 0.34 to 0.53; P < 0.001) for all patients.19
The focus of this manuscript is on understanding both the function of the various devices (i.e., technological assessment) available to guide the anesthesiologist interested in the practice of GDT as well as the clinical evidence base to support various technologies (i.e., clinical data).
Devices
Pulmonary artery catheter
The pulmonary artery catheter (PAC), considered by many to be the clinical gold standard for the measurement of cardiac output, has been used in many GDT trials, though primarily in the management of critically ill patients.18,19 The development of alternative less-invasive means of measuring cardiac output (e.g., esophageal Doppler), a shift of focus from cardiac output to volume status optimization, and a series of prospective randomized controlled trials that failed to show improvements in mortality when applied to critically ill patients,20-22 have precluded the PAC from use in ERAS protocols. For these reasons, PACs are not further addressed in this review.
Esophageal Doppler
Technological assessment
The esophageal Doppler monitor (EDM) was developed in an effort to measure cardiac output without the requirement for a PAC.23 The technology is based on the Doppler principle, which relates the velocity (v) of a moving object to the change in frequency that occurs when a sound wave is reflected off the object.24 This can be described mathematically as:
where Δf represents the frequency difference between the emitted and returned (ultra)sound signal, c represents the speed of sound in tissue, f 0 represents the frequency of the incident ultrasound beam, cos represents cosine, θ represents the angle of incidence, and v represents the velocity of a moving reflector. The accuracy of Doppler measurements is dependent on the angle of incidence (θ); accordingly, as θ increases, the Doppler-derived velocity of the object will be increasingly underestimated.
The only currently available clinical device, the CardioQ™ EDM (or ODM in the United Kingdom) is made by Deltex Corporation (Chichester, West Sussex, United Kingdom) (Fig. 1). The CardioQ requires insertion of a small esophageal probe via the nose or mouth to a depth of approximately 35-45 cm. The patient’s age, height, and weight are entered into the device’s software and the velocity of descending aortic blood flow is converted to an estimate of cardiac output using a nomogram-based estimate of the aortic cross-sectional area.23 Additionally, measurements are recorded for corrected flow time (FTc), i.e., the duration of systolic flow divided by the square root of the cardiac cycle time (330-360 msec is considered normal), and for stroke volume variation (SVV) as a surrogate for intravascular volume status.
To guide fluid therapy, the clinician can use FTc (or SVV) to detect relative hypovolemia. If hypovolemia is suspected based on FTc or SVV, a fluid challenge is given. If cardiac index or stroke volume increases (e.g., by 10%), the patient is deemed fluid responsive and a fluid bolus is re-administered. This process continues until the stroke volume or cardiac index no longer increases with fluid administration, or until FTc or SVV has normalized (in which case, intravascular volume should be normal).25
The CardioQ has several potential sources of error and disadvantages. Measurement of descending aortic blood flow neglects flow to the brain and upper extremities and requires the use of a conversion factor. The area of the descending thoracic aorta is estimated based on the same normative data of height and weight – it is not measured specifically for the patient being monitored. The angle of incidence is also not precisely known. Additionally, the device is not truly continuous, as its position within the esophagus can shift during anesthesia and surgery. Furthermore, it is susceptible to signal artifact during electrocautery and therefore requires periodic operator intervention to ensure a high-quality Doppler signal. Because it is uncomfortable for patients, esophageal Doppler is typically used only in anesthetized or sedated patients.
Despite these potential limitations, the data to support the accuracy of Doppler technology (not limited to esophageal Doppler) are quite strong. Overall, comparisons with invasive technologies (electromagnetic flowmeters26-29 and transit-time flow probes)30-32 in animal models and the Fick method in both animals29,33 and humans34-47 have been favourable.
Clinical data
Of all devices available to optimize fluid management in the context of ERAS protocols, esophageal Doppler is supported by the largest, most compelling body of evidence. The use of this device for fluid optimization has been studied in at least seven prospective randomized controlled trials encompassing 694 subjects undergoing diverse procedures, including orthopedic, abdominal, trauma, and urologic surgery. The mean weighted average of these trials suggests a reduction of 3.7 days in hospital length of stay (LOS) (Table 2).25,48-53
In addition to these randomized controlled trials, the United Kingdom’s National Health Service Technology Adoption Centre conducted a case study of esophageal Doppler as part of its enhanced recovery effort. Based on the use of EDM in 649 patients undergoing major surgery at three hospitals (as compared with 658 matched patients who did not received EDM in the 12 months prior), the National Health Service (NHS) documented a 3.6-day reduction in hospital LOS.54
As a result of the accumulating evidence suggesting improved outcomes with the use of EDM, the NHS and the National Institute for Health and Care Excellence (NICE) group released practice guidelines which state:
“The case for adopting the CardioQ-EDM in the NHS is supported by the evidence. There is a reduction in post-operative complications, use of central venous catheters and in-hospital stay (with no increase in the rate of re-admission or repeat surgery) compared with conventional clinical assessment with or without invasive cardiovascular monitoring.”55
Similarly, Centers for Medicare & Medicaid Services (Agency for Healthcare Research and Quality [AHRQ]) in the United States examined the data on esophageal Doppler monitoring, and concluded that:
“The addition of esophageal Doppler monitoring for guided fluid replacement to a protocol using CVP [central venous pressure] and conventional clinical assessment during surgery leads to a clinically significant reduction in the rate of major complications and total complications in surgical patients compared to CVP plus conventional clinical assessment. The strength of evidence supporting this finding is strong.”56
Arterial waveform analysis
Technological assessment
Arterial waveform analyzers attempt to estimate stroke volume (and cardiac output) using sophisticated evaluation of the shape of the arterial waveform. The principles of arterial waveform analysis have been extensively reviewed elsewhere,57 but most devices are based on the Windkessel theory developed by Frank. These devices typically estimate stroke volume using a variation of the following equation:
where k is a constant, P is an estimate of pressure (how this is measured differs in each technique), AS is the area under the blood pressure waveform during systole, and AD is the area under the blood pressure waveform during diastole. The major exception to this is the FloTrac Vigileo device made by Edwards Lifesciences (Irvine, CA, USA), which uses a proprietary empirically-derived algorithm to estimate stroke volume.58
Broadly, arterial waveform analyzers can be classified as uncalibrated or calibrated devices. The FloTrac Vigileo, ProAQT (Pulsion, Munich, Germany), MostCare (Vytech, Vygon, Italy), and LiDCOrapid (LiDCO, London, UK) devices do not require calibration. In contrast, the PiCCO (Pulsion, Munich, Germany) and the LiDCO+ (LiDCO, London, UK) are calibrated by transpulmonary thermodilution (which requires a central venous catheter and a brachial or femoral arterial catheter, but not a pulmonary artery catheter) and lithium dilution, respectively (Table 2). The purpose of calibration is to correct the estimate of k for changes in afterload.57 Because they rely on analysis of a blood pressure tracing, these devices can be used in patients who are fully awake.
The majority of experimental59-61 and clinical62-65 data suggests that calibration of arterial waveform analyzers improves accuracy, although this finding is not universal.64,66-68 The accuracy of these devices generally decreases during periods of hemodynamic instability;59,60,64,69-71 thus, there appears to be a tradeoff between convenience and reliability, especially in situations in which loading conditions are expected to change.
By measuring the area under the curve (or stroke volume) with each heartbeat, and comparing the minimal vs maximal value over one respiratory cycle, arterial waveform analyzers are able to measure SVV, an indication of the patient’s location on the Frank-Starling curve (Fig. 2). It is important to point out that, while some arterial waveform analyzers may not measure cardiac output accurately in the setting of extreme hemodynamic conditions, their ability to measure pulse pressure variation (PPV) in response to positive pressure ventilation (hence fluid responsiveness) is likely not compromised. Furthermore, the continuous nature of these devices is a significant advantage in a busy operating room environment.
Clinical data
Arterial waveform analyzers have been utilized in many GDT trials, primarily for the care of critically ill patients.18,19 Compared with esophageal Doppler, they have not been studied as thoroughly in conjunction with ERAS protocols, in part because they have not been commercially available for the same period of time. Anesthesiologists have started to repeat these fluid optimization studies using arterial waveform analyzers as alternatives to EDM (Table 2).72-77 Five trials72,73,75-77 documented reductions in LOS as well as an improvement in meaningful clinical outcomes, but not all studies demonstrated a benefit.74 The mean weighted average reduction in LOS for these trials (2.2 days) is less than the reduction in LOS seen with EDM (3.7 days), but the total number of studies (11) and subjects (1,018) precludes statistically meaningful comparisons.
Several points are worth mentioning. First, the earliest arterial waveform analyzer trial was published ten years after the first EDM trial, and some of the observed differences with regard to clinical efficacy may be related to other changes in care over this decade. Second, arterial waveform analyzers cannot be used reliably in the setting of aortic insufficiency or an irregular heart rhythm. Lastly, much of the data supporting the ability of SVV to predict fluid responsiveness was conducted using tidal volumes of 8-10 mL·kg−1. These devices have not been adequately validated at lower tidal volumes or in subjects with spontaneous ventilation. That being said, estimates of stroke volume (as opposed to SVV) should not be affected by these differences in intrathoracic pressure or volume.
Photoplethysmography
Technological assessment
The photoplethysmographic (PPG) waveform is produced by directing red or near-infrared light into a body part (e.g., finger) and plotting the intensity of transmitted radiation as a function of time.78 Hemoglobin absorbs both red and near-infrared light; therefore, as pulsatile arterial blood enters and leaves the body part, transmittance of red and near-infrared light will change accordingly. As one might expect, the raw PPG waveform oscillates with respiration at the respiratory rate. The utility of this information was lost on the developers of pulse oximetry who considered it an “artifact” and went so far as to apply a high-pass filter to PPG waveforms in order to remove this unwanted source of “noise”.79 Indeed, most commercial pulse oximeters filter out low-frequency oscillations.
The Masimo Radical-7® (Masimo Corporation, Irvine, CA, USA) device is a pulse oximeter designed specifically to quantify the amount of low-frequency variation in the PPG tracing, as well as to display the raw waveform in real time (Fig. 3). Pleth variability index (PVI®) is the photoplethysmographic analogue of PPV from the arterial line and compares the largest pulse oximeter pulse pressure (PPmax) with the smallest pulse oximeter pulse pressure (PPmin) over the course of one breath. PVI is defined as:
where PP is equal to the amplitude of the PPG waveform. Thus, PVI is analogous to PPV80 from the arterial waveform. Several studies have confirmed that PVI can predict the cardiovascular response to both passive leg raising81 and fluid administration in patients whose lungs are mechanically ventilated.82-85 Despite the growing body of data suggesting that PVI is capable of predicting fluid responsiveness, there does not seem to be strong agreement between PVI and PPV.86-90 The reasons for this paradox (excellent predictor of fluid responsiveness yet not in agreement with arterial-derived metrics) are not clear but may be related to the dependence of PVI on perfusion.91
While the Masimo device may not be as effective as its more invasive counterparts during periods of malperfusion, it has three major advantages – relative low cost in comparison with its competitors, the ubiquity of pulse oximetry (which of course is a Canadian Anesthesiologists’ Society basic monitoring standard),92 and ease of use.
Alternatives to the Masimo device include the Edwards ClearSight system™ (Edwards Lifesciences, Irvine, CA, USA) and the CNSystems CNAP (CNSystems, Graz, Austria), both of which utilize the volume clamp technique, and the former of which utilizes the physiocal technique to reproduce a blood pressure tracing accurately from multiple finger cuffs. The volume clamp technique utilizes an inflatable finger bladder connected to a highly responsive feedback controller that automatically adjusts the bladder pressure to maintain a constant level of infrared transmittance through the finger. As blood volume increases (and transmittance of infrared radiation decreases), the cuff is inflated; conversely, as blood volume decreases (and transmittance of infrared radiation increases), the cuff is deflated. The cuff pressure required to maintain stable transmittance is the same as the arterial blood pressure in the finger, and in this way, arterial finger pressure can be measured continuously.93 Critical to the success of the volume clamp technique is the ability to keep the peripheral arteries in an unstretched state. This is accomplished using the physiocal technique, wherein the finger cuff pressure is increased in stepwise fashion, and pressure is selected at the maximal PPG amplitude – this is the feedback setpoint. Periodically, the volume clamp technique is paused and the physiocal technique reapplied.94 The NexFin device then applies arterial waveform analysis algorithms (above) to the resultant waveform to estimate stroke volume and SVV.
Clinical data
The Masimo Radical-7 has been utilized in one GDT study to date, though it was not part of a specific ERAS protocol. Forget et al. randomized general surgery patients to fluid management guided by traditional parameters (mean arterial pressure, central venous pressure) or PVI and found lower lactate levels at every time point in the PVI group despite receiving 500 mL less fluid.95 The NexFin device has not yet been utilized as a GDT device for ERAS, but given the accuracy of its blood pressure measurements96-98 and its completely non-invasive nature, it is promising.
Venous oxygen saturation
Technological assessment
Mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2) measure the oxygen saturation of pulmonary arterial and central venous blood, respectively, using specially designed oximetry catheters. These devices are based on the premise that inadequate oxygen delivery (as may be seen in shock states) or ineffective consumption of oxygen (as may be seen in sepsis) will manifest as an abnormality in either SvO2 or ScvO2.99 Advantages of SvO2 and ScvO2 include their reliability, continuous nature, and rapid response time. The major disadvantage of this technology is the requirement for central venous catheterization, which incurs several risks, the most important of which may be central line-associated bloodstream infection.100
Clinical data
Mixed venous oxygen saturation and ScvO2 have not been used as part of ERAS protocols specifically; thus, their potential utility can be estimated only by extrapolating from published data in the critically ill and other perioperative patient populations. Mixed venous oxygen saturation was used as a therapeutic endpoint in a large multicentre randomized controlled trial of critically ill patients but did not lead to improvements in survival.101 A smaller single-centre randomized controlled trial of early GDT in septic patients found a significant reduction in mortality when hemodynamics were modified to achieve a target ScvO2 > 70%.102 A more recent larger multicentre randomized controlled trial designed to confirm these findings found no such difference.103
A small randomized controlled trial in patients undergoing major abdominal surgery found that titration of oxygen extraction ratio (O2ER; based on ScvO2) to < 27% reduced LOS and organ failure.104 Importantly, the O2ER group had lower lactates and higher ScvO2 than the control group at the majority of time points, showing physiologic efficacy. A subsequent larger randomized controlled trial focusing on maintenance of SvO2 > 70% (and lactate < 2 mEq·L−1 in cardiac surgical patients led to a slight reduction in morbidity and LOS, although SvO2 and lactate did not appear to be appreciably different between groups, making the result difficult to interpret.105 A large retrospective observational analysis of SvO2 catheter use in cardiac surgical patients found no difference on outcomes associated with SvO2 catheter use.106
Tissue oxygen saturation
Technological assessment
Tissue oximetry offers an exciting alternative to SvO2 and ScvO2 catheterization. Based on the principles of near-infrared spectroscopy (NIRS) – which analyze the non-pulsatile component of electromagnetic radiation capable of penetrating 2-3 cm into tissue – NIRS devices are able to estimate the tissue oxygen saturation (StO2), i.e., a mixture of arterial (30%) and venous (70%) blood, of brain or muscle.107,108
Major advantages of NIRS-based estimates of StO2 include their reliability in states of low perfusion (as they do not require pulsatility) and the ability to monitor multiple end-organs (as opposed to SvO2 and ScvO2, which are able to assess only global measures of oxygen supply and demand). The main disadvantages of NIRS technology are cost and the inability to distinguish between arterial and venous blood, i.e., assuming an arterial to venous ratio of 30:70 may lead to erroneous measurements. Published data on cerebral oximetry devices suggest they suffer from some extracranial contamination of their signals109 and interdevice differences (which complicate interpretation).110
Clinical data
There is at least one randomized controlled trial showing the successful use of cerebral oximetry to improve outcomes in patients undergoing cardiac surgery.111 While there was not a significant difference in the incidence of stroke (the study was not powered to detect this), use of cerebral oximetry led to a reduction in a composite index of overall morbidity. The reasons for this are complex but likely reflect the ability of the brain to autoregulate during cardiopulmonary bypass,112,113 its position as a sentinel organ,114 as well as the benefits of protocolized oxygen-centric hemodynamic management in terms of organ function, which has been shown in medical102 as well as both non-cardiac104 and cardiac105 surgical patient populations (although it is important to point out that not all studies have been positive).103 Given the brain’s ability to autoregulate, one would expect it to be highly specific but insensitive for perfusion abnormalities; thus, investigators have sought other organ systems to serve as a more sensitive sign of malperfusion or impending organ injury. There does appear to be a relationship between low muscle StO2 values (measured in the thenar eminence) and Sequential Organ Failure Assessment (SOFA) and APACHE II scores in critically ill patients.115 As with SvO2 and ScvO2 catheterization, StO2 (brain or muscle) has not (yet) been utilized as an endpoint for therapy in the context of ERAS protocols.
Bioimpedance and bioreactance
Technological assessment
Bioimpedance and bioreactance devices are based on Ohm’s law, which relates electrical current (I) to voltage (V) and resistance (R) by the equation:
The human thorax is made up of various materials, all of which resist the flow of electrical current to different degrees. Over the course of one heartbeat, the volume of intrathoracic fluid changes, and these changes manifest as changes in impedance (resistance to pulsatile flow). Bioimpedance devices apply a small electrical current across the chest and continuously measure impedance, which is related to intrathoracic blood volume. These devices assume that impedance is exclusively a function of changes in intrathoracic blood; they are susceptible to electrical noise, electrode positioning, and pulmonary edema, and are not particularly accurate.116-124 Bioreactance, in which the phase shift between the applied and measured voltage is correlated to stroke volume, was developed in an effort to reduce the sensitivity to artifact.125
Advantages of bioimpedance and bioreactance devices include their completely noninvasive nature as well as their ability to provide continuous measurements.
Clinical data
The NICOM (Cheetah Medical, Newton, MA, USA) device was recently compared with EDM for GDT based on stroke volume in 100 patients undergoing colorectal surgery. There was no difference in LOS between the NICOM-guided and EDM-guided groups, although the study may not have been adequately powered to detect clinically significant differences in LOS. Additionally, there was very poor agreement between NICOM- and EDM-based estimates of stroke volume, with 95% intervals exceeding ± 50 mL. That said, there were no significant differences between devices with regard to the decision to give intravenous fluids (the fluid management protocol was based on a ≥ 10% increase in stroke volume with fluid challenge). This suggests that trending between the two devices is reliable, although the authors did not examine this specifically.126
Future directions
The relative contribution of specific intraoperative GDT to ERAS protocols is not known. Because the use of these devices incurs additional cost and, in some cases, risk, future research should focus on the additional value of intraoperative GDT in comparison with the simple fluid restriction used in many ERAS protocols. Brandstrup et al. attempted to address this question in a single study of 150 patients undergoing colorectal surgery and found no difference in complications or LOS between patients guided by esophageal Doppler and those guided by a more simplistic fluid restriction regimen. It would be premature to make practice changes based on this single study, but it is thought provoking and additional work is needed in this area.127
Evidence is accumulating that decreasing tidal volumes used for intraoperative mechanical ventilation leads to improved outcomes.128,129 Many measures of fluid responsiveness were validated using 8-10 mL·kg−1 tidal volumes, and because they are dependent on intrathoracic pressure changes, they may not be as useful as tidal volumes in contemporary practice which have generally decreased to the 5-6 mL·kg−1 range. A reduction in bowel edema does not likely justify an increased risk of pulmonary injury, and future work is needed in this area.
Lastly, many of the monitors designed for intraoperative GDT do not work in patients with spontaneous ventilation.130 As anesthesiologists become increasingly involved in the perioperative experience, they will find themselves unable to apply their intraoperative fluid management strategies to their postoperative patients until additional means of measuring fluid responsiveness are developed for patients receiving spontaneous ventilation following tracheal extubation. Currently, the only available means of measuring fluid responsiveness in these patients is by performance of a passive leg raising maneuver.131
Conclusions
Many, but not all, ERAS protocols utilize intraoperative GDT to optimize fluid management. Most of these devices attempt to assess fluid responsiveness in real time, either by assessing respiratory variation in blood pressure or flow or by measuring the change in cardiac output that occurs after a fluid bolus is administered. Of all available devices, esophageal Doppler monitors are supported by the largest and most compelling body of data, but they can only be used intraoperatively and are not truly continuous. Arterial waveform analyzers offer a truly continuous estimate of fluid responsiveness but require the placement of an intra-arterial catheter. Their estimates of cardiac output are likely less reliable than those of esophageal Doppler, especially when loading conditions change. Furthermore, arterial waveform analyzers are not supported by as strong an evidence base, but this is primarily because fewer studies have been conducted. The PPG devices cannot be recommended for ERAS protocols based on clinical outcomes data, but the physiologic studies conducted with the PVI, the relatively low cost of the devices, and the fact that all anesthetized patients receive pulse oximetry suggest that the PVI may be an extremely useful intraoperative monitoring tool in relatively healthy patients. Venous oxygen saturation has no established role in ERAS protocols. NIRS-based tissue oximetry may eventually serve as a therapeutic endpoint, although it has not been tested in the context of ERAS. Bioimpedance devices are relatively inaccurate monitors of cardiac output and have not been tested as a therapeutic endpoint in ERAS protocols. Bioreactance devices are relatively new, and a single study suggests very little difference in intraoperative fluid administration as compared with EDM, but additional studies are needed. At this time, we cannot conclude which device has the most beneficial effects on patient outcomes; therefore, future research should include comparisons of the effects of different monitoring devices on meaningful clinical endpoints.
Key points
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Intraoperative fluid management is frequently protocolized in Enhanced Recovery After Surgery protocols.
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Available devices to guide fluid therapy differ based on the parameter they measure (e.g., cardiac output vs stroke volume variation) as well as their underlying mechanistic principles, level of invasiveness, and cost.
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Devices that integrate the impact of intrathoracic pressure changes during mechanical ventilation on cardiac output likely best predict hemodynamic responses to fluid administration.
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Future research should compare different strategies for fluid management, including goal-directed therapy vs fluid restriction, examination of their impact on relevant clinical outcomes and cost, and extension of the fluid responsiveness concept to patients whose lungs are ventilated using low tidal volume lung-protective strategies and to patients with spontaneous breathing.
References
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606-17.
Vanounou T, Pratt W, Fischer JE, Vollmer CM Jr, Callery MP. Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 2007; 204: 570-9.
Tang J, Humes DJ, Gemmil E, Welch NT, Parsons SL, Catton JA. Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages. Ann R Coll Surg Engl 2013; 95: 323-8.
Reismann M, Dingemann J, Wolters M, Laupichler B, Suempelmann R, Ure BM. Fast-track concepts in routine pediatric surgery: a prospective study in 436 infants and children. Langenbecks Arch Surg 2009; 394: 529-33.
Porter GA, Pisters PW, Mansyur C, et al. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 2000; 7: 484-9.
Khreiss W, Huebner M, Cima RR, et al. Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Dis Colon Rectum 2014; 57: 557-63.
Kennedy EP, Rosato EL, Sauter PK, et al. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution—the first step in multidisciplinary team building. J Am Coll Surg 2007; 204: 917-23; discussion 923-4.
Kennedy EP, Grenda TR, Sauter PK, et al. Implementation of a critical pathway for distal pancreatectomy at an academic institution. J Gastrointest Surg 2009; 13: 938-44.
Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013; 122(2 Pt 1): 319-28.
di Sebastiano P, Festa L, De Bonis A, et al. A modified fast-track program for pancreatic surgery: a prospective single-center experience. Langenbecks Arch Surg 2011; 396: 345-51.
Daneshmand S, Ahmadi H, Schuckman AK, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol 2014; DOI:10.1016/j.juro.2014.01.097.
Connor S, Cross A, Sakowska M, Linscott D, Woods J. Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection. HPB (Oxford) 2013; 15: 294-301.
Blom RL, van Heijl M, Bemelman WA, et al. Initial experiences of an enhanced recovery protocol in esophageal surgery. World J Surg 2013; 37: 2372-8.
Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 2008; 95: 1387-93.
Brandstrup B, Tonnesen H, Beier-Holgersen R, et al.; Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238: 641-8.
Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology 2008; 109: 723-40.
Bartels K, Thiele RH, Gan TJ. Rational fluid management in today’s ICU practice. Crit Care 2013; 17(Suppl 1): S6.
Gurgel ST, do Nascimento P Jr. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011; 112: 1384-91.
Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011; 112: 1392-402.
Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348: 5-14.
Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003; 290: 2713-20.
Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005; 366: 472-7.
Lowe GD, Chamberlain BM, Philpot EJ, Willshire RJ. Oesophageal Doppler Monitor (ODM) Guided Individualised Goal Directed Fluid Management (iGDFM) in Surgery – a Technical Review. Deltex Medical Technical Review 2010; Available from URL: http://www.deltexmedical.com/downloads/TechnicalReview.pdf (accessed August 2014).
Doppler JC. Ueber das farbige Licht der Doppelsterne und einiger anderer Gestirne des Himmels. Abhandl Konigl Bohm Ges Ser 1843; 2: 465-82.
Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002; 97: 820-6.
Steingart RM, Meller J, Barovick J, Patterson R, Herman MV, Teichholz LE. Pulsed Doppler echocardiographic measurement of beat-to-beat changes in stroke volume in dogs. Circulation 1980; 62: 542-8.
Spencer KT, Lang RM, Neumann A, Borow KM, Shroff SG. Doppler and electromagnetic comparisons of instantaneous aortic flow characteristics in primates. Circ Res 1991; 68: 1369-77.
Gregoretti S, Henderson CT, Bradley EL Jr. Simultaneous cardiac output measurements by transtracheal Doppler, electromagnetic flow meter, and thermodilution during various hemodynamic states in pigs. Anesth Analg 1991; 73: 455-9.
Kamal GD, Symreng T, Starr J. Inconsistent esophageal Doppler cardiac output during acute blood loss. Anesthesiology 1990; 72: 95-9.
Aadahl P, Aakhus S, Saether OD, Stomholm T, Myhre HO. Cardiac output measurements during cross-clamping of the descending thoracic aorta in pigs. A comparison between transit-time ultrasound, thermodilution and pulsed Doppler ultrasound. Acta Anaesthesiol Scand 2000; 44: 180-5.
Critchley LA, Peng ZY, Fok BS, Lee A, Phillips RA. Testing the reliability of a new ultrasonic cardiac output monitor, the USCOM, by using aortic flowprobes in anesthetized dogs. Anesth Analg 2005; 100: 748-53.
Wong DH, Watson T, Gordon I, et al. Comparison of changes in transit time ultrasound, esophageal Doppler, and thermodilution cardiac output after changes in preload, afterload, and contractility in pigs. Anesth Analg 1991; 72: 584-8.
Welch E, Duara S, Suguihara C, Bandstra E, Bancalari E. Validation of cardiac output measurements with noninvasive Doppler echocardiography by thermodilution and Fick methods in newborn piglets. Biol Neonate 1994; 66: 137-45.
Alverson DC, Eldridge M, Dillon T, Yabek SM, Berman W Jr. Noninvasive pulsed Doppler determination of cardiac output in neonates and children. J Pediatr 1982; 101: 46-50.
Christie J, Sheldahl LM, Tristani FE, Sagar KB, Ptacin MJ, Wann S. Determination of stroke volume and cardiac output during exercise: comparison of two-dimensional and Doppler echocardiography, Fick oximetry, and thermodilution. Circulation 1987; 76: 539-47.
Gentles TL, Neutze JM, Caulder AL, Greene ER. Cardiac output measurements in congenital heart disease: validation of a simple, portable Doppler method. J Ultrasound Med 2001; 20: 365-70.
Gola A, Pozzoli M, Capomolla S, et al. Comparison of Doppler echocardiography with thermodilution for assessing cardiac output in advanced congestive heart failure. Am J Cardiol 1996; 78: 708-12.
Ihlen H, Amlie JP, Dale J, et al. Determination of cardiac output by Doppler echocardiography. Br Heart J 1984; 51: 54-60.
Magnin PA, Stewart JA, Myers S, von Ramm O, Kisslo JA. Combined Doppler and phased-array echocardiographic estimation of cardiac output. Circulation 1981; 63: 388-92.
Marx GR, Hicks RW, Allen HD. Measurement of cardiac output and exercise factor by pulsed Doppler echocardiography during supine bicycle ergometry in normal young adolescent boys. J Am Coll Cardiol 1987; 10: 430-4.
Sanders SP, Yeager S, Williams RG. Measurement of systemic and pulmonary blood flow and QP/QS ratio using Doppler and two-dimensional echocardiography. Am J Cardiol 1983; 51: 952-6.
Sjoberg BJ, Wranne B. Cardiac output determined by ultrasound-Doppler: clinical applications. Clin Physiol 1990; 10: 463-73.
Strauss AL, Kedra AW, Payen DM, Levy BI, Rieger H, Martineaud JP. Noninvasive determination of stroke volume with impulse Doppler echocardiography: comparison with the Fick method (German). Herz 1986; 11: 269-76.
Bojanowski LM, Timmis AD, Najm YC, Gosling RG. Pulsed Doppler ultrasound compared with thermodilution for monitoring cardiac output responses to changing left ventricular function. Cardiovasc Res 1987; 21: 260-8.
Davies JN, Allen DR, Chant AD. Non-invasive Doppler-derived cardiac output: a validation study comparing this technique with thermodilution and Fick methods. Eur J Vasc Surg 1991; 5: 497-500.
Smith HJ, Grottum P, Simonsen S. Doppler flowmetry in the lower thoracic aorta. An indirect estimation of cardiac output. Acta Radiol Diagn (Stockh) 1985; 26: 257-63.
Valtier B, Cholley BP, Belot JP, de la Coussaye JE, Mateo J, Payen DM. Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med 1998; 158: 77-83.
Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997; 315: 909-12.
Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002; 88: 65-71.
Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005; 95: 634-42.
Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006; 93: 1069-76.
Chytra I, Pradl R, Bosman R, Pelnar P, Kasal E, Zidkova A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care 2007; 11: R24.
Pillai P, McEleavy I, Gaughan M, et al. A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol 2011; 186: 2201-6.
National Institute for Health and Care Excellence. Oesophageal Doppler-Guided Fluid Management During Major Surgery: Reducing Postoperative Complications and Bed Days. Available from URL: http://www.evidence.nhs.uk/ (accessed August 2014).
National Institute for Health and Care Excellence. CardioQ-ODM Oesophageal Doppler Monitor, 2011. Available from URL: http://www.nice.org.uk/guidance/MTG3 (accessed August 2014).
Centers for Medicare and Medicaid Service. Quality AfHRa. Esophageal Doppler Ultrasound-Based Cardiac Output Monitoring for Real-Time Therapeutic Management of Hospitalized Patients. Available from URL: http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details.aspx?TAId=45&bc=BAAgAAAAAAAA& (accessed August 2014).
Thiele RH, Durieux ME. Arterial waveform analysis for the anesthesiologist: past, present, and future concepts. Anesth Analg 2011; 113: 766-76.
Pratt B, Roteliuk L, Hatib F, Frazier J, Wallen RD. Calculating arterial pressure-based cardiac output using a novel measurement and analysis method. Biomed Instrum Technol 2007; 41: 403-11.
Cooper ES, Muir WW. Continuous cardiac output monitoring via arterial pressure waveform analysis following severe hemorrhagic shock in dogs. Crit Care Med 2007; 35: 1724-9.
Johansson A, Chew M. Reliability of continuous pulse contour cardiac output measurement during hemodynamic instability. J Clin Monit Comput 2007; 21: 237-42.
Bein B, Meybohm P, Cavus E, et al. The reliability of pulse contour-derived cardiac output during hemorrhage and after vasopressor administration. Anesth Analg 2007; 105: 107-13.
Hadian M, Kim HK, Severyn DA, Pinsky MR. Cross-comparison of cardiac output trending accuracy of LiDCO, PiCCO, FloTrac and pulmonary artery catheters. Crit Care 2010; 14: R212.
Cecconi M, Dawson D, Casaretti R, Grounds RM, Rhodes A. A prospective study of the accuracy and precision of continuous cardiac output monitoring devices as compared to intermittent thermodilution. Minerva Anestesiol 2010; 76: 1010-7.
Krejci V, Vannucci A, Abbas A, Chapman W, Kangrga IM. Comparison of calibrated and uncalibrated arterial pressure-based cardiac output monitors during orthotopic liver transplantation. Liver Transpl 2010; 16: 773-82.
Zollner C, Haller M, Weis M, et al. Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: a prospective criterion standard study in patients after cardiac surgery. J Cardiothorac Vasc Anesth 2000; 14: 125-9.
Button D, Weibel L, Reuthebuch O, Genoni M, Zollinger A, Hofer CK. Clinical evaluation of the FloTrac/Vigileo system and two established continuous cardiac output monitoring devices in patients undergoing cardiac surgery. Br J Anaesth 2007; 99: 329-36.
Costa MG, Della Rocca G, Chiarandini P, et al. Continuous and intermittent cardiac output measurement in hyperdynamic conditions: pulmonary artery catheter vs. lithium dilution technique. Intensive Care Med 2008; 34: 257-63.
Hofer CK, Button D, Weibel L, Genoni M, Zollinger A. Uncalibrated radial and femoral arterial pressure waveform analysis for continuous cardiac output measurement: an evaluation in cardiac surgery patients. J Cardiothorac Vasc Anesth 2010; 24: 257-64.
Schuerholz T, Meyer MC, Friedrich L, Przemeck M, Sumpelmann R, Marx G. Reliability of continuous cardiac output determination by pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006; 50: 407-13.
Hamm JB, Nguyen BV, Kiss G, et al. Assessment of a cardiac output device using arterial pulse waveform analysis, Vigileo, in cardiac surgery compared to pulmonary arterial thermodilution. Anaesth Intensive Care 2010; 38: 295-301.
Jeong YB, Kim TH, Roh YJ, Choi IC, Suh JH. Comparison of uncalibrated arterial pressure waveform analysis with continuous thermodilution cardiac output measurements in patients undergoing elective off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2010; 24: 767-71.
Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care 2007; 11: R100.
Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 2010; 14: R118.
Buettner M, Schummer W, Huettemann E, Schenke S, van Hout N, Sakka SG. Influence of systolic-pressure-variation-guided intraoperative fluid management on organ function and oxygen transport. Br J Anaesth 2008; 101: 194-9.
Jones C, Kelliher L, Dickinson M, et al. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg 2013; 100: 1015-24.
Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. J Clin Monit Comput 2013; 27: 249-57.
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005; 9: R687-93.
Nilsson LM. Respiration signals from photoplethysmography. Anesth Analg 2013; 117: 859-65.
Shelley KH. Photoplethysmography: beyond the calculation of arterial oxygen saturation and heart rate. Anesth Analg 2007; 105(6 Suppl): S31-6.
Michard F, Chemla D, Richard C, et al. Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effects of PEEP. Am J Respir Crit Care Med 1999; 159: 935-9.
Keller G, Cassar E, Desebbe O, Lehot JJ, Cannesson M. Ability of pleth variability index to detect hemodynamic changes induced by passive leg raising in spontaneously breathing volunteers. Crit Care 2008; 12: R37.
Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre. Br J Anaesth 2008; 101: 200-6.
Zimmermann M, Feibicke T, Keyl C, et al. Accuracy of stroke volume variation compared with pleth variability index to predict fluid responsiveness in mechanically ventilated patients undergoing major surgery. Eur J Anaesthesiol 2010; 27: 555-61.
Hood JA, Wilson RJ. Pleth variability index to predict fluid responsiveness in colorectal surgery. Anesth Analg 2011; 113: 1058-63.
Loupec T, Nanadoumgar H, Frasca D, et al. Pleth variability index predicts fluid responsiveness in critically ill patients. Crit Care Med 2011; 39: 294-9.
Solus-Biguenet H, Fleyfel M, Tavernier B, et al. Non-invasive prediction of fluid responsiveness during major hepatic surgery. Br J Anaesth 2006; 97: 808-16.
Landsverk SA, Hoiseth LO, Kvandal P, Hisdal J, Skare O, Kirkeboen KA. Poor agreement between respiratory variations in pulse oximetry photoplethysmographic waveform amplitude and pulse pressure in intensive care unit patients. Anesthesiology 2008; 109: 849-55.
Hengy B, Gazon M, Schmitt Z, et al. Comparison between respiratory variations in pulse oximetry plethysmographic waveform amplitude and arterial pulse pressure during major abdominal surgery. Anesthesiology 2012; 117: 973-80.
Thiele RH, Colquhoun DA, Forkin KT, Durieux ME. Assessment of the agreement between photoplethysmographic and arterial waveform respiratory variation in patients undergoing spine surgery. J Med Eng Technol 2013; 37: 409-15.
Feldman JM, Sussman E, Singh D, Friedman BJ. Is the pleth variability index a surrogate for pulse pressure variation in a pediatric population undergoing spine fusion? Paediatr Anaesth 2012; 22: 250-5.
Broch O, Bein B, Gruenewald M, et al. Accuracy of the pleth variability index to predict fluid responsiveness depends on the perfusion index. Acta Anaesthesiol Scand 2011; 55: 686-93.
Merchant R, Chartrand D, Dain S, et al. Guidelines to the practice of anesthesia—Revised Edition 2014. Can J Anesth 2014; 61: 46-59.
Boehmer RD. Continuous, real-time, noninvasive monitor of blood pressure: Penaz methodology applied to the finger. J Clin Monit 1987; 3: 282-7.
Imholz BP, Wieling W, van Montfrans GA, Wesseling KH. Fifteen years experience with finger arterial pressure monitoring: assessment of the technology. Cardiovasc Res 1998; 38: 605-16.
Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg 2010; 111: 910-4.
Lemson J, Hofhuizen CM, Schraa O, Settels JJ, Scheffer GJ, van der Hoeven JG. The reliability of continuous noninvasive finger blood pressure measurement in critically ill children. Anesth Analg 2009; 108: 814-21.
Hofhuizen CM, Lemson J, Hemelaar AE, et al. Continuous non-invasive finger arterial pressure monitoring reflects intra-arterial pressure changes in children undergoing cardiac surgery. Br J Anaesth 2010; 105: 493-500.
Martina JR, Westerhof BE, van Goudoever J, et al. Noninvasive continuous arterial blood pressure monitoring with Nexfin(R). Anesthesiology 2012; 116: 1092-103.
Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest 2010; 138: 476-80; discussion 484-5.
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol 2014; 35: 56-62.
Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med 1995; 333: 1025-32.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-77.
ProCESS Investigators; Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370: 1683-93.
Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest 2007; 132: 1817-24.
Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 2000; 90: 1052-9.
London MJ, Moritz TE, Henderson WG, et al. Standard versus fiberoptic pulmonary artery catheterization for cardiac surgery in the Department of Veterans Affairs: a prospective, observational, multicenter analysis. Anesthesiology 2002; 96: 860-70.
Jobsis FF. Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters. Science 1977; 198: 1264-7.
Benni PB, Chen B, Dykes FD, et al. Validation of the CAS neonatal NIRS system by monitoring vv-ECMO patients: preliminary results. Adv Exp Med Biol 2005; 566: 195-201.
Davie SN, Grocott HP. Impact of extracranial contamination on regional cerebral oxygen saturation: a comparison of three cerebral oximetry technologies. Anesthesiology 2012; 116: 834-40.
Grocott HP, Davie SN. Cerebral oximetry determination of desaturation with norepinephrine administration may be device manufacturer specific. Anesthesiology 2013; 118: 982.
Murkin JM, Adams SJ, Novick RJ, et al. Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg 2007; 104: 51-8.
Slater JM, Orszulak TA, Cook DJ. Distribution and hierarchy of regional blood flow during hypothermic cardiopulmonary bypass. Ann Thorac Surg 2001; 72: 542-7.
Boston US, Slater JM, Orszulak TA, Cook DJ. Hierarchy of regional oxygen delivery during cardiopulmonary bypass. Ann Thorac Surg 2001; 71: 260-4.
Vretzakis G, Georgopoulou S, Stamoulis K, et al. Cerebral oximetry in cardiac anesthesia. J Thorac Dis 2014; 6(Suppl 1): S60-9.
Lima A, van Bommel J, Jansen TC, Ince C, Bakker J. Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients. Crit Care 2009; 13(Suppl 5): S13.
Belardinelli R, Ciampani N, Costantini C, Blandini A, Purcaro A. Comparison of impedance cardiography with thermodilution and direct Fick methods for noninvasive measurement of stroke volume and cardiac output during incremental exercise in patients with ischemic cardiomyopathy. Am J Cardiol 1996; 77: 1293-301.
Engoren M, Barbee D. Comparison of cardiac output determined by bioimpedance, thermodilution, and the Fick method. Am J Crit Care 2005; 14: 40-5.
Teo KK, Hetherington MD, Haennel RG, Greenwood PV, Rossall RE, Kappagoda T. Cardiac output measured by impedance cardiography during maximal exercise tests. Cardiovasc Res 1985; 19: 737-43.
Yung GL, Fedullo PF, Kinninger K, Johnson W, Channick RN. Comparison of impedance cardiography to direct Fick and thermodilution cardiac output determination in pulmonary arterial hypertension. Congest Heart Fail 2004; 10(2 Suppl 2): 7-10.
Braden DS, Leatherbury L, Treiber FA, Strong WB. Noninvasive assessment of cardiac output in children using impedance cardiography. Am Heart J 1990; 120: 1166-72.
Yakimets J, Jensen L. Evaluation of impedance cardiography: comparison of NCCOM3-R7 with Fick and thermodilution methods. Heart Lung 1995; 24: 194-206.
Wong DH, Tremper KK, Stemmer EA, et al. Noninvasive cardiac output: simultaneous comparison of two different methods with thermodilution. Anesthesiology 1990; 72: 784-92.
Kemps HM, Thijssen EJ, Schep G, et al. Evaluation of two methods for continuous cardiac output assessment during exercise in chronic heart failure patients. J Appl Physiol 1985; 2008(105): 1822-9.
Salandin V, Zussa C, Risica G, et al. Comparison of cardiac output estimation by thoracic electrical bioimpedance, thermodilution, and Fick methods. Crit Care Med 1988; 16: 1157-8.
Keren H, Burkhoff D, Squara P. Evaluation of a noninvasive continuous cardiac output monitoring system based on thoracic bioreactance. Am J Physiol Heart Circ Physiol 2007; 293: H583-9.
Waldron NH, Miller TE, Thacker JK, et al. A prospective comparison of a noninvasive cardiac output monitor versus esophageal Doppler monitor for goal-directed fluid therapy in colorectal surgery patients. Anesth Analg 2014; 118: 966-75.
Brandstrup B, Svendsen PE, Rasmussen M, et al. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 2012; 109: 191-9.
Lellouche F, Dionne S, Simard S, Bussieres J, Dagenais F. High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology 2012; 116: 1072-82.
Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369: 428-37.
Thiele RH, Bartels K, Esper S, Ikeda K, Gan TJ. Real-time Doppler-based arterial vascular impedance and peripheral pressure-flow loops: a pilot study. J Cardiothorac Vasc Anesth 2014; 28: 36-41.
Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care 2011; 1: 1.
Competing interests
Dr. Gan reports having received research support, honoraria, and/or consulting fees from Covidien, Edwards Lifesciences, Cheetah Medical within the last five years.
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Thiele, R.H., Bartels, K. & Gan, TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anesth/J Can Anesth 62, 169–181 (2015). https://doi.org/10.1007/s12630-014-0265-z
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DOI: https://doi.org/10.1007/s12630-014-0265-z