Conclusions

Perioperative hemodynamic GDT with a protocol incorporating restrictive fluid maintenance and inotropic therapy to achieve the best possible DO₂ in very high-risk surgical patients can be easily performed with the use of minimally invasive hemodynamic monitoring to obtain continuous monitoring of CO and is related to better patient outcomes. It is possible that with more reliable and easy-to-use hemodynamic monitoring during anesthesia, fluid maintenance volumes might be safely reduced.

Key messages

◆ Morbidity and mortality are high in some groups of patients, particularly elderly patients with low cardiorespiratory reserves who undergo extensive noncardiac surgery.

◆ Perioperative alterations in DO₂ are closely correlated to the development of MOF and death.

◆ Randomized clinical trials have shown reductions in postoperative complications and mortality rates when strategies aimed at optimizing tissue perfusion are used in the perioperative period.

◆ The optimal perioperative fluid regimen for major noncardiac surgery patients is unclear.

◆ The preemptive use of GDT with fluids and inotropes targeting DO₂ and a more restrictive strategy of fluid maintenance during surgery leads to fewer major complications in high-risk patients undergoing major surgery.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

SML contributed to the study design, the statistical analysis, the analysis and interpretation of results, the drafting of the manuscript and critical revisions of the manuscript. LSR contributed to the study design and the acquisition, analysis and interpretation of data. KN was the study coordinator. FRML contributed to the study design, acquisition of data, conduct of the trial, analysis and interpretation of the results and critical revision of the manuscript. NEO and GSC contributed to the study design, acquisition of data and conduct of the trial. PGB contributed to the acquisition of data, the conduct of the trial and the analysis and interpretation of results. AF contributed to the acquisition of data and the conduct of the trial. JGN contributed to the study design and acquisition of data.

Acknowledgements

We thank Bragenix Innovative Technologies for providing the LiDCO™plus Hemodynamic Monitor used during the study.

References

1. Cullinane M, Gray AJG, Hargraves CMK, Lansdown M, Martin IC, Schubert M: The 2003 report of the National Confidential Enquiry into Perioperative Deaths.[http://www.ncepod.org.uk/pdf/2003/03full.pdf] webcite

2. Fowkes FG, Lunn JN, Farrow SC, Robertson IB, Samuel P: Epidemiology in anaesthesia. III: Mortality risk in patients with coexisting physical disease.

Br J Anaesth 1982, 54:819-825. PubMed Abstract | Publisher Full Text 

3. Shoemaker WC, Appel PL, Kram HB: Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients.

Chest 1992, 102:208-215. PubMed Abstract | Publisher Full Text 

4. Lobo SM, Rezende E, Knibel M, Silva N, Páramo JA, Nácul FE, Mendes CL, Assunção M, Costa RC, Grion CC, Pinto SF, Mello PM, Maia MO, Duarte PA, Gutierrez F, Silva JM Jr, Lopes MR, Cordeiro JA, Mellot C: Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients.

Anesth Analg 2011, 112:877-883. PubMed Abstract | Publisher Full Text 

5. Barbee RW, Reynolds PS, Ward KR: Assessing shock resuscitation strategies by oxygen debt repayment.

Shock 2010, 33:113-122. PubMed Abstract | Publisher Full Text 

6. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee T: Prospective trial of supranormal values of survivors as therapeutic goals in high risk surgical patients.

Chest 1988, 94:1176-1185. PubMed Abstract | Publisher Full Text 

7. Boyd O, Grounds RM, Benett ED: A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients.

JAMA 1993, 270:2699-2707. PubMed Abstract | Publisher Full Text 

8. Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E: Reducing the risk of major surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.

BMJ 1999, 318:1099-1103. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 

9. Lobo SM, Salgado PF, Castillo VG, Borim AA, Polachini CA, Palchetti JC, Brienzi SL, de Oliveira GG: Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients.

Crit Care Med 2000, 28:3396-3404. PubMed Abstract | Publisher Full Text 

10. Berlauk JF, Abrams JH, Gilmour IJ, O'Connor SR, Knighton DR, Cerra FB: Pre-operative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery.

Ann Surg 1991, 214:289-297. PubMed Abstract | Publisher Full Text |PubMed Central Full Text 

11. Donati A, Loggi S, Preiser JC, Orsetti G, Münch C, Gabbanelli V, Pelaia P, Pietropaoli P:Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients.

Chest 2007, 132:1817-1824. PubMed Abstract | Publisher Full Text 

12. Pölönen P, Ruokonen E, Hippeläinen M, Pöyhönem M, Takala J: A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients.

Anesth Analg 2000, 90:1052-1059. PubMed Abstract | Publisher Full Text 

13. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC:Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery.

Br J Anaesth 2005, 95:634-642. PubMed Abstract | Publisher Full Text 

14. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS:Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery.

Anesthesiology 2002, 97:820-826. PubMed Abstract | Publisher Full Text 

15. Mythen MG, Webb AR: Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery.

Arch Surg 1995, 130:423-429. PubMed Abstract | Publisher Full Text 

16. 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, 93:1069-1107. PubMed Abstract | Publisher Full Text 

17. Sinclair S, James S, Singer M: Intraoperative intravascular volume optimisation and length of stay after repair of proximal femoral fracture: randomised controlled trial.

BMJ 1997, 315:909-912. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 

18. 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. PubMed Abstract | Publisher Full Text 

19. 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-R693. PubMed Abstract | BioMed Central Full Text |PubMed Central Full Text 

20. Lopes M, 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. PubMed Abstract | BioMed Central Full Text |PubMed Central Full Text 

21. Kern JW, Shoemaker WC: Meta-analysis of hemodynamic optimization in high-risk patients.

Crit Care Med 2002, 30:1686-1689. PubMed Abstract | Publisher Full Text 

22. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Tai B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F, 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, 238:641-648. PubMed Abstract | Publisher Full Text |PubMed Central Full Text 

23. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I: Effect of intraoperative fluid management on outcome after intraabdominal surgery.

Anesthesiology 2005, 103:25-32. PubMed Abstract | Publisher Full Text 

24. Holte K, Foss NB, Andersen J, Valentiner L, Lund C, Bie P, Kehlet H: Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study.

Br J Anaesth 2007, 99:500-508. PubMed Abstract | Publisher Full Text 

25. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP: Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial.

Lancet 2002, 359:1812-1818. PubMed Abstract | Publisher Full Text 

26. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA: A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer.

Ann Surg 2007, 245:867-872. PubMed Abstract | Publisher Full Text |PubMed Central Full Text 

27. Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J: Metaanalysis of standard, restrictive and supplemental fluid administration in colorectal surgery.

Br J Surg 2009, 96:331-341. PubMed Abstract | Publisher Full Text 

28. McArdle GT, McAuley DF, McKinley A, Blair P, Hoper M, Harkin DW: Preliminary results of a prospective randomized trial of restrictive versus standard fluid regime in elective open abdominal aortic aneurysm repair.

Ann Surg 2009, 250:28-34. PubMed Abstract | Publisher Full Text 

29. González-Fajardo JA, Mengibar L, Brizuela JA, Castrodeza J, Vaquero-Puerta C: Effect of postoperative restrictive fluid therapy in the recovery of patients with abdominal vascular surgery.

Eur J Vasc Endovasc Surg 2009, 37:538-543. PubMed Abstract | Publisher Full Text 

30. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH, Spittell JA Jr, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A Jr, Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.

Circulation 1996, 93:1278-1317. PubMed Abstract 

31. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ: POSSUM and Portsmouth POSSUM for predicting mortality.

Br J Surg 1998, 85:1217-1220. PubMed Abstract | Publisher Full Text 

32. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

Crit Care Med 1992, 20:864-874. PubMed Abstract | Publisher Full Text 

33. Lobo SM, Lobo FR, Polachini CA, Patini DS, Yamamoto AE, de Oliveira NE, Serrano P, Sanches HS, Spegiorin MA, Queiroz MM, Christiano AC Jr, Savieiro EF, Alvarez PA, Teixeira SP, Cunrath GS: Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients.

Crit Care 2006, 10:R72. PubMed Abstract | BioMed Central Full Text |PubMed Central Full Text 

34. Sark Y, Vincent JL, Reinhart K, Groeneveld J, Michalopoulos A, Sprung CL, Artigas A, Ranieri VM, Sepsis Occurrence in Acutely Ill Patients Investigators: High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury.

Chest 2005, 128:3098-3108. PubMed Abstract | Publisher Full Text 

35. Møller AM, Pedersen T, Svendsen PE, Engquist A: Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance.

Eur J Anaesthesiol 2002, 19:57-62. PubMed Abstract 

36. Bennett-Guerrero E, Feierman DE, Barclay GR, Parides MK, Sheiner PA, Mythen MG, Levine DM, Parker TS, Carrol SF, White ML, Winfree WJ: Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation.

Arch Surg 2001, 136:1177-1183. PubMed Abstract | Publisher Full Text 

37. Futier E, Constantin JM, Petit A, Chanques G, Kwiatkowski F, Flamein R, Slim K, Sapin V, Jaber S, Bazin JE: Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial.

Arch Surg 2010, 145:1193-200. PubMed Abstract | Publisher Full Text 

38. Hiltebrand LB, Kimberger O, Arnberger M, Brandt S, Kurz A, Sigurdsson GH: Crystalloids versus colloids for goal-directed fluid therapy in major surgery.

Crit Care 2009, 13:R40. PubMed Abstract | BioMed Central Full Text |PubMed Central Full Text 

39. Lobo SM, Orrico SR, Queiroz MM, Contrim LM, Cury PM: Comparison of the effects of lactated Ringer solution with and without hydroxyethyl starch fluid resuscitation on gut edema during severe splanchnic ischemia.

Braz J Med Biol Res 2008, 41:634-639. PubMed Abstract | Publisher Full Text 

40. Jhanji S, Thomas B, Ely A, Watson D, Hinds CJ, Pearse RM: Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS Trust.

Anaesthesia 2002, 63:695-700. PubMed Abstract | Publisher Full Text 

41. Warrillow SJ, Weinberg L, Parker F, Calzavacca P, Licari E, Aly A, Bagshaw S, Christophi C, Bellomo R: Perioperative fluid prescription, complications and outcomes in major elective open gastrointestinal surgery.

Anaesth Intensive Care 2010, 38:259-265. PubMed Abstract 

42. Brandstrup B, Svensen C, Engquist A: Hemorrhage and operation cause a contraction of the extracellular space needing replacement: evidence and implications? A systematic review.

Surgery 2006, 139:419-432. PubMed Abstract | Publisher Full Text