Perioperative Goal-Directed Therapy (PGDT) Using Hemodynamic Monitoring Is an Important Part of Enhanced Recovery After Surgery (ERAS) Initiatives

Patients undergoing major surgery are faced with an inherent risk of morbidity and mortality (See Table 1). These risks can increase depending on a patient’s cardiovascular and hemodynamic condition and are known to contribute to a variety of postoperative complications and increased lengths of stay (LOS) in the hospital.1,2 Specific factors that influence a patient’s LOS during postoperative rehabilitation include the need for analgesia, intravenous fluids, and lack of mobility.3

eras1To minimize recovery time and reduce postoperative complications for a variety of high- to moderate-risk surgical patients, hospitals and surgical teams around the world have adopted a comprehensive set of perioperative practice guidelines known as Enhanced Recovery After Surgery (ERAS).

ERAS guidelines consist of 22 preoperative, intraoperative, and postoperative protocols, which have been shown to lead to a reduction in complications and hospital LOS, improvements in cardiopulmonary function, earlier return of bowel function, enhanced mobilization, and earlier resumption of normal activities.4,5,6 

One critical element of all ERAS programs is a protocol known as perioperative goal-directed therapy (PGDT), which helps ensure adequate hydration and maintain euvolemia while avoiding hypervolemia or hypovolemia that can contribute to postoperative complications (See Figure 1).7,8 To achieve optimal fluid balance for the surgical patient, PGDT relies on continuous monitoring of a variety of hemodynamic targets, which can all be derived from minimally invasive cardiac output (CO) monitoring technologies.

PGDT Protocols Contribute to Improved Outcomes and Reduced Length of Stay

By improving cardiovascular function and balancing fluid intake, PGDT helps clinicians maintain adequate oxygen supply perioperatively. The implementation of PGDT protocols guided by continuous hemodynamic monitoring has also been shown to help decrease nausea, vomiting, and incidence of ileus (intestinal obstruction) while allowing patients to take solid food earlier, become more alert, and start walking sooner after surgery, ultimately reducing hospital LOS.7,8

The current evidence base shows that perioperative management, specifically the use of PGDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient’s optimal fluid balance. Meta-analyses of published studies focused on major abdominal surgery show that applying ERAS practice guidelines reduces postoperative complications by up to 50% and hospital LOS by 2.5 days.9,10 

ERAS guidelines were initially created for colorectal surgery but have since been studied and adapted for use across a wide range of medical specialties, including gynecology, thoracic, vascular, pediatric, and orthopedic surgery. Clinical awareness of the impact of ERAS is continuing to grow with help from organizations and societies such as the Enhanced Recovery Partnership (ERP), the Association of Surgeons of Great Britain and Ireland, the French Society of Anesthesiology (SFAR), and the Enhanced Recovery After Surgery Society.11,12,13,14

 

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References

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  2. Schilling, et al. Prioritizing quality improvement in general surgery. J Am Coll Surg. 2008. (n=129,233)
  3. Varadhan KK, Lobo DN, Ljungqvist O. Enhanced Recovery After Surgery: the future of improving surgical care. Crit Care Clin. 2010 Jul;26(3):527–47.
  4. Eskicioglu C, Forbes SS, Aarts MA, et al. Enhanced Recovery After Surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13:2321–9.
  5. Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbolle P, Hendel HW, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function, and body composition. Br J Surg 2002;89(4):446–53.
  6. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009;136(3):842–7.
  7. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia 2009 Nov;103(5):637–46.
  8. Bellamy, et al. Wet, dry, or something else? Editorial. BJA, 2006.
  9. Corcoran T, Rhodes JE, Clarke S, Myles PS, and Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012 Mar;114(3):640–51.
  10. Varandhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clinical Nutrition (Edinburgh, Scotland) 2010 Aug;29(4):434–40.
  11. Mythen et al. Perioperative fluid management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine 2012.
  12. Powell-Tuck, et al. British consensus guidelines on intravenous fluid therapy for adult surgical patients.
  13. Vallet, et al. Guidelines for perioperative haemodynamic optimization. Ann Fr Anesth Reanim 2013.
  14. Gustafsson, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society. World J Surg 2013.
  15. Ramsingh, D.S., Sanghvi, C., Gamboa, J. et al, 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;27:249–257.
  16. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011;342:d3016.