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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