Impact of Goal-Directed Perioperative Fluid Management in High-Risk Surgical Procedures

Guidelines for the perioperative administration of fluid
are often based on static hemodynamic targets such as
central venous pressure, and delayed volume status
indexes such as blood pressure, heart rate, capillary
refill, and urine output. Traditional fluid management
protocols also rely heavily on algorithmic estimates
of fluid deficit, intravascular fluid volume status, fluid
loss, and basal fluid requirements to guide perioperative
fluid administration. Such formulaic approaches
lack definitive physiologic endpoints for determining
fluid optimization and fail to address the roles of tissue
oxygenation and end-organ perfusion in achieving
positive long-term patient outcomes. Recent advances
in hemodynamic monitoring have produced sophisticated
dynamic measures of volume status, such as
stroke volume variation and pulse pressure variation,
which may serve as functional indexes for perioperative
fluid administration.
This article reviews randomized controlled trials measuring
the impact of perioperative goal-directed therapy
on outcomes among patients undergoing high-risk
surgical procedures. A broad literature search was conducted,
and 12 studies met the inclusion criteria. Studies
were evaluated for design, population, goal-directed
therapy targets, monitoring devices used, clinical endpoints,
methods, and results. Goal-directed therapy was
associated with decreased hospital stay compared with
the control group (in 7 studies) and reduced number of
postoperative complications (7 studies).
Keywords: Fluid management, goal-directed therapy,
hemodynamic monitoring, optimization, perioperative.
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AUTHORS
Crystal D. Trinooson, CRNA, MS, is a staff nurse anesthetist at Keck Medical
Center of the University of Southern California (USC). She received
her master of science in nurse anesthesiology from the Keck School of
Medicine of USC, Program of Nurse Anesthesia.
Michele E. Gold, CRNA, PhD, is the program director and associate
professor of clinical anesthesiology at Keck School of Medicine of USC,
Program of Nurse Anesthesia.