Intraoperative Hemodynamics: Additional Resources-Goal-directed therapy: what is the goal again? Article

Goal-directed therapy: what is the goal again? Article

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This article discusses the current state and development of goal-directed therapy (GDT) in perioperative medicine, focusing on intraoperative hypotension (IOH) and hemodynamic instability. The rise in awareness and management strategies in combating IOH is essential due to its association with negative postoperative outcomes, including acute kidney injury (AKI) and myocardial injury. Traditional monitoring methods are considered outdated; hence, new GDT strategies incorporating advanced hemodynamic monitors are recommended to improve outcomes by optimizing preload, contractility, and afterload management.<br /><br />Recent literature strongly supports the development and use of GDT protocols, which have been proven to decrease complications such as surgical site infections and postoperative nausea and vomiting. The review examines the historical challenges of implementing GDT due to insufficient evidence and a lack of advanced hemodynamic monitoring, and suggests that incorporating these protocols can offer a targeted approach.<br /><br />Despite promising improvements with GDT, challenges remain, including appropriate protocol compliance and understanding by clinicians, particularly in differentiating this from outdated strategies like goal-directed fluid therapy (GDFT) that showed mixed results. The ability of advanced monitors to incorporate software such as the Hypotension Prediction Index (HPI) highlights the improvements in predicting hypotensive events.<br /><br />Cost considerations and logistical challenges with implementing GDT universally are noted, but it is emphasized that moderate to high-risk patients and surgeries can significantly benefit from these advanced strategies. Furthermore, ongoing education and targeted interventions are advised to propagate these improved protocols to enhance patient safety and reduce perioperative complications. Lastly, emerging closed-loop systems and technology guided by artificial intelligence are discussed as the future direction for improving intraoperative hemodynamic management, potentially paving the way for automatic and continuous adjustments in patient monitoring and medication administration.

Keywords

goal-directed therapy

perioperative medicine

intraoperative hypotension

hemodynamic instability

acute kidney injury

advanced hemodynamic monitors

Hypotension Prediction Index

protocol compliance

closed-loop systems

artificial intelligence