Correspondence  |   March 2018
Goal-directed Hemodynamic Therapy: Neither for Anyone, Neither the Same for Everyone
Author Notes
  • Infanta Leonor University Hospital, Madrid, Spain (J.R.-M.).
  • (Accepted for publication November 27, 2017.)
    (Accepted for publication November 27, 2017.)×
Article Information
Correspondence   |   March 2018
Goal-directed Hemodynamic Therapy: Neither for Anyone, Neither the Same for Everyone
Anesthesiology 3 2018, Vol.128, 682-683. doi:10.1097/ALN.0000000000002050
Anesthesiology 3 2018, Vol.128, 682-683. doi:10.1097/ALN.0000000000002050
Gómez-Izquierdo et al. report the results of a randomized, methodologically flawless clinical trial to analyze the influence of goal-directed hemodynamic therapy in the postoperative ileus within a well-established enhanced recovery protocol.1  This strategy eliminates all the confounding factors that could alter the results of a single intervention. Taking into account that fluid therapy in the control group was based on traditional principles, the conclusion about the goal-directed hemodynamic therapy obtained from this study should be generalizable. Nevertheless, there are certain aspects to consider:
There is scientific interest in removing the goal-directed hemodynamic therapy from the enhanced recovery protocols and questioning the value of its individual components, especially the value of the stroke volume optimization.2  However, intraoperative fluid management outside clinical trials is extremely variable,3  and both an excessively restrictive and an excessively liberal approach lead to an increase in postoperative ileus.4  Moreover, observational studies performed within enhanced recovery protocols repeatedly showed that inadequate fluid therapy was independently associated with postoperative complications.5,6  Although it has been suggested that goal-directed hemodynamic therapy, and especially the stroke volume optimization,2  lead to excessive fluid administration, the systematic review recently published by Michard et al. confirmed otherwise.7  The same outcome has been corroborated by a Gómez-Izquierdo et al. study, in which similar amounts of fluids were given on the day of surgery.1  The administration of vasopressors and inotropics were also similar in both groups. Interestingly, these drugs were administered to both groups without a clinical protocol. Additionally, although the goal-directed hemodynamic therapy group had higher cardiac output, stroke volume, and mean arterial pressure values throughout the surgery, these were not significantly higher compared with the control arm.1  Consequently, using an equivalent amount of fluids and vasopressors, both groups reached the same hemodynamic goals, which could explain the lack of efficacy of the goal-directed hemodynamic therapy in this trial, even with a significantly higher weight balance gain on the first day in the control group. As in previous trials,8  it would have been interesting to analyze which (risk) patients and which hemodynamic values were associated with postoperative complications.
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