Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists

Abstract

IntroductionSeveral studies have demonstrated that perioperative hemodynamic optimization has the ability to improve postoperative outcome in high-risk surgical patients. All of these studies aimed at optimizing cardiac output and/or oxygen delivery in the perioperative period. We conducted a survey with the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) to assess current hemodynamic management practices in patients undergoing high-risk surgery in Europe and in the United States.MethodsA survey including 33 specific questions was emailed to 2,500 randomly selected active members of the ASA and to active ESA members.ResultsOverall, 368 questionnaires were completed, 57.1% from ASA and 42.9% from ESA members. Cardiac output is monitored by only 34% of ASA and ESA respondents (P = 0.49) while central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents (P < 0.01). Specifically, the pulmonary artery catheter is being used much more frequently in the US than in Europe in the setup of high-risk surgery (85.1% vs. 55.3% respectively, P < 0.001). Clinical experience, blood pressure, central venous pressure, and urine output are the most widely indicators of volume expansion. Finally, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved.ConclusionsIn conclusion, these results point to a considerable gap between the accumulating evidence about the benefits of perioperative hemodynamic optimization and the available technologies that may facilitate its clinical implementation, and clinical practices in both Europe and the United States.

Guiding Goal-Directed Therapy

“…To achieve that goal, as stated by Arthur Guyton in his Textbook of Medical Physiology, one needs ''an adequate perfusion pressure in order to force blood into the capillaries of all organs and an adequate cardiac output (CO) to deliver oxygen and substrates, and to remove carbon dioxide and other metabolic products'' [6,7]. However, while blood pressure monitoring is part of the American Society of Anesthesiologists (ASA) guidelines for basic monitoring [8], CO is rarely monitored, even during high-risk surgery [9]. Fluid therapy in the OR has traditionally been guided by basic static parameters such as heart rate, blood pressure, urine output, peripheral oxygen saturation, and central venous pressure (CVP).…”

Impact of advanced monitoring variables on intraoperative clinical decision-making: an international survey

“…With an alpha error of 0.05, a beta error of 0.80, an ideal physician/expert ratio of 10, we determined that we needed at least 18 experts and 178 physicians. Based on our previous survey [6], it was expected that approximately 15 % of those inquired would answer this survey. Using this estimation, we needed to send the survey to at least 1187 participants.…”

Do we need to monitor cardiac output in spontaneously breathing patients?

“…Moreover, only 30% of the European anaesthesiologists and 5% of the American anaesthesiologists followed a pre-defined optimisation protocol [9]. This survey demonstrates two things: first, we have to provide more convincing evidence that minimal invasive cardiac output monitoring tools embedded in pre-defined optimisation protocols are accurate; and second, we are too slow transferring already available evidence-based practice in daily routine.…”

“…A survey by Cannesson et al, of North American and European anaesthesiologists' intra-operative management of patients undergoing high-risk surgery, revealed that only approximately one third of the respondents in both Europe and the USA used cardiac output monitoring [9]. Moreover, only 30% of the European anaesthesiologists and 5% of the American anaesthesiologists followed a pre-defined optimisation protocol [9].…”