You may have more complications than you think.

Variability in volume administration suggests patients aren’t being managed in the optimal volume range – a contributing factor to post-surgical complications. 2,3

Start here. Know more about your true complication rate. Understand how controlling variability and keeping patients in the optimal volume range can help reduce post-surgical complications.

You can take action now to reduce complications.

You may avoid a number of preventable post-surgical complications by maintaining your patient in the optimal volume range through Perioperative Goal-Directed Therapy (PGDT) protocols which utilize dynamic and flow-based hemodynamic parameters. 1,4,7,17,18

Edwards' Enhanced Surgical Recovery Program can help you implement PGDT.

The 4-step process can help your hospital implement evidence-based Perioperative Goal-Directed Therapy (PGDT) in your moderate and high-risk surgery procedures to reduce post-surgical complications, 2,5,6 associated costs 1,7,8 and standardize care.

See what you can do right now to impact post-surgical complications by controlling variability in volume administration:

Is variability in volume administration raising your complication rate?

Complications from excessive and insufficient volume administration. 2,3

Both hypo- and hypervolemia may deleteriously affect organ function. Are you consistently maintaining your patients in the optimal volume range? Or is there inexplicable variability in volume administration by procedure? By surgical team?

Identifying variability in volume administration is action you can take now to start reducing your complication rate. Determine if volume administration is consistent across the same procedure, or if volume administration levels vary from clinician to clinician. To start now, contact us

volume administration graph


Complications have a human cost.

Independent of preoperative patient risk, the occurrence of even a single post-surgical complication within 30 days reduced median patient survival by 69%. 9

The most important determinant of post-surgical survival was the occurrence of any complication within 30 days post-surgery. 9

Review the clinical bulletin


Complications are not exceptions.

Complications occur in 25% of moderate to high-risk surgeries. 4

Review the clinical study 4


You can impact variability.

You can help reduce post-surgical complications by maintaining patients in the optimal volume range using dynamic and flow-based hemodynamic parameters to guide volume administration. 1,4,7,18,17

Excessive volume administration: 2,3

  • Pulmonary edema, prolonged mechanical ventilation 1,17
  • GI dysfunction (abdominal compartment
    syndrome, ileus, anastomotic leak) 18
  • Hemodilution and coagulopathy *

Insufficient volume administration: 2,3

  • Low preload, low cardiac output, low BP, low perfusion 2
  • Arrhythmia (hypovolemia) 2
  • GI dysfunction (postoperative ileus, PONV, upper GI bleeding, anastomotic leak 18
  • Infectious complication (tissue hypoperfusion) 2
  • Acute renal insufficiency or failure 2

Volume administration variability and the impact on morbidity rates are often underestimated by clinicians when not measured from objective data.

The odds of patients developing at least one post-surgical complication increase with co-morbidities (patient risk) and the complexity and duration of the surgical procedure (procedure risk). 4,20

Estimate your potential reduction in post-surgical complications

See the risks by:

Complication rates depend on the surgical procedure10

ProcedureMorbidity rate %
Esophagectomy 55.1
Pelvic exenteration 45.0
Pancreatectomy 34.9
Colectomy 28.9
Gastrectomy 28.7
Liver resection 27

Review the clinical study 10

Complication rates depend on the patient11

Risk factorOdd Ratio
ASA 4/5 VS ½ 1.9
ASA 3 VS ½ 1.5
Dyspnea at rest vs. none 1.4
History of COPD 1.3
Dyspnea with minimal exertion vs. none 1.2

Review the clinical study 11

You can take action now to reduce complications

by controlling volume administration variability in moderate to high-risk surgeries.

Dynamic and flow-based parameters are shown to be more informative in determining fluid responsiveness than conventional,
pressure-based parameters. 12

Perioperative Goal-Directed Therapy (PGDT) is a clinician-directed treatment protocol which utilizes key hemodynamic parameters to help guide optimal volume administration and support individualized patient care.


A large body of evidence shows clinical and economic benefits of hemodynamic optimization through PGDT.

Randomized Controlled Trials

Meta-Analyses

30+ Randomized Controlled Trials and 14+ Meta-Analyses have demonstrated clinical benefits of hemodynamic optimization over standard volume management, including reduction of avoidable and costly complications across a wide range of moderate to high-risk surgical populations. 5,6,13-19

Contact us to review the evidence

Evaluate clinical evidence supporting Perioperative Goal-Directed Therapy (PGDT)

30+ Randomized Controlled Trials demonstrate benefit

More than 3,000 patients have been enrolled in these 32 positive RCTs.

#Title, Author, and YearMain Benefits
1 Individually optimized hemodynamic therapy reduces complications and length of stay in the Intensive Care Unit. Goepfert 2013 Morbidity
2 Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Salzwedel 2013 Morbidity
Hospital LOS
3 Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Zhang 2013 Morbidity
4 Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. Zheng 2013 Morbidity
Hospital LOS
5 Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Bisgaard 2012 Morbidity
6 Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. Ramsingh 2012 Morbidity
Hospital LOS
7 Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. Scheeren 2012 Morbidity
8 Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Cecconi 2011 Morbidity
9 A double-blind randomized controlled clinical trial to assess the effect of doppler optimized intraoperative fluid management on outcome following radical cystectomy. Pillai 2011 Morbidity
10 Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Benes 2010 Morbidity
11 Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Jhanji 2010 Morbidity
12 Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Mayer 2009 Morbidity
Hospital LOS
13 Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Chytra 2007 Morbidity
Hospital LOS
14 Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Donati 2007 Morbidity
Hospital LOS
15 Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Lopes 2007 Morbidity
Hospital LOS
16 Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Noblett 2006 Morbidity
Hospital LOS
17 Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Pearse 2005 Morbidity
Hospital LOS
18 Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Wakeling 2005 Morbidity
Hospital LOS
19 Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. McKendry 2004 Hospital LOS
20 Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Conway 2002 Morbidity
21 Goal-directed Intraoperative fluid administration reduces length of hospital stay after major surgery. Gan 2002 Morbidity
Hospital LOS
22 Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Venn 2002 Morbidity
23 Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Lobo 2000 Morbidity
Mortality
(16vs50%)
24 A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Polonen 2000 Morbidity
Hospital LOS
25 Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimization of oxygen delivery. Wilson 1999 Morbidity
Hospital LOS
Cost-savings
26 Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Ueno 1998 Morbidity
27 Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Sinclair 1997 Hospital LOS
28 Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Mythen 1995 Morbidity
Hospital LOS
29 A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk patients. Boyd 1993 Morbidity
Mortality
(6vs22%)
Cost-savings
30 Prospective trial of supranormal values as goals of resuscitation in severe trauma. Fleming 1992 Morbidity
31 Perioperative optimization of cardiovascular hemodynamics improves outcomes in peripheral vascular surgery. Berlauk 1991 Morbidity
32 Prospective trial of supranormal values of survivors as therapeutic goals in high-risk patients. Shoemaker 1988 Morbidity
Mortality
(21vs34%)
Cost-savings

Download full list here

14+ Meta-Analyses confirm benefit

Reduction in Post-Surgical Complications

Reduce 56% : Hamilton et al. Anesth Analg 2011 5

Reduce 23% : Pearse et al. JAMA 2014 6

Reduction in Hospital Length of Stay (LOS)

Reduce 1.95 days : Corcoran et al. Anesth Analg 2012 7

Reduce 1.16 days : Grocott et al. Br J Anaesth 2013 1

Download full list here

Hemodynamic optimization through PGDT is demonstrated to reduce complications, 5,6

Length of Stay (LOS) and associated costs in your moderate to high-risk surgery patients. 1,7

Reduced LOS by 1.16 - 1.95 days

$18,000

Approximate extra cost of treating 1+ complication

Average in U.S.

Estimate your potential cost of complications


Demonstrated value of hemodynamic optimization through PGDT.

ProcedureTitle, Author, and Year
Abdominal Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Salzwedel 2013
Abdominal Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. Zheng 2013
Abdominal Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. Ramsingh 2012
Abdominal Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. Scheeren 2012
Abdominal Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Jhanji 2010
Abdominal Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Mayer 2009
Abdominal and Vascular Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Benes 2010
Bowel Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Noblett 2006
Bowel Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Wakeling 2005
Bowel Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Conway 2002
Cardiac Individually optimized hemodynamic therapy reduces complications and length of stay in the Intensive Care Unit. Goepfert 2013
Cardiac Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Conway 2002
Cardiac Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. McKendry 2004
Cardiac A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Polonen 2000
Cystectomy A double-blind randomized controlled clinical trial to assess the effect of doppler optimized intraoperative fluid management on outcome following radical cystectomy. Pillai 2011
General Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Lopes 2007
General Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Pearse 2005
General Goal-directed Intraoperative fluid administration reduces length of hospital stay after major surgery. Gan 2002
General Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Lobo 2000
General A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk patients. Boyd 1993
General Prospective trial of supranormal values of survivors as therapeutic goals in high-risk patients. Shoemaker 1988
General and Vascular Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Donati 2007
General and Vascular Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimization of oxygen delivery. Wilson 1999
Hepatectomy Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Ueno 1998
Hip Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Cecconi 2011
Hip Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Venn 2002
Hip Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Sinclair 1997
Thoracic Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Zhang 2013
Trauma Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Chytra 2007
Trauma Prospective trial of supranormal values as goals of resuscitation in severe trauma. Fleming 1992
Vascular Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Bisgaard 2012
Vascular Perioperative optimization of cardiovascular hemodynamics improves outcomes in peripheral vascular surgery. Berlauk 1991
Reduction inAverage odd or risk ratio
(confidence interval)
Author
(reference)
Acute kidney injury 0.64 (0.50-0.83)
0.67 (0.46-0.98)
0.71 (0.57-0.90)
Brienza
Corcoran
Grocott
Arrythmias 0.54 (CI: 0.35-0.85) Arulkumaran
Cardiovascular
complications
0.54 (CI: 0.38-0.76) Arulkumaran
Complications 0.45 (CI: 0.34-0.60) Cecconi
Hospital length of stay -2.44 (CI: -4.03 to -0.84)
NA
-2.34 (CI: -2.91 to -1.77)
Aya Bungaard-Nielsen Phan
Ileus NA Bungaard-Nielsen
Minor GI complications 0.29 (0.17-0.50) Giglio
Major GI complications 0.42 (0.27-0.65) Giglio
Mortality 0.67 (0.55-0.82) Gurgel
Mortality Rate 0.61 (0.46-0.81) Poeze
Organ dysfunction 0.62 (0.55-0.70) Gurgel
Postoperative complications 0.33 (CI: 0.15-0.73) Aya
Postoperative morbidity 0.37 (CI: 0.27-0.50) Phan
Post-op nausea & vomiting NA Bungaard-Nielsen
Pneumonia 0.74 (0.57-0.96)
0.71 (0.55-0.92)
Corcoran
Dalfino
Respiratory failure 0.51 (0.28-0.93) Grocott
Surgical site infection 0.58 (0.46-0.74)
0.65 (0.50-0.84)
Dalfino
Grocott
Tissue hypoxia NA Srinivasa
Total morbidity rate NA
0.68 (0.58-0.80)
0.44 (0.35-0.55)
Bungaard-Nielsen Grocott Hamilton
Urinary tract infection 0.44 (0.22-0.88) Dalfino

Advanced hemodynamic monitoring

versus conventional care.

Conventional volume management, based on standard monitoring, including central venous pressure (CVP),
is suboptimal. 21,22 Clinical studies have shown CVP is not able to predict fluid responsiveness 21 and that changes in blood pressure cannot be used to track changes in stroke volume (SV) or in cardiac output (CO) induced by volume expansion. 22

View webinar on hemodynamic management of patients: Taking the guesswork out of the equation


Where do you want to be?

Optimal Volume Range

Hemodynamic optimization through Perioperative Goal-Directed Therapy (PGDT) can help ensure your patient is maintained in the optimal volume range and may help reduce post-surgical complications. 2 To examine individualized therapy for your moderate to high-risk patients.

Complications from excessive and insufficient volume
administration 2,3

Volume load

Frank-Starling relationship between preload and stroke volume (SV)

Frank-Starling relationship between preload and stroke volume (SV)

Maintaining patients in the optimal volume range is key.

Clinical evidence demonstrates that optimal volume management is possible when dynamic parameters are used within a protocol such as PGDT. 2,3,24,25 Both hypo- and hypervolemia may deleteriously affect organ function and lead to post- surgical complications. 2,3

It is important to note, even protocolized treatment requires individualized therapy, as clinicians utilize each patient’s individual Frank-Starling curve toward the goal of maintaining volume administration in the optimal zone. 2


Value of dynamic and flow-based parameters versus conventional care.

In patients at risk of developing complications, hemodynamic optimization using dynamic and flow-based hemodynamic parameters such as Stroke Volume (SV), stroke volume variation (SVV) and cardiac output (CO) may be useful, when used in PGDT, to decrease post-surgical morbidity. 12

Stroke Volume (SV) and cardiac output (CO) are useful to assess the effects of fluid administration. 12

SVV has been shown to have a very high sensitivity and specificity in determining fluid responsiveness when compared to conventional indicators of volume status (HR, MAP, CVP). 26-28

Learn more about:

SV protocol studiesAbdominalBowelCardiacCystectomyGeneralHipTraumaVascular
Bisgaard 2012 x
Scheeren 2012 x
Pillai 2011 x
Jhanji 2010 x
Chytra 2007 x
Noblett 2006 x
Wakeling 2005 x
McKendry 2004 x
Conway 2002 x
Gan 2002 x
Venn 2002 x
Sinclair 1997 x
Mythen 1995 x

Frank-Starling relationship between preload and stroke volume (SV)

Frank-Starling

SVV protocol studiesAbdominalAbdominal and VascularCardiacThoracic
Goepfert 2013 x
Zhang 2013 x
Zheng 2013 x
Ramsingh 2012 x
Scheeren 2012 x
Benes 2010 x
Mayer 2009 x

Mechanical Ventilation 32,33
Currently, literature supports the use of SVV only on patients who are 100% mechanically (control mode) ventilated with tidal volumes of more than 8cc/kg and fixed respiratory rates.

Spontaneous Breathing 32,33
Currently, literature does not support the use of SVV with patients who are spontaneously breathing due to the irregular nature of rate and tidal volumes.

Arrhythmias 32,33
Arrhythmias can dramatically affect SVV values. Thus, the utility of SVV as a guide for volume resuscitation is greatest in absence of arrhythmias.

PEEP 32,33
Increasing levels of positive end expiratory pressure (PEEP) may cause an increase in SVV, the effects of which may be corrected by additional volume resuscitation if warranted.

Vascular Tone 32,33
The effects of vasodilatation therapy may increase SVV and should be considered before treatment with additional volume.

DO 2 protocol studiesAbdominalGeneralGeneral and VascularHepatectomyHipTraumaVascular
Bisgaard 2012 x
Cecconi 2011 x
Jhanji 2010 x
Pearse 2005 x
Lobo 2000 x
Wilson 1999 x
Ueno 1998 x
Boyd 1993 x
Fleming 1992 x
Shoemaker 1988 x

PGDT can be implemented in a single procedure or as part of a larger initiative within ERAS, ERP, GIFTSUP, NSQIP or Perioperative Surgical Home.

You can implement Perioperative Goal-Directed Therapy (PGDT) in a single procedure, to assess impact on complication reduction. PGDT can also be implemented as part of a larger initiative, to standardize the patient care you deliver in your OR.


What can you do right now to impact post-surgical complications.

Enhanced Surgical Recovery program

This program can help you implement Perioperative Goal-Directed Therapy (PGDT) today in your moderate to high-risk surgeries. Start here. Start now.

The Edwards’ Enhanced Surgical Recovery Program is a 4-step process designed to help your surgical team implement hemodynamic optimization through PGDT in your hospital.

  • Select surgical procedure(s)
  • Assess current morbidity rate and/or LOS
  • Estimate potential clinical and economic benefits of PGDT
  • Build core team
  • Choose PGDT treatment protocol
  • Choose a hemodynamic monitoring platform
  • Train and develop competence
  • Establish PGDT as new SOP and add to checklist
  • Analyze morbidity rates and/or LOS
  • Measure clinical and economic outcome benefits

When evidence inspires action.

Your vision for reducing patient complications begins with an evidence-based choice to implement PGDT. Edwards’ Enhanced Surgical Recovery Program process can help you implement and sustain compliance of PGDT.

What your peers are saying.

If you would like to join our community (coming soon), please sign up via the link below.


PGDT Protocols

*Data on file

References:

  1. Grocott et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review. Br J Anaesth 2013
  2. Bellamy MC. Wet, dry or something else? Br J Anaesth 2006;97(6):755-757
  3. Cannesson M. Arterial pressure variation and goal-directed fluid therapy. J Cardiothorac Vasc Anesth 2010;24(3):487-497
  4. Ghaferi, A. et al. Variation in Hospital Mortality Associated with Inpatient Surgery. N Engl J Med 2009
  5. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high risk surgical patients. Anesth Analg 2011; 112: 1392–402
  6. Pearse M, Harrison D, MacDonald N, et al. For the OPTIMISE Study Group. Effect of a Perioperative, Cardiac Output-Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastro-Intestinal Surgery: A Randomized Clinical Trial and Systemic Review. JAMA 2014 doi:10.1001/jama.2014.5305.
  7. Corcoran et al. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012
  8. Brienza N, Giglio MT, Marucci M, Fiore T. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med 2009; 37: 2079–90
  9. Khuri SF et al. Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Ann Surg 2005
  10. Schilling et al. Prioritizing quality improvement in general surgery. J Am Coll Surg. 2008;207:698-704.
  11. Khuri et al Successful Implementation of the Department of Veterans Affairs’ NSQIP in the Private Sector: The Patient Safety in Surgery Study. Ann Surg 2008
  12. Michard & Biais. Rational fluid management: dissecting facts from fiction. Br J Anaesth 2012
  13. Arkilic, C. F., Taguchi, A., Sharma, N., Ratnaraj, J., Sessler, D. I., & Read, T. E. Supplemental perioperative fluid administration increases tissue oxygen pressure. Surgery,133: 49-55. (2003)
  14. Aya H. D., Cecconi M, Hamilton M, and Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. British Journal of Anaesthesia, doi:10.1093/bja/aet020
  15. Brienza N, Giglio MT, Marucci M, Fiore T. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med 2009; 37: 2079–90
  16. Cecconi M, Corredor C, Arulkumaran N, Abuella G, Ball J, Grounds R.M., Hamilton M, and Rhodes A. Clinical review: Goal-directed therapy - what is the evidence in surgical patients? The effect on different risk groups. Critical Care 2013, 17:209
  17. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N. Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 2011; 15: R154
  18. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2009; 103: 637–46
  19. Phan T.D., MBBS, FRCA, Ismail H., MD, FFARCS(I), FRCA FANZCA, Heriot A,G, MD, FRCS, FRACS, KwokMHo, MPH, FANZCA, FJFICM. Improving Perioperative Outcomes: Fluid Optimization with the Esophageal Doppler Monitor, a Metaanalysis and Review. American College of Surgeons doi:10.1016/j.jamcollsurg.2008.08.007
  20. Boltz, et al. Synergistic Implications of Multiple Postoperative Outcomes. Am J Med Qual 2012
  21. Marik & Cavallazzi. Does central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013
  22. Le Manach et al. Can changes in arterial pressure be used to detect changes in cardiac output during volume expansion in the perioperative period? Anesthesiology 2013
  23. Bennett D. Arterial Pressure: A Personal View. Functional Hemodynamic Monitoring. Berlin: Springer-Verlag, 2005. ISBN: 3-540-22349-5
  24. Berkenstadt H, et al. Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg 2001;92:984-989.
  25. Michard F. changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103:419-428.
  26. Gan TJ: Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery. Anesthesiology 2002, 820-826 29.
  27. O’Leary MJ: Preventing renal failure in the critically ill. BMJ 2001, 1437-1439
  28. Pearse. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. Critical Care 2005, R687-693
  29. Michard & Biais. Rational fluid management: dissecting facts from fiction. Br J Anaesth 2012
  30. Pearse. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. Critical Care 2005, R687-693
  31. Lawson et al. Association Between Occurrence of a Postoperative Complication and Readmission. Implications for Quality Improvement and Cost Savings. Ann Surg 2013
  32. Michard F, Volume management using dynamic parameters: the good, the bad, and the ugly. Chest 2005; 128:1902–1903
  33. Perel et al. Bench-to-bedside review: Functional hemodynamics during surgery – should it be used for all high-risk cases? Critical Care 2013; 17:203

All information provided by Edwards Lifesciences is gathered from third party sources and is presented for informational purposes only. This information is not intended to describe, recommend, or suggest any use, feature, or benefit of any Edwards product and does not constitute reimbursement, medical or legal advice. Edwards makes no representation or warranty regarding his information or its completeness, accuracy or timeliness. It is not intended to make a recommendation regarding clinical practice. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently; service providers are responsible for all decisions relating to clinical serves, coding and reimbursement submissions. Accordingly, Edwards strongly recommends consultation with payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

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