Perioperative GoalDirected Therapy

Protocol Summary

APPROVED

Evidence-based, perioperative Goal-Directed Therapy (GDT) protocols.

Several single centre randomized controlled trials, meta-analysis and quality
improvement programs have shown that perioperative GDT decreases postoperative
complications and hospital length of stay when compared to standard fluid
management.1-5
This summary describes the three main perioperative GDT strategies which have been
successfully used to decrease postoperative morbidity and length of stay:
- Stroke Volume (SV) optimization with fluid
- Oxygen Delivery Index (iDO2) optimization with fluid and inotropes
- Pulse Pressure Variation (PPV) or Stroke Volume Variation (SVV)
optimization with fluid
This summary does not recommend the use of any specific medical device, and the
choice of the treatment protocol is left at the discretion of the anesthesiologist in charge.

APPROVED

SV Protocol

Overview
Using the SV protocol consists in giving successive small (200-250 ml) fluid boluses until
the SV reaches a plateau value (the plateau of the Frank-Starling relationship).
Many single centre randomized controlled trials6-12 and a multicentre quality
improvement program,13 showing a decrease in post-operative complications or hospital
length of stay in the perioperative GDT group, were based on this protocol.
This protocol is now officially recommended by the National Institute for Clinical
Excellence in the UK and by the French Society of Anesthesiology & Intensive Care (SFAR).

Measure SV

ve small
plateau value

s6-12 and a
ng a decrease
of stay in the
ocol.

e National
the French
).

YES

200-250 ml fluid over 5-10 minutes

SV increase >10%?

NO

YES

Monitor SV for clinical signs of fluid loss

NO

SV reduction >10%

From Kuper et al.13

Abbreviation: SV: Stroke Volume.
From Kuper et al.13
Abbreviation: SV: Stroke Volume.

APPROVED

iDO2 Protocol

Overview
Using a iDO2 optimization protocol consists first in optimizing SV with fluid, as described
in the SV protocol.
Once SV has been optimized with fluid, iDO2 is calculated. If iDO2 is <600 ml/min/m2 an
inotrope (dobutamine or dopexamine) is introduced to achieve the iDO2 goal of 600 ml/
min/m2.
Inotropes should not be used or must be discontinued (if already introduced) in case of
tachycardia, cardiac arrhythmia or ischemia.
Several single centre randomized controlled trials, showing a decrease in post-operative
complications or hospital length of stay in the perioperative GDT group, were based on
this protocol.14-19

Keep:
SaO2 >95%
Hb >8 mg/dl

HR <100 bpm
MAP between 60 and 100 mm Hg

Achieve SV max and then target DO2I to 600 ml/min*m2

O Protocol

timizing
2

250 ml HES bolus

Keep:
SaO2 >95%
Hb >8 mg/dl

ated.
Increase of SV >10% or
view
or
blood loss >250 ml
during fluid challenge
al
a iDO2 optimization protocol consists first in optimizing
NO
h fluid, as described in the SV protocol.

d (if already
stable
SV
been optimized with fluid, iDO2 isSVcalculated.
or has
ischemia.
>20 min
2
2 is <600 ml/min/m an inotrope (dobutamine or
amine) is introduced to achieve the iDOYES
showing
2 goal
2
ml/min/m
.
pital
length

YES
Achieve SV max and then target DO2I to 600 ml/min*m2
250 ml HES bolus

NO NO

Increase of SV >10% or
blood loss >250 ml
during fluid challenge

DO2I
NO

al single centre randomized controlled trials, showing

ease in post-operative complications or hospital length
YES
y in the perioperative GDT group, were based
on this
14-19
ol.

SV stable
Dobutamine:
Increase by 3 mcg/kg*min
Decrease or STOP if
HR >100 bpm
or signs of cardiac ischemia

Check every 10 minutes

If DO2I falls below 600 ml/min*m2, restart algorithm

From From
Cecconi Cecconi
et al.19

YES

NO

See oxygen delivery

d on this
pes should not be used or must be discontinued (if already
uced) in case of tachycardia, cardiac arrhythmia or ischemia.
600 ml/min*m2

HR <100 bpm
MAP between 60 and 100 mm Hg

>20 min

NO NO

YES

See oxygen delivery

DO2I
600 ml/min*m2

NO

et al.19

Abbreviations: DO2I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl

YES
Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; SaO2: Oxygen Saturation;
Abbreviations:
DO
I:
Oxygen
Delivery
Index;
Hb:
Hemoglobin;
SV: Stroke Volume.
2

Dobutamine:
Increase by 3 mcg/kg*min
Decrease or STOP if
HR >100 bpm
or signs of cardiac ischemia

HES: Hydroxyethyl
:
Oxygen
Saturation;
Starch; HR: Heart Rate; MAP: Mean Arterial
Pressure;
SaO
Check every 10 minutes
2
If DO I falls below 600 ml/min*m , restart algorithm
SV: Stroke Volume.
2

From Cecconi et al.19

Abbreviations: DO2I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl
Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; SaO2: Oxygen Saturation;
SV: Stroke Volume.

APPROVED

PPV/SVV Protocol

Overview
Using a PPV/SVV optimization protocol consists in giving fluid to maintain these dynamic
parameters below a predetermined cutoff value.
Several single centre randomized controlled trials, showing a decrease in post-operative
complications or hospital length of stay in the perioperative GDT group, were based on
this protocol.20-24

GDT Group
(ventilate 8 ml/kg)

n giving fluid
edetermined

showing a
tal length of
ed on this

SVV >12%

NO

Monitor SVV and CO

YES

250 ml Albumin bolus

(may repeat to max of 20 ml/kg)

NO

NO

SVV >12%

>20 ml/kg Albumin?

YES

Crystalloid 3:1 replacement

(consider PRBCs, monitor ABGs)

YES

From Ramsingh et al.24

From Ramsingh et al.24

Abbreviations:
Arterial
Gases;
Cardiac Output; P-POSSUM:
Abbreviations:
ABGs: ABGs:
Arterial Blood
Gases; Blood
CO: Cardiac
Output;CO:
P-POSSUM:
Portsmouth
Physiologic
and Operative
Severity
Score for
the Enumeration
of for the Enumeration of
Portsmouth
Physiologic
and
Operative
Severity
Score
Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke
Volume
Variation.
Mortality
and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke
Volume Variation.

APPROVED

References

Meta-analysis
1.
2.
3.
4.
5.

Brienza et al. Crit Care Med 2009

Giglio et al. Br J Anaesth 2009
Dalfino et al. Crit Care 2011
Hamilton et al. Anesth Analg 2011
Corcoran et al. Anesth Analg 2012

SV protocol studies
6. Sinclair et al. BMJ 1997
7. Venn et al. Br J Anaesth 2002
8. Gan et al. Anesthesiology 2002
9. Conway et al. Anaesthesia 2002
10. Wakeling et al. Br J Anaesth 2005
11. Noblett et al. Br J Surg 2006
12. Pillai et al. J Urology 2011
13. Kuper et al. BMJ 2011

iDO2 protocol studies

14. Shoemaker et al. Chest 1988

15. Boyd et al. JAMA 1993
16. Wilson et al. BMJ 1999
17. Lobo et al. Crit Care Med 2000
18. Pearse et al. Crit Care 2005
19. Cecconi et al. Crit Care 2011

PPV/SVV protocol studies

20. Lopes et al. Crit Care 2007
21. Benes et al. Crit Care 2010
22. Ping et al. Hepatogastroenterology 2012
23. Zang et al. Clinics 2012
24. Ramsingh et al. J Clin Monit Comput 2012

APPROVED

Evidence-based, perioperative Goal-Directed

Therapy (GDT) protocols.
Several single centre randomized controlled trials, meta-analysis and
quality improvement programs have shown that perioperative GDT
decreases postoperative complications and hospital length of stay
when compared to standard fluid management.1-5
This summary describes the three main perioperative GDT
strategies which have been successfully used to decrease
postoperative morbidity and length of stay:
- Stroke Volume (SV) optimization with fluid
- Oxygen Delivery Index (iDO2) optimization with
fluid and inotropes
- Pulse Pressure Variation (PPV) or Stroke Volume
Variation (SVV) optimization with fluid
This summary does not recommend the use of any specific
medical device, and the choice of the treatment protocol is left
at the discretion of the anesthesiologist in charge.

APPROVED