[From Goal-Directed Therapy to Personalized Hemodynamic Management]

Area of Science:

• Anesthesiology
• Critical Care Medicine
• Cardiovascular Physiology

Background:

• Traditional goal-directed therapy (GDT) aims for adequate tissue oxygenation via hemodynamic optimization.
• Cardiac output, influenced by preload, afterload, and contractility, is key; static preload measures lack predictive value for fluid responsiveness.

Purpose of the Study:

• To evaluate the shift from standardized GDT to personalized hemodynamic management in perioperative care.
• To explore the efficacy of individualized hemodynamic targets versus fixed algorithms.

Main Methods:

• Review of randomized trials (OPTIMISE, iPEGASUS, INPRESS, TAPIR, IMPROVE) comparing GDT and personalized approaches.
• Analysis of hemodynamic monitoring techniques, including static and dynamic indices (e.g., central venous pressure, stroke volume variation, pulse pressure variation).

Main Results:

• Large trials of standardized GDT algorithms did not consistently show outcome benefits.
• Personalized hemodynamic management, targeting patient-specific values (e.g., mean arterial pressure, cardiac index), shows mixed results, with some studies suggesting advantages and others finding no significant differences.
• Current guidelines recommend advanced monitoring for high-risk patients but lack universal target values.

Conclusions:

• A personalized, cardiac index-guided approach integrating clinical and metabolic indicators is promising.
• Avoid rigid algorithms and indiscriminate inotrope use; clinical judgment is paramount for safe, patient-centered perioperative care.