Decision support and automation in goal-directed fluid therapy: current evidence and remaining questions

Goal-directed fluid therapy (GDFT) individualizes perioperative fluid administration according to dynamic hemodynamic variables, but its implementation remains inconsistent and its impact on patient-centered outcomes is still debated. Decision-support and automated systems have been developed to improve adherence, identify fluid responsiveness more efficiently, and reduce the workload of protocolized hemodynamic management. This structured narrative review summarizes the evidence across four outcome levels: process, surrogate hemodynamic, intermediate physiological, and patient-centered clinical. The most consistent evidence concerns process improvement: decision support increases protocol adherence and improves the proportion of fluid challenges that achieve a predefined stroke volume response, largely on non-randomized evidence. Improvements in surrogate hemodynamic control have also been reported, and selected randomized trials suggest favorable effects on microcirculatory flow and lactate. These findings should not be interpreted as evidence of clinical benefit. Fluid responsiveness does not necessarily indicate a need for fluid administration, and most available studies remain small, single-center, or focused on surrogate outcomes. Evidence that these systems improve postoperative complications, acute kidney injury, length of stay, or mortality is currently lacking. Ongoing multicenter trials should address this gap. Decision support appears to improve how perioperative fluids are administered, but whether it improves what ultimately happens to patients remains unresolved.