Perioperative Goal-Directed Hemodynamic Therapy: From Invasive Monitoring To Automated Physiological Closed-Loop Systems

Perioperative goal-directed hemodynamic therapy (GDHT) has evolved from invasive “supra-physiological” maximization of oxygen delivery into minimally and non-invasively guided automated stroke volume optimization. Throughout this evolution, investigators have simultaneously developed novel monitors, updated strategies, and automated technologies to aid them in GDHT implementation. In particular, closed-loop systems have been created to both increase GDHT compliance and decrease physician workload. Currently, these automated systems offer an elegant approach to help the clinician optimize cardiac output and end-organ perfusion during the perioperative period. Most notably, automated fluid optimization guided by dynamic parameters of fluid responsiveness has shown its feasibility, safety, and impact. Making the leap into fully automated GDHT has been accomplished on a small scale, but there are considerable challenges that must be surpassed before integrating all hemodynamic components into an automated system during general anesthesia. In this review we will discuss the potential future of automated GDHT by covering the key events that paved the way from initially complex and time consuming approaches to simple yet effective hands-free strategies.