Perioperative goal-directed hemodynamic therapy aims at optimizing global hemodynamics during the perioperative period by titrating fluids, vasopressors, and/or inotropes to reach predefined hemodynamic goals. Current evidence indicates that treating patients according to perioperative goal-directed hemodynamic therapy protocols reduces morbidity and mortality, particularly in patients having high-risk surgery. However, its adoption into clinical practice is still weak.

This strategy has also improved greatly over the past 40 years. Monitoring technology has evolved to enable very invasive devices to be replaced by much less invasive (and even totally non-invasive) equipment. Simultaneously, our whole approach to monitoring has shifted from using a few static, single measures to a functional, dynamic, and multivariable approach. Finally, we are moving from standard, protocolized hemodynamic strategies to a more personalized approach to ensure appropriate management of each patient. For this purpose, closed-loop systems are an appealing added value to ensure that therapies are delivered appropriately to all patients.

Despite major advancements in surgery and anesthesia, the risk of mortality following cardiac and non-cardiac surgery remains high and is frequently associated with perioperative organ dysfunction. Neurological derangements range from brief postoperative delirium to postoperative cognitive dysfunction to perioperative stroke with associated impact on quality of life and mortality. Major adverse cardiac events and arrhythmias play a significant role in adverse clinical outcomes following all surgical procedures. GI dysfunction represents one of the more common complications following surgery, while hepatic dysfunction remains infrequent but largely uninvestigated. Perioperative endocrine dysfunction consists of both hyperglycemia and hypoglycemia, both of which can have significant effects on perioperative course and recovery. Postoperative pulmonary complications remain one of the more common perioperative complications depending on patient-related and surgical factors. Perioperative acute kidney injury is common in the perioperative setting. This chapter briefly explores the impact of cardiac and non-cardiac surgery on individual organ systems and some of the effects of these perturbations on perioperative morbidity and mortality.

Systems for describing congenital cardiac malformations have frequently been based on embryological concepts and theories. As useful as these systems have been, they have often had the effect of confusing the clinician, rather than clarifying the basic anatomy of a given lesion. As far as the surgeon is concerned, the essence of a particular malformation lies not in its presumed morphogenesis, but in the underlying anatomy. An effective system for describing this anatomy must be based on the morphology as it is observed. At the same time, it must be capable of accounting for all congenital cardiac conditions, even those that, as yet, might not have been encountered. To be useful clinically, the system must be not only broad and accurate, but also clear and consistent. The terminology used, therefore, should be unambiguous. It should be as simple as possible. The sequential segmental approach provides such a system.1

In spite of numerous studies about fluid management and hemodynamic monitoring in thoracic anesthesia, the heterogeneity of the results has led to the fact that there is still no strong evidence on this topic. The historical recommendation of restricted fluid management has been replaced by normovolemia, but there are still many unsolved problems. Most importantly, not only the amount of the fluid, but also its indication, timing, the addition of a vasopressor and/or inotrope, its dosage, protection of glycocalyx layer and several other parameters play a role in the relationship of fluid strategy and overall outcome. Regarding the postoperative outcome, fluid management in its extensive form should be considered as an important part of a strategy.

Goal-directed therapy (GDT) is associated with certain limitations, mainly because “open thorax” can affect the cardiopulmonary interaction. Still, it can give objective hints to achieve stable hemodynamics, protection of glycocalyx, prevention of pulmonary edema and avoidance of postoperative organ injury.

The main aim of a perioperative fluid therapy is to maintain or normalize the patient’s homeostasis. Small children have higher fluid volumes, metabolic rates and fluid needs than adults. Therefore, short perioperative fasting periods (formula milk 4 hours, breast milk 3 hours, clear fluids 1 hour) are important to avoid iatrogenic dehydration, hypotension, ketoacidosis and uncooperative behavior. Balanced electrolyte solutions with 1–2.5% glucose are favored for intraoperative maintenance infusion. Glucose- free balanced electrolyte solutions should then be added as needed to replace intraoperative fluid deficits or minor blood loss. Gelatin solutions or hydroxyethyl starch are useful in hemodynamically unstable patients or those with major blood loss, especially when crystalloids alone are not effective and blood products are not indicated. The monitoring should focus on the maintenance or restoration of a stable tissue perfusion.In nonsurgical or postoperative children, balanced electrolyte solutions should be used instead of hypotonic solutions, both with 5% glucose, as recent clinical studies and reviews showed a lower incidence of hyponatremia.

Organ dysfunction often occurs in the perioperative setting and in sepsis. Alterations in systemic hemodynamics may play a role, but even when these are within therapeutic goals, organ dysfunction may still occur. Microcirculatory alterations, a key determinant of tissue perfusion and of mitochondrial dysfunction, may play a role in the development of organ dysfunction. In this chapter, we discuss the evidence for alterations in microcirculatory and mitochondrial functions and their relevance, in circulatory failure and in the perioperative setting.

Fluid administration in the operating room is a cornerstone of perioperative hemodynamic optimization Functional assessment of fluid response aims at evaluating the hemodynamic changes associated with the interplay between heart and lungs on flow and pressure parameters, with the purpose of tailoring fluid administration to predefined physiological targets and specific patient needs. In patients under mechanical ventilation, the fixed and repetitive inspiratory and expiratory pressure changes affect right ventricle’s preload, afterload and, hence, stroke volume, finally determining the changes on the dynamic indices of fluid responsiveness, such as pulse pressure variation and stroke volume variation. These changes may even be enhanced by the application of maneuvers that may potentiate heart–lung interactions, the so-called functional hemodynamic tests. This chapter analyzes methods and variables to assess fluid responsiveness in the perioperative setting, how to perform functional hemodynamic tests and how to interpret them considering potential confounding factors and limitations.

Restoring the microcirculation and tissue oxygenation is the ultimate goal of hemodynamic resuscitation. Hand-held vital microscopes enable direct visualization of the sublingual microcirculation of RBC flow through the capillaries and the density of perfused capillaries. The association between alterations of sublingual microvascular parameters and patient outcomes during shock validates that these parameters are clinically relevant for the assessment of patients in shock. Assessment of sublingual microvascular perfusion parameters at the bedside is only conceivable if hand-held vital microscopes are easy to use and if the analysis of the images can be done in real time. Studies have shown that real-time point-of-care assessment by visual inspection of microcirculatory properties at the bedside shows good agreement with off-line evaluation of the microcirculation. The development of automatic microcirculatory analysis software systems will be the next step to obtain high-performance quantitative analysis at the patient’s bedside and for caregivers to adhere to this monitoring technique. Lastly, the impact of sublingual microcirculation on patient outcome remains to be proven during the perioperative setting.

Fluid management is a complex yet fundamental aspect in the care of patients undergoing cardiac surgery, and different to that for patients in general intensive care and other surgical specialties. The underlying cardiac disease and impaired cardiovascular reserve of patients in this high-risk population means that significant hemodynamic alterations can impact adversely on their short- and long-term outcomes. Volume replacement during and after cardiac surgery is not influenced by filling pressures in isolation, but requires a critical balance with vasomotor tone, fluid responsiveness and cardiac contractility. The timing, type, volume and monitoring of fluid administration are important considerations. So far, the evidence does not favor a specific choice of fluid therapy and none of the available fluid therapies has been assessed for comparative endothelial homeostatic potential. This leaves a significant knowledge gap and an incentive for researchers, clinicians and industry to design and test safer and more efficacious choices for clinical use.

The coronary circulation consists of the coronary arteries and veins, together with the lymphatics of the heart. Since the lymphatics, apart from the thoracic duct, are of very limited significance to operative anatomy, they will not be discussed at any length in this chapter. The veins, relatively speaking, are similarly of less interest. In this chapter, therefore, we concentrate on those anatomical aspects of arterial distribution that are pertinent to the surgeon, limiting ourselves to brief discussions of the cardiac venous drainage and the cardiac lymphatics.

In the USA, injury is the leading cause of death among individuals between the ages of 1 and 44 years, and the third leading cause of death overall. Approximately 20 to 40% of trauma deaths occurring after hospital admission are related to massive hemorrhage and are potentially preventable with rapid hemorrhage control and improved resuscitation techniques. Over the past decade, the treatment of this population has transitioned into a damage control strategy with the development of resuscitation strategies that emphasize permissive hypotension, limited crystalloid administration, early balanced blood product transfusion, and rapid hemorrhage control. This resuscitation approach initially attempts to replicate whole blood transfusion, utilizing an empiric 1:1:1 ratio of plasma:platelets:red blood cells, and then transitions, when bleeding slows, to a goal-directed approach to reverse coagulopathy based on viscoelastic assays. Traditional resuscitation strategies with crystalloid fluids are appropriate for the minimally injured patient who presents without shock or ongoing bleeding. This chapter focuses on the assessment and resuscitation of seriously injured trauma patients who present with ongoing blood loss and hemorrhagic shock.

Because of the low nurse-to-patient ratio on surgical wards and the intermittent nature of blood pressure spot-checks, there is increasing evidence that hemodynamic deterioration may be overlooked for hours. Several non-obtrusive systems have recently been developed to monitor blood pressure continuously and non-invasively. They may help to free nurses from time-consuming and repetitive tasks and to detect clinical deterioration earlier, decrease the number of rapid response team interventions, ICU admissions, cardiac arrests, and deaths. From a sensor standpoint, wireless wearables are emerging as the ideal solution for monitoring on the wards because they are patient friendly and they enable early mobilization, which is a key element of enhanced recovery programs. Clinical studies are needed to clarify what are the best strategies to effectively respond to early deterioration alerts. Such strategies may include the quick assessment of cardiac function with a POCUS device. Future trials will also have to investigate what is the impact on key outcome variables such as ICU admission and hospital length of stay, and which patients may benefit the most from recent mobile monitoring and ultrasound innovations.

In perioperative medicine, optimal fluid management during and after the surgery is often debated. However, it is clear that poor fluid management and periods of hypotension are closely linked to worse outcomes. Both excessively liberal and restrictive fluid regimens lead to harm. Goal-directed pathways, where fluid or vasopressor administration targets a predefined hemodynamic parameter, are occasionally used. However, these require advanced hemodynamic monitoring, have limited evidence to support them and are often too complex, resulting in unsuccessful implementation.

Artificial intelligence (AI) focuses on machines capable of replicating human decision making. Within AI, predictive analytics use existing data to predict future events. These predictions can be integrated into open- or closed-loop systems, guiding fluid or vasopressor administration and reducing the clinician’s cognitive burden. This chapter provides an introduction to predictive analytics in perioperative fluid management, an overview of published literature, andsuggestions as to how the technology might develop in the future.

Crystalloid electrolyte solutions include isotonic saline, Ringer’s lactate, Ringer’s acetate, and Plasma-Lyte. In the perioperative period these fluids are used to compensate for anesthesia-induced vasodilation, small to moderate blood losses and urinary excretion. Although evaporation consists of electrolyte-free water, such fluid losses are relatively small during short-term surgery.

These fluids expand the plasma volume to a lesser degree than colloid fluids as they hydrate both the plasma and the interstitial fluid space. However, the distribution to the interstitial fluid space takes 25–30 min to be completed, likely due to the restriction of fluid movement by the finer filaments in the interstitial gel. The slow distribution gives crystalloid electrolyte solutions a fairly good plasma volume expanding effect as long as the infusion continues and shortly thereafter.

Isotonic (0.9%) saline is widely used but has an electrolyte composition that deviates from that of the ECF (““unbalanced””). This fluid is best reserved for special indications only. Isotonic saline may also be considered in trauma and in children undergoing surgery. Hypertonic saline might be used in neurotrauma and, possibly, in preoperative emergency care.

Because of the low nurse-to-patient ratio on surgical wards and the intermittent nature of blood pressure spot-checks, there is increasing evidence that hemodynamic deterioration may be overlooked for hours. Several non-obtrusive systems have recently been developed to monitor blood pressure continuously and non-invasively. They may help to free nurses from time-consuming and repetitive tasks and to detect clinical deterioration earlier, decrease the number of rapid response team interventions, ICU admissions, cardiac arrests, and deaths. From a sensor standpoint, wireless wearables are emerging as the ideal solution for monitoring on the wards because they are patient friendly andenable early mobilization,a key element of enhanced recovery programs. Clinical studies are needed to clarify what are the best strategies to effectively respond to early deterioration alerts. Such strategies may include the quick assessment of cardiac function with a POCUS device.

Fluid administration is one of the basic components in the management of neurosurgical patients. However, there is still debate on the ideal fluid. Issues related to adequate volume replacement and effects on the intracranial pressure persist. Studies have demonstrated the harmful effects of colloids over crystalloids. Normal saline has remained a fluid of choice but there is now emerging evidence that it, too, is not free of its harmful effects. Hypertonic saline has also been accepted by many practitioners, but its use and administration require close monitoring. There is now growing evidence on the use of balanced solutions for neurosurgical patients. However, this evidence comes from a small number of studies. Hemodynamic monitoring for fluid therapy in these patients is prudent as these patients are prone to hypovolemia. Dynamic parameters like stroke volume variance and pulse pressure variance are considered more reliable to monitor fluid therapy in comparison to static parameters. This chapter briefly covers various clinical situations in neurosciences with respect to fluid therapy and use of hemodynamic monitoring while providing fluid therapy and its effect on patient outcome.