Saugel Bernd, Reuter Daniel A
Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany.
Front Med (Lausanne). 2018 Jan 30;5:12. doi: 10.3389/fmed.2018.00012. eCollection 2018.
"Perioperative goal-directed therapy" (PGDT) aims at an optimization of basic and advanced global hemodynamic variables to maintain adequate oxygen delivery to the end-organs. PGDT protocols help to titrate fluids, vasopressors, or inotropes to hemodynamic target values. There is considerable evidence that PGDT can improve patient outcome in high-risk patients if both fluids and inotropes are administered to target hemodynamic variables reflecting blood flow. Despite this evidence, PGDT strategies aiming at an optimization of blood flow seem to be not well implemented in routine clinical care. The analysis of the arterial blood pressure waveform using invasive uncalibrated pulse contour analysis can be used to assess hemodynamic variables used in PGDT protocols. Pulse contour analysis allows the assessment of stroke volume (SV)/cardiac output (CO) and pulse pressure variation (PPV)/stroke volume variation (SVV) and thus helps to titrate fluids and vasoactive agents based on principles of "functional hemodynamic monitoring." Pulse contour analysis-based PGDT treatment algorithms can be classified according to the hemodynamic variables they use as targets: PPV/SVV, SV/CO, or a combination of these variables. From a physiologic point of view, algorithms using both dynamic cardiac preload and blood flow variables as hemodynamic targets might be most effective in improving patient outcome. Future research should focus on the improvement of hemodynamic treatment algorithms and on the identification of patient subgroups in which PGDT based on uncalibrated pulse contour analysis can improve patient outcome.
“围手术期目标导向治疗”（PGDT）旨在优化基础和高级的整体血流动力学变量，以维持向终末器官的充足氧输送。PGDT方案有助于将液体、血管升压药或正性肌力药滴定至血流动力学目标值。有大量证据表明，如果同时给予液体和正性肌力药以达到反映血流的目标血流动力学变量，PGDT可改善高危患者的预后。尽管有此证据，但旨在优化血流的PGDT策略在常规临床护理中似乎并未得到很好的实施。使用侵入性未校准脉搏轮廓分析对动脉血压波形进行分析，可用于评估PGDT方案中使用的血流动力学变量。脉搏轮廓分析可评估每搏量（SV）/心输出量（CO）以及脉压变异（PPV）/每搏量变异（SVV），从而有助于根据“功能性血流动力学监测”原则滴定液体和血管活性药物。基于脉搏轮廓分析的PGDT治疗算法可根据它们用作目标的血流动力学变量进行分类：PPV/SVV、SV/CO或这些变量的组合。从生理学角度来看，将动态心脏前负荷和血流变量均用作血流动力学目标的算法可能在改善患者预后方面最为有效。未来的研究应聚焦于血流动力学治疗算法的改进，以及识别基于未校准脉搏轮廓分析的PGDT可改善患者预后的患者亚组。
