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Review Article
Haemodynamic monitoring in the peri-operative period: the past,
the present and the future
X. Watson1 and M. Cecconi2

1 Registrar in Anaesthetics and Intensive Care, 2 Reader in Anaesthesia and Intensive Care Medicine/Clinical Director
Adult Critical Care, St Georges Hospital, London, UK

Summary
Over recent years there has been an increase in the implementation of goal-directed therapy using minimally invasive
haemodynamic monitoring techniques to guide peri-operative care. Since the introduction of the pulmonary artery
flotation catheter in the 1980s, various haemodynamic monitors have been developed, each associated with their own
benefits and limitations. Goal-directed therapy has been well-established as a standard of care in the peri-operative
period and has largely been associated with a reduction in morbidity and mortality. However, evidence over the last
few years from major studies has led us to question: what is the future for goal-directed therapy? Care of the peri-
operative patient has significantly evolved over the last decade and this needs to be taken into account when assess-
ing the results of these studies. We should therefore not look at the effects of goal-directed therapy in isolation but
as part of a progressive care bundle. Additionally, other markers of haemodynamic status have also begun to be fur-
ther appreciated and these are worthy of further investigation. We feel that the future for haemodynamic monitoring
remains promising with new areas of interest continuously emerging, but further research is still required.
.................................................................................................................................................................
Correspondence to: X. Watson
Email: ugm2xw@doctors.org.uk
Accepted: 1 October 2016
Keywords: cardiac output and haemodynamic monitoring; goal-directed therapy; peri-operative

Introduction anaesthesia. In recent years there has been increased

Approximately 2.7 million surgical procedures are per-
formed each year in the UK, with approximately 4%
of patients undergoing non-cardiac surgery dying in
hospitals postoperatively [1, 2], and an even larger
proportion developing postoperative complications [3].
Although the causes are multifactorial, it is believed
that tissue hypoperfusion and the imbalance between
oxygen delivery and oxygen consumption plays a sig-
nificant role [4, 5]. Achieving haemodynamic stability
and ensuring adequate oxygen delivery in the peri-
operative period is therefore of paramount importance
and is a core component in the provision of
interest and implementation of goal-directed therapy
(GDT) with the use of minimally invasive haemody-
namic monitors to improve tissue oxygen delivery [6].
Haemodynamic monitoring describes the ‘real-
time’ measurement of cardiovascular variables and
dynamic parameters of fluid responsiveness to guide
administration of intravenous fluids, vasopressors and
inotropic therapy [7]. Over the last few decades, there
have been significant advancements in the develop-
ment of less invasive technology and increased avail-
ability which, coupled with a large body of evidence
showing reduced mortality and complications, has led

© 2017 The Association of Anaesthetists of Great Britain and Ireland 7


Anaesthesia 2017, 72 (Suppl. 1), 7–15 Watson and Cecconi | Haemodynamic monitoring in the peri-operative period
to the concept of GDT becoming significantly embed-
ded in clinical practice [8, 9]. No single device exists
at present that is able to provide the clinician with a
complete and 100% accurate evaluation of cardiovascu-
lar status, and each monitor is associated with its own
benefits and limitations. Recent evidence, however, has
cast doubt on the beneficial effects of GDT and the
gap between the supporting evidence for its use and its
implementation in clinical practice is wider than ever.
This review will revisit the physiological rationale
for GDT, and discuss the most commonly-used
haemodynamic monitoring devices and variables used
in clinical care, with a focus on the most recent evi-
dence. It will also look at how current practice has
evolved and what the future for GDT and haemody-
namic monitoring holds.
Brief history
In the 1980s, using data from the pulmonary artery
flotation catheter (PAC), Shoemaker et al. noted higher
postoperative indices of oxygen delivery and reduced
oxygen debt in survivors of major surgery compared
with non-survivors [10–12]. When these higher indices
found in survivors were used as targets, they found an
improvement in survival. Later studies similarly showed
that patients with increased oxygen delivery indices
were more likely to survive major surgery, and that
measuring oxygen delivery could predict postoperative
outcome [10, 11]. Shoemaker et al. subsequently
hypothesised that attainment of ‘supranormal’ physio-
logical parameters; a cardiac output of > 4.5 l.min.m2,
oxygen delivery of > 600 ml.min.m2 and oxygen con-
sumption of > 170 ml.min.m2 would be associated with
improved survival after major surgery.
Drawing on this hypothesis, other studies went on
to demonstrate that using a PAC-based protocol with
fluids and inotropic support and reducing the ‘oxygen
debt’ significantly decreased mortality and organ fail-
ure in high-risk non-cardiac surgical patients [10, 13].
However, over time, observational data showed an
association between use of the PAC and increased
mortality in the ITU. At the same time, evidence
started to emerge that targeting supranormal values
with a PAC yielded no benefit over standard care in
elderly surgical patients when started late or when high
dose of vasoactive drugs were used [14, 15].
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With the focus trending away from PACs,
researchers started to develop novel methods of opti-
mising the cardiovascular system using fluids to target
stroke volume (SV) and inotropes to target cardiac
output and oxygen delivery. Less invasive haemody-
namic monitors were developed in parallel to the
implementation of peri-operative protocols. These pro-
tocols aimed to optimise cardiac output with fluids,
and in some protocols with inotropes, to increase oxy-
gen delivery, in order to compensate for the increased
metabolic response of major surgery. With a growing
body of evidence, further minimally invasive haemody-
namic monitors were developed and the practice of
GDT progressed.
Haemodynamic monitoring and
variables
Traditionally, anaesthetists have used parameters such
as heart rate (HR), blood pressure (BP), central venous
pressure (CVP) and urine output to guide their peri-
operative care, but although readily available, these
variables have consistently shown to be neither sensi-
tive or specific enough to provide an accurate evalua-
tion of the cardiovascular status as a whole [16]. Both
HR and CVP have been proven to be inaccurate indi-
cators of volume status [17], and research has shown
that the relationship between arterial pressure, ventric-
ular stroke volume and venous return is non-linear,
thereby preventing the arterial pressure from being
used as an endpoint for cardiac output monitoring
and optimisation [18–20].
Central venous pressure has previously been used
to guide peri-operative fluid therapy, but a CVP of
between 5 mmHg to 20 mmHg has certainly almost
no predictive value, and changes in CVP with a fluid
bolus have not been shown to be predictive of fluid
status [21]. Central venous pressure is well-known to
be affected by other variables, such as intrathoracic
pressure, venous resistance and pulmonary vascular
resistance, and a recent study demonstrated that there
is little value in using CVP as a marker of adequate
systemic oxygen delivery after major surgery [22].
Both central and mixed venous oxygen saturations
(Scv02, Sv02) have been used as markers to reflect on
the balance between oxygen delivery and oxygen con-
sumption, with an increased oxygen consumption

Watson and Cecconi | Haemodynamic monitoring in the peri-operative period
proportional to delivery resulting in decreased values.
Although Sv02 has not been well-studied outside of
cardiac surgery [23], Scv02 has been shown to be asso-
ciated with reduced morbidity and length of stay in
patients undergoing abdominal surgery [24].
Various haemodynamic monitors are currently
clinically available, each associated with their own ben-
efits and limitations. Additionally, each monitor will
vary in its accuracy and precision. In order to interpret
the values generated by these monitors, clinicians need
to understand how the circulation is regulated. One
relevant approach is to consider how best to combine
measurements of the different variables within a con-
ceptual framework model of the circulation [25]. Guy-
ton stated that the cardiac output and central venous
pressure are determined by the interactions between
both cardiac function and venous return to the heart.
This is the focus of cardiovascular modelling [25].
Another approach is to consider the ability of a device
to detect changes in cardiac output following a thera-
peutic intervention, particularly in haemodynamically
unstable patients as this will have a direct impact on
the therapeutic intervention [16, 26]. The analysis of
the general trend over the specific measurement could
also be argued as of greater clinical significance.
Cardiac output can be measured using invasive,
minimally invasive and non-invasive devices, with the
PAC enabling pulmonary artery thermodilution being
the most invasive.
Pulmonary artery catheter
This is currently the gold standard monitor, with an
estimated accuracy of 12–15% with triplicate injection
of iced saline and poorer accuracy in obese or elderly
patients [16, 27]. It allows for direct measurements of
central venous, right-sided intracardiac, pulmonary
arterial and pulmonary artery wedge pressures, and
can estimate both systemic and pulmonary vascular
resistance [7]. It also has a role in assessing whether
the cardiac output is providing adequate oxygen deliv-
ery to meet the metabolic demands of the tissue, the
basis for which GDT has been developed [7]. Unfortu-
nately, PACs are unable to effectively predict fluid
responsiveness using stroke volume variation (SVV), as
the cardiac output is measured by thermodilution over
a 15-s period. Additionally, its time lag makes it
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Anaesthesia 2017, 72 (Suppl. 1), 7–15
difficult to use when performing a fluid challenge with
a small amount of fluid given in 5–10 min [28].
Real-time monitoring of fluid
responsiveness
Fluid responsiveness can be defined as an increase in
SV or cardiac output by 10–15% in response to a fluid
challenge, although the rate and volume of fluid is
variable [21]. Fluid is titrated until it reaches the pla-
teau of the Frank–Starling curve as seen in Fig. 1 [29].
In patients whose lungs are mechanically ventilated,
the cyclical variations in SV and pulse pressure caused
by the heart–lung interaction can be used to predict
fluid responsiveness before giving fluids.
Pulse pressure analysis uses the arterial waveform
to calculate cardiac output and SV, and can also calcu-
late dynamic parameters such as stroke volume varia-
tion (SVV) and pulse pressure variation (PPV). Pulse
pressure is dependent on the amount of blood ejected
into the aorta and is thereby related to stroke volume.
The arterial pressure waveform is, however, not
directly proportional to SV and is related to the
changes between SV and changes in vascular resis-
tance, compliance and impedance [7]. Devices there-
fore use complex algorithms to analyse the pulse
pressure and determine the SV and many of these
devices require calibration. The PiCCO requires cali-
bration with thermodilution, whereas the FloTrac uses
the standard deviation of the arterial pulse pressure
around the mean arterial pulse pressure and an auto
calibration factor. The LiDCOTM plus uses pulse power
analysis [7]. The FloTrac, since its introduction in
2005, has been continuously updated, and now inte-
grates ‘third-generation’ software; studies have shown
reasonable agreement with pulmonary artery thermod-
ilution [30, 31]. Although it has not been extensively
studied in GDT, there are limited data showing benefi-
cial effects in reducing postoperative complications
[32, 33]. The LiDCOplus technique stands for lithium-
diluted cardiac output, which, using pulse power
analysis, converts the arterial waveform into a vol-
ume-time waveform to calculate cardiac output [24].
The LiDCOrapid system uses a nomogram to calculate
the patient’s specific aortic compliance, and therefore
prior calibration with lithium dilution is not required
[30]. The use of both LiDCO systems in
9

Anaesthesia 2017, 72 (Suppl. 1), 7–15 Watson and Cecconi | Haemodynamic monitoring in the peri-operative period
Figure 1 Fluid optimisation based on cardiac output
monitoring. Fluid is titrated until the stroke volume
increases by <10%. (Adapted from [29, 39])
peri-operative GDT have been extensively studied and
evidence has demonstrated both reduced length of
stay and postoperative outcomes [34–36].
Various haemodynamic indices exist which have
been used to predict fluid responsiveness and optimise
the cardiovascular state. Pulse pressure variation values
around 13% and SVV values around 10–13% accu-
rately predict fluid responsiveness, with reported pre-
dictive values of more than 0.85 [37, 38] in patients
whose lungs are mechanically ventilated in sinus
rhythm without arrhythmias. This is in stark contrast
to the 50% accuracy rate of a clinician to predict
whether a patient is fluid responsive based on clinical
criteria alone [37]. The pleth variability index (PVI)
calculated with non-invasive monitoring has also pro-
ven to be effective in predicting fluid responsiveness
[39].
Intra-operative SVV-guided fluid optimisation has
also been shown to decrease gastrointestinal complica-
tions in patients undergoing major abdominal surgery
and reduce wound infections after high-risk surgery
[39, 40]. Intra-operative PPV has additionally been
proven to reduce duration of mechanical ventilation,
morbidity and length of stay in non-cardiac, high-risk
surgery [41]. Although the theoretical advantage of
dynamic indices is that they reflect the changes in SV
with changes in intrathoracic pressures, they are
nonetheless associated with various limitations.
Patients’ lungs must be mechanically ventilated with a
tidal volume of at least 6ml.kg 1, in sinus rhythm with
10
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a closed chest and normal abdominal pressures for
these devices to accurately predict fluid responsiveness
[16, 41, 42]. The effect of intrathoracic pressure on SV
varies depending on the function of the left ventricle,
and therefore PPV is not a useful indicator in these
patients [43]. Pulse pressure variation is also affected
by the presence of cardiac arrhythmias, peripheral
vasoconstriction and the use of vasopressors [44]. It
has also been demonstrated that despite being effective
as a predictive marker, in up to 25% of patients, PPV
can fall in the ‘grey zone’ between 9% and 13% mak-
ing it difficult to determine if a patient is indeed fluid
responsive [16].
With regard to non-invasive devices, PVI is the
most widely studied in GDT. The pleth variability
index is calculated by measuring both the minimal and
maximal plethysmographic waveform amplitudes and
calculating the percentage difference [16]. Although
there are various factors which will affect the wave-
form, there is evidence to suggest that it has reason-
able reliability in predicting fluid responsiveness in
patients undergoing anaesthesia, although further
research is warranted [45].
Oesophageal Doppler
The oesophageal Doppler monitor (ODM) and arterial
pressure waveform analysis are the two most common
minimally invasive methods of haemodynamic moni-
toring. The ODM, which uses the pulse-wave Doppler
principle has gained in popularity, with increasing evi-
dence showing that fluid optimisation with its use can
improve patient outcome [45–47]. The oesophageal
Doppler is inserted into the oesophagus of the anaes-
thetised patient at mid-thoracic level and calculates
CO by measuring blood flow velocity in the descend-
ing aorta and using the cross-sectional diameter of the
aorta, often using nomograms. In 2010, the British
National Institute for Health and Care Excellence rec-
ommend its use in patients undergoing major or high-
risk surgery-based primarily on the reduced length of
hospital stay associated with the ODM [48]. However,
this was a finding that was not reported in all the studies
that NICE examined and of note, NICE only considered
the results from eight randomised, controlled trials to
formulate their guidance [49]. Additionally, many of the
trials examined were single-centre studies with an
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Watson and Cecconi | Haemodynamic monitoring in the peri-operative period Anaesthesia 2017, 72 (Suppl. 1), 7–15

extremely heterogeneous population, which brings into monitoring and their benefits and limitations is shown
question the validity of their conclusions. in Table 1 [52].

Bioreactance Evidence for goal-directed therapy

Another novel non-invasive method of measuring car-
diac output is thoracic bioreactance. This is based on
the application of a high-frequency transthoracic cur-
rent and the analysis of variations of voltage in each
heartbeat. The NICOM device is an example of this
method and consists of four pads placed across the
chest connected to a monitor. An advantage of this
system is that it can be used in patients whose lungs
are mechanically ventilated and in patients who are
spontaneously breathing alike, and in the presence of
cardiac arrhythmias [16].
A recent study using bioimpedance technology in
GDT demonstrated similar performance compared
with the ODM, and studies have shown encouraging
results regarding its precision compared with pul-
monary artery thermodilution [50, 51] The use of elec-
trocautery, however, interferes with the thoracic
bioimpedance signal, making it unlikely that it will
become a widely applicable device in the future,
although, again, further research is necessary. An over-
view of the various devices used for haemodynamic
In recent years, the focus has moved away from ‘max-
imisation’ of cardiac output to ‘optimisation’ in the
peri-operative period. Goal-directed therapy has been
well-established as a standard of care in anaesthesia
due to the strong body of evidence behind it and its
benefits in reducing both morbidity and mortality [8,
53]. Although the majority of the evidence for GDT is
centred around patients undergoing major gastroin-
testinal surgery, there is an increasing body of evidence
for its use in orthopaedic [54], cardiac [55, 56] and
vascular surgery [57]. However, the last couple of years
have seen a shift in the evidence, with recent studies
showing little or no benefit of GDT in the peri-opera-
tive period, leading clinicians to question its clinical
utility.
The OPTIMISE study is the largest study to date
of peri-operative GDT and its results were published
in 2014 [58]. It was a multicentre, randomised, blinded
trial which enrolled 734 patients undergoing major
abdominal surgery. The intervention group were moni-
tored with calibrated waveform analysis and

Table 1 Overview of minimally and less invasive haemodynamic modalities. Adapted from Geisen et al. [49].

Modality Device Features Requirements CCO response Additional variables

Pulse pressure analysis
Calibrated PiCCOplus Thermistor-tipped CVP 3s CVP, GEDV,
arterial catheter EVLW, SVV, PPV
LiDCOplus Lithium dilution set Arterial catheter Beat by beat SVV, PPV
EV1000/volume Thermistor-tipped CVP Beat by beat CVP, GEDV,
view arterial catheter EVLW, SVV
Uncalibrated LiDCOrapid n/a Arterial catheter Beat by beat SVV, PPV
FloTrac/Vigileo Specific arterial Arterial catheter 20 s SVV,
pressure transducer
Non-invasive Nexfin Finger pressure cuff n/a Beat by beat SVV, PPV
Doppler
Transoesophageal CardioQ Oesophageal probe n/a Beat by beat n/a
Transthoracic USCOM Transthoracic probe n/a Intermittent n/a
Bioimpedance
Thoracic NICOM Specific electrodes n/a Continuous SVV
bioreactance
Plethysmographic analysis
Plethysmogram MASIMO Specific n/a n/a PVI
variability transcutaneous
probe

CCO, continuous cardiac output; CVP, central venous pressure GEDV, global end-diastolic volume; EVLW, extravascular lung
water; SVV, stroke volume variation, PPV, pulse pressure variation; PVI, pleth variability index..

© 2017 The Association of Anaesthetists of Great Britain and Ireland 11


Anaesthesia 2017, 72 (Suppl. 1), 7–15 Watson and Cecconi | Haemodynamic monitoring in the peri-operative period
underwent haemodynamic optimisation with colloid
boluses and dopexamine infusion specifically targeting
SV for the duration of the surgical procedure and 6 h
postoperatively. Although the study showed there was
no difference in mortality or postoperative complica-
tions at day 30, when a planned subanalysis was per-
formed removing the first ten patients per site, a
significant reduction in postoperative complications
was demonstrated.
The POEMAS study, a multicentre, randomised trail
also published in the same year, randomly allocated
patients undergoing major abdominal surgery to non-
invasive monitoring using chest bioreactance and a
tailored haemodynamic protocol. Again there was no dif-
ference in mortality, length of stay or complications [59].
More recently the POMO study was published in
2015, and this was also a multicentre, double-blind,
randomised trial enrolling over 200 patients undergo-
ing major elective surgery. The intervention was ran-
domisation to a GDT protocol and specifically
targeting the patient’s pre-operative oxygen delivery
values. Interestingly, the study demonstrated that those
patients who were able to achieve their pre-operative
oxygen delivery targets in the postoperative period sus-
tained reduced morbidity and infectious complications
[60]. As well as demonstrating a lack of benefit, delete-
rious effects have been seen in healthy aerobically fit
patients undergoing major colorectal surgery receiving
GDT by the development of volume overload [61].
Although this finding has not been reproduced by
other studies, it is a significant observation that war-
rants further exploration in future studies.
Despite these negative trials, it is important to take
into consideration that the care of the surgical patient
in the peri-operative period has evolved significantly
over the last few years. The progressive development
of enhanced recovery after surgery (ERAS) pro-
grammes which encompass haemodynamic monitoring
and GDT have altered what we think of as ‘standard
care’ and it may be that ‘best practice’ has actually
become ‘standard care’. The ability to detect the effect
of a single intervention has therefore been hampered.
Other possibilities suggested by Cecconi and Rhodes
are that the large body of evidence may have suffered
from publication bias or that, as mentioned previously,
it may be that there are harmful effects of SV
12
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optimisation such as volume overload which need
further exploration [62].
Despite recent negative evidence, there is still a
future for GDT, but perhaps not in the manner origi-
nally or currently envisaged. Care of the peri-operative
patient is continuously progressing and our under-
standing of cardiovascular physiology and prediction
of fluid responsiveness has significantly evolved over
the last few years. Implementation of peri-operative
enhanced recovery programmes have taught us how to
encompass bundles effectively in clinical care, and this
will only continue to improve as these bundles become
further embedded in ‘standard care’. It may be that we
no longer focus on specific haemodynamic variables
per se but that we include GDT as part of a progres-
sive peri-operative bundle. There are still many areas
that warrant further research and further research
studies comparing GDT with a control group will have
to take the change in baseline care into account. As
Pinsky noted: ‘no monitoring device, no matter how
simple or sophisticated, will improve patients outcome
unless coupled to a treatment which itself improves
outcome’. Therefore, the next challenge in the peri-
operative era will be to determine the right goals to
target and integrate them into appropriate protocols
which can be used to guide peri-operative care.
While there are some studies that have shown no
increased benefit for GDT with minimally invasive
techniques, most literature has consistently demon-
strated a reduction in morbidity when applied to high-
risk surgical patients [7, 9].
Further developments
Other potential markers of haemodynamic status which
are worthy of further research include vascular tone and
the microcirculation. It is well-known by all anaes-
thetists that general anaesthesia influences vascular tone
and therefore has a considerable effect on whether a
patient is deemed to be ‘preload or fluid responsive’.
However, being preload responsive does not necessarily
equate to a patient requiring extra fluid as this can be
seen in healthy haemodynamically stable patients with
adequate organ perfusion [63, 64]. It is important for
the clinician to therefore assess whether a reduced mean
arterial pressure under anaesthesia is due to a decreased
vascular tone or inadequate blood flow.
© 2017 The Association of Anaesthetists of Great Britain and Ireland

Watson and Cecconi | Haemodynamic monitoring in the peri-operative period
Assessment of vasomotor tone using dynamic arte-
rial elastance (Eadyn) may therefore be of clinical util-
ity. Research has shown that when the arterial tone
and ventricular systolic function is coupled, ventricular
performance is maximised [65]. Eadyn is defined as
the PPV to SVV ratio measured during a single posi-
tive breath and has been suggested to provide a func-
tional assessment of arterial tone [62]. Eadyn has been
shown to predict the response to a single fluid chal-
lenge in both patients whose lungs are mechanically
ventilated and spontaneously breathing patients [66,
67]. The development of GDT protocols potentially
incorporating the assessment of Eadyn in the future
could have significant benefits in helping guide the
clinician as to whether the first-line intervention
should actually be fluid or whether a vasopressor is in
fact required to restore vascular tone before further
optimisation [62].
Another potential area of interest is microcircula-
tory dysfunction. Although it has been extensively
studied in the critical care setting, the evidence of its
effect on peri-operative outcomes is currently lacking.
Studies have shown that implementation of GDT is
linked to improved microcirculatory flow in the peri-
operative period and that patients with poor oxygen
delivery who had increased morbidity had an increased
rate of microcirculatory dysfunction postoperatively
[68, 69]. Although both assessment of Eadyn and
microcirculatory dysfunction may be potential targets
in the future of GDT, further research is warranted to
specifically determine their effect on peri-operative
outcomes.
Closed-loop systems for haemodynamic optimisa-
tion are another emerging development in GDT. These
systems operate by tracking haemodynamic parameters
such as HR, SV and MAP using software which allows
the administration of fluid until the SV reaches the
plateau of the Frank–Starling curve [70]. By monitor-
ing SV and tracking SVV and PPV, the system aims
to keep the haemodynamic status of the patient at the
plateau of the curve for the duration of the surgical
procedure. Although this system has been validated
against trained anaesthetists in a simulated model,
there is limited evidence to such its feasibility and
applicability in routine clinical practice.
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Anaesthesia 2017, 72 (Suppl. 1), 7–15
Conclusions
In conclusion, we have seen that the implementation
of GDT with the use of minimally and less invasive
monitors to guide peri-operative practice has become
rapidly established and accepted over the last few
years. Although recent evidence has cast some doubt
over the beneficial effects, the majority of the literature
has demonstrated improved morbidity and mortality
in certain populations. Care of the peri-operative
patient is continuously evolving and our standards of
care have changed and this needs to be taken into
account in future studies. Haemodynamic monitoring
in the peri-operative period remains promising with
exciting new areas emerging which are of potential
interest in the future.
Competing interests
MC has received consulting and speaker fees from
LiDCO Edwards Lifesciences, Maquet and Cheetah.
No other funding or competing interests declared.
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