Edwards Critical Care Education

Perioperative Goal-Directed Therapy Protocol Summary

Issue Date: March 2013

Evidence-based, Perioperative Goal-Directed Therapy (PGDT) protocols

Note: This protocol summary is designed to help inform clinicians

of key published protocols used to guide hemodynamic monitoring

in high-risk surgery. It is not intended to recommend a specific

protocol, but to guide hemodynamic optimization through

Perioperative Goal-Directed Therapy protocols that have

been shown to reduce the number of peri- and postoperative

complications, and improve patient outcomes.1-3 These

protocols represent individual strategies to help physicians either

titrate or tailor fluid therapy in an individual patient or clinical

situation. Since every case is different, physicians must weigh the

risks and benefits of initiating any specific protocol.

Please refer to Edwards Critical Care Education at Edwards.com/ccEducation for updates and additional information.

Issue Date: March 2013

Considering a protocol

The following algorithm is provided to help you select the most

appropriate Perioperative Goal-Directed Therapy (PGDT) protocol

for your patient. Your selection deserves careful consideration.

NO

NONO

YES

YES

Is my patient at risk* of developing post-op complications?

Consider PGDTConventional care

(eg BP, CVP, HR,urine output)

Any limitation† to the use of SVV?

Use an SV-based treatment protocol

(NHS, Cecconi)

Use an SVV-based treatment protocol

(Benes, Ping, Ramsingh)

*At risk because of comorbidities or the surgical procedure itself.† Limitations to the use of SVV: Spontaneous breathing, tidal volume <7 ml/kg, open chest, atrial fibrillation, right ventricular failure, and laproscopic surgery.

2 3

Abbreviations: BP: Blood Pressure; CVP: Central Venous Pressure; HR: Heart Rate; SV: Stroke Volume; SVV: Stroke Volume Variation.

Evidence-based, Perioperative Goal-Directed Therapy (PGDT) protocols

Note: This protocol summary is designed to help inform clinicians

of key published protocols used to guide hemodynamic monitoring

in high-risk surgery. It is not intended to recommend a specific

protocol, but to guide hemodynamic optimization through

Perioperative Goal-Directed Therapy protocols that have

been shown to reduce the number of peri- and postoperative

complications, and improve patient outcomes.1-3 These

protocols represent individual strategies to help physicians either

titrate or tailor fluid therapy in an individual patient or clinical

situation. Since every case is different, physicians must weigh the

risks and benefits of initiating any specific protocol.

Please refer to Edwards Critical Care Education at Edwards.com/ccEducation for updates and additional information.

Issue Date: March 2013

Considering a protocol

The following algorithm is provided to help you select the most

appropriate Perioperative Goal-Directed Therapy (PGDT) protocol

for your patient. Your selection deserves careful consideration.

NO

NONO

YES

YES

Is my patient at risk* of developing post-op complications?

Consider PGDTConventional care

(eg BP, CVP, HR,urine output)

Any limitation† to the use of SVV?

Use an SV-based treatment protocol

(NHS, Cecconi)

Use an SVV-based treatment protocol

(Benes, Ping, Ramsingh)

*At risk because of comorbidities or the surgical procedure itself.† Limitations to the use of SVV: Spontaneous breathing, tidal volume <7 ml/kg, open chest, atrial fibrillation, right ventricular failure, and laproscopic surgery.

2 3

Abbreviations: BP: Blood Pressure; CVP: Central Venous Pressure; HR: Heart Rate; SV: Stroke Volume; SVV: Stroke Volume Variation.

OvErviEw

Randomized controlled trial

Undergoing elective abdominal surgery >2 h with expected blood loss >1000 ml

One or more of the following: Ischemic heart disease or severe heart dysfunction, moderate to severe chronic obstructive pulmonary disease, aged 70+, ASA III or more

Central Venous Pressure, Stroke Volume Variation, Cardiac Index

Fluid (Colloid), Dobutamine

Decrease in 30-day postoperative complications (56%), decrease in hospital length of stay (10%)

Benes Protocol1

NO

NO

NO

YES

YES

NONO

NONO

NONO

YES

YES

YES

SVV ≥10%and CVP <15 mm Hg

Colloid bolus 3 ml/kgover 5 minutes

CVP rise ≤3 mm Hg

SVV <10% andno change or decrease of Cl

Dobutamine infusion toreach Cl ≥2.5 l/min/m2

Cl <2.5 l/min/m2

Measure and record SVV, Cl

Repeat monitoring of SVV, Clduring next 5 minutes

NONO

YES

EnD PRoToCol

Study Design

Patient Population

Inclusion Criteria

Target Parameters

4 5

Intervention

Primary Outcomes

Abbreviations: CI: Cardiac Index; CVP: Central Venous Pressure; SVV: Stroke Volume Variation.

OvErviEw

Randomized controlled trial

Undergoing elective abdominal surgery >2 h with expected blood loss >1000 ml

One or more of the following: Ischemic heart disease or severe heart dysfunction, moderate to severe chronic obstructive pulmonary disease, aged 70+, ASA III or more

Central Venous Pressure, Stroke Volume Variation, Cardiac Index

Fluid (Colloid), Dobutamine

Decrease in 30-day postoperative complications (56%), decrease in hospital length of stay (10%)

Benes Protocol1

NO

NO

NO

YES

YES

NONO

NONO

NONO

YES

YES

YES

SVV ≥10%and CVP <15 mm Hg

Colloid bolus 3 ml/kgover 5 minutes

CVP rise ≤3 mm Hg

SVV <10% andno change or decrease of Cl

Dobutamine infusion toreach Cl ≥2.5 l/min/m2

Cl <2.5 l/min/m2

Measure and record SVV, Cl

Repeat monitoring of SVV, Clduring next 5 minutes

NONO

YES

EnD PRoToCol

Study Design

Patient Population

Inclusion Criteria

Target Parameters

4 5

Intervention

Primary Outcomes

Abbreviations: CI: Cardiac Index; CVP: Central Venous Pressure; SVV: Stroke Volume Variation.

Randomized controlled trial

Undergoing elective total hip replacement under regional anesthesia

ASA II

Stroke Volume, Oxygen Delivery

Fluid (Colloid), Dobutamine

Decrease in postoperative complications (20%)

Cecconi Protocol2

OvErviEw

Study Design

Patient Population

Intervention

InclusionCriteria

6

Target Parameters

Primary Outcomes

Abbreviations: Do2I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; Sao2: Oxygen Saturation; SV: Stroke Volume.

NO

YES

NONONO

NONO

NONO

YES

YES

YES

Check every 10 minutesIf DO2I falls below 600 ml/min*m2, restart algorithm

Achieve SV max and then target DO2I to 600 ml/min*m2

Keep:• SaO2 >95%• Hb >8 mg/dl

• HR <100 bpm• MAP between 60 and 100 mm Hg

250 ml HES bolus

See oxygen delivery

Dobutamine:Increase by 3 mcg/kg*minDecrease or STOP if HR >100 bpm or signs of cardiac ischemia

SV stable

>20 min

Increase of SV >10% or blood loss >250 ml

during fluid challenge

DO2I†

≥600 ml/min*m2

EnD PRoToCol

† Resuscitation to achieve a DO2I value of 600 is presented as a goal and not intended to be a hard target. This protocol is intended as guidance, and healthcare professionals should use sound clinical judgment and individualize therapy to each specific patient care situation.

Modified from Cecconi, et al. Crit Care. 2011;15:R132. Based upon Shoemaker3 protocol.

7

Randomized controlled trial

Undergoing elective total hip replacement under regional anesthesia

ASA II

Stroke Volume, Oxygen Delivery

Fluid (Colloid), Dobutamine

Decrease in postoperative complications (20%)

Cecconi Protocol2

OvErviEw

Study Design

Patient Population

Intervention

InclusionCriteria

6

Target Parameters

Primary Outcomes

Abbreviations: Do2I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; Sao2: Oxygen Saturation; SV: Stroke Volume.

NO

YES

NONONO

NONO

NONO

YES

YES

YES

Check every 10 minutesIf DO2I falls below 600 ml/min*m2, restart algorithm

Achieve SV max and then target DO2I to 600 ml/min*m2

Keep:• SaO2 >95%• Hb >8 mg/dl

• HR <100 bpm• MAP between 60 and 100 mm Hg

250 ml HES bolus

See oxygen delivery

Dobutamine:Increase by 3 mcg/kg*minDecrease or STOP if HR >100 bpm or signs of cardiac ischemia

SV stable

>20 min

Increase of SV >10% or blood loss >250 ml

during fluid challenge

DO2I†

≥600 ml/min*m2

EnD PRoToCol

† Resuscitation to achieve a DO2I value of 600 is presented as a goal and not intended to be a hard target. This protocol is intended as guidance, and healthcare professionals should use sound clinical judgment and individualize therapy to each specific patient care situation.

Modified from Cecconi, et al. Crit Care. 2011;15:R132. Based upon Shoemaker3 protocol.

7

NO YES

YES

NONONO

NONO

YES

YES

Measure SV

200-250 ml fluid over 5-10 minutes

SV reduction >10%

Monitor SV for clinical signs of fluid loss

SV increase >10%?

NHS-NiCE/Kuper Protocol4-13

Study Design

Patient Population

Intervention

InclusionCriteria

Quality improvement program (before-after comparison)

Undergoing emergency and elective abdominal, orthopedic, gynecologic, urologic, and vascular surgery

Three cohorts of patients aged ≤60, 61-71, and ≥71 years with ASA >I

Stroke Volume

Fluid

3.7-day decrease in hospital length of stay (25%)

EnD PRoToCol

OvErviEw

8 9

Target Parameters

Primary Outcomes

Abbreviation: SV: Stroke Volume.

NO YES

YES

NONONO

NONO

YES

YES

Measure SV

200-250 ml fluid over 5-10 minutes

SV reduction >10%

Monitor SV for clinical signs of fluid loss

SV increase >10%?

NHS-NiCE/Kuper Protocol4-13

Study Design

Patient Population

Intervention

InclusionCriteria

Quality improvement program (before-after comparison)

Undergoing emergency and elective abdominal, orthopedic, gynecologic, urologic, and vascular surgery

Three cohorts of patients aged ≤60, 61-71, and ≥71 years with ASA >I

Stroke Volume

Fluid

3.7-day decrease in hospital length of stay (25%)

EnD PRoToCol

OvErviEw

8 9

Target Parameters

Primary Outcomes

Abbreviation: SV: Stroke Volume.

Randomized controlled trial

Undergoing radical gastrectomy, colon cancer resection, rectal cancer, and Whipple surgery

ASA I or ASA II

Stroke Volume Variation

Fluid

Faster recovery time to normal diet (16%), decrease in hospital length of stay (19%)

OvErviEw

Ping Protocol14

NONO

YES YES

Fluid to maintain the patient in the range

Maintain SVV11%-13%

BP drops >30%from baseline

Atropine .05 mg

HR <50 beats/min

Ephedrine 6 mg

EnD PRoToCol

Study Design

TargetParameters

Intervention

InclusionCriteria

10 11

Patient Population

Primary Outcomes

Abbreviations: BP: Blood Pressure; HR: Heart Rate; SVV: Stroke Volume Variation.

Randomized controlled trial

Undergoing radical gastrectomy, colon cancer resection, rectal cancer, and Whipple surgery

ASA I or ASA II

Stroke Volume Variation

Fluid

Faster recovery time to normal diet (16%), decrease in hospital length of stay (19%)

OvErviEw

Ping Protocol14

NONO

YES YES

Fluid to maintain the patient in the range

Maintain SVV11%-13%

BP drops >30%from baseline

Atropine .05 mg

HR <50 beats/min

Ephedrine 6 mg

EnD PRoToCol

Study Design

TargetParameters

Intervention

InclusionCriteria

10 11

Patient Population

Primary Outcomes

Abbreviations: BP: Blood Pressure; HR: Heart Rate; SVV: Stroke Volume Variation.

ramsingh Protocol15

NONO

YES

YES

GDT Group(ventilate 8 ml/kg)

>20 ml/kg Albumin?

250 ml Albumin bolus(may repeat to max of 20 ml/kg)

SVV >12% Monitor SVV and CO

SVV >12%

NONO

NONO

YESCrystalloid 3:1 replacement

(consider PRBCs, monitor ABGs)

EnD PRoToCol

Randomized, single-blinded controlled trial

Undergoing major abdominal surgery, urologic, gastrointestinal or gynecologic cancer resection, and Whipple surgery

P-POSSUM mean predicted mortality rate of 1.4*

Stroke Volume Variation

Fluid (Colloid)

Faster return of GI function (3 vs 4 days), faster return of PO intake (4 vs 5 days), and a 2.5-day decrease in hospital length of stay (33%)

OvErviEw

Study Design

TargetParameters

Intervention

InclusionCriteria

12 13

Patient Population

Primary Outcomes

Abbreviations: ABGs: Arterial Blood Gases; Co: Cardiac Output; P-PoSSUM: Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke Volume Variation.

* No differences other than age were statistically significant. P-POSSUM scores predicted mortality and showed no difference between the groups.

ramsingh Protocol15

NONO

YES

YES

GDT Group(ventilate 8 ml/kg)

>20 ml/kg Albumin?

250 ml Albumin bolus(may repeat to max of 20 ml/kg)

SVV >12% Monitor SVV and CO

SVV >12%

NONO

NONO

YESCrystalloid 3:1 replacement

(consider PRBCs, monitor ABGs)

EnD PRoToCol

Randomized, single-blinded controlled trial

Undergoing major abdominal surgery, urologic, gastrointestinal or gynecologic cancer resection, and Whipple surgery

P-POSSUM mean predicted mortality rate of 1.4*

Stroke Volume Variation

Fluid (Colloid)

Faster return of GI function (3 vs 4 days), faster return of PO intake (4 vs 5 days), and a 2.5-day decrease in hospital length of stay (33%)

OvErviEw

Study Design

TargetParameters

Intervention

InclusionCriteria

12 13

Patient Population

Primary Outcomes

Abbreviations: ABGs: Arterial Blood Gases; Co: Cardiac Output; P-PoSSUM: Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke Volume Variation.

* No differences other than age were statistically significant. P-POSSUM scores predicted mortality and showed no difference between the groups.

Donati Protocol16

Pre-op (T0):

Post-op (T2):

Intra-op (T1):

Fluid challenge• Colloids (when Hb >10 g/dl)• PBC (when Hb <10 g/dl)If O2ER† still >27%

CVP <10 cm H2Oor SVV > 12%

CVP >10 cm H2Oor SVV < 12%

CVP or SVV

O2ER† (hourly)

Group A Group B

Arterial and central venous lineCheck SaO2—ScvO2—calculate O2ER†

Similar management to intra-opChecks of O2ER† at the end of anesthesia, 0.5, 1, 2, and 6 hours, and day +1

Standard management(MAP, urine output, CVP)

≤27% >27%

No change(or decrease Dobutamine)

Dobutamine

EnD PRoToCol

Multicenter randomized controlled trial

Undergoing elective abdominal extensive surgery or abdominal aortic surgery

ASA II

Central Venous Pressure, Oxygen Extraction Ratio

Fluid (Colloid), Dobutamine

Decrease in postoperative complications (60%), decrease in hospital length of stay (16%)

OvErviEw

Study Design

TargetParameters

Intervention

InclusionCriteria

14 15

Patient Population

Primary Outcomes

Abbreviations: CVP: Central Venous Pressure; Hb: Hemoglobin; MAP: Mean Arterial Pressure; o2ER: Oxygen Extraction Ratio; Sao2: Oxygen Saturation; Scvo2: Central Venous Oxygen Saturation.

Modified Donati Protocol: Donati A, et al. Chest. 2007;132:1817-1824. †O2ER is estimated based on use of ScvO2.

Donati Protocol16

Pre-op (T0):

Post-op (T2):

Intra-op (T1):

Fluid challenge• Colloids (when Hb >10 g/dl)• PBC (when Hb <10 g/dl)If O2ER† still >27%

CVP <10 cm H2Oor SVV > 12%

CVP >10 cm H2Oor SVV < 12%

CVP or SVV

O2ER† (hourly)

Group A Group B

Arterial and central venous lineCheck SaO2—ScvO2—calculate O2ER†

Similar management to intra-opChecks of O2ER† at the end of anesthesia, 0.5, 1, 2, and 6 hours, and day +1

Standard management(MAP, urine output, CVP)

≤27% >27%

No change(or decrease Dobutamine)

Dobutamine

EnD PRoToCol

Multicenter randomized controlled trial

Undergoing elective abdominal extensive surgery or abdominal aortic surgery

ASA II

Central Venous Pressure, Oxygen Extraction Ratio

Fluid (Colloid), Dobutamine

Decrease in postoperative complications (60%), decrease in hospital length of stay (16%)

OvErviEw

Study Design

TargetParameters

Intervention

InclusionCriteria

14 15

Patient Population

Primary Outcomes

Abbreviations: CVP: Central Venous Pressure; Hb: Hemoglobin; MAP: Mean Arterial Pressure; o2ER: Oxygen Extraction Ratio; Sao2: Oxygen Saturation; Scvo2: Central Venous Oxygen Saturation.

Modified Donati Protocol: Donati A, et al. Chest. 2007;132:1817-1824. †O2ER is estimated based on use of ScvO2.

References

1. Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118.

2. Cecconi M, Fasano N, Langiano N, et al. Goal directed haemodynamic therapy during elective total hip arthrosplasty under regional anaesthesia. Crit Care. 2011;15(3):R132.

3. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176-1186.

4. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hyperperfusion during cardiac surgery. Arch Surg. 1995;130(4):423-429.

5. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315(7113):909-912.

6. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88(1):65-71.

7. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820-826.

8. Conway D, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57(9):845-849.

9. McKendry M, McGloin H, Saberi D, Caudwell L, Brady A, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258.

10. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler-guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95(5):634-642.

11. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076.

12. Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care. 2007;11(1):R24.

13. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011;342:d3016.

14. Ping W, Hong-Wei W, Tai-Di Z. Effect of stroke volume variability- guided intraoperative fluid restriction on gastrointestinal functional recovery [published online ahead of print]. Hepatogastroenterology. 2012;59(120). doi:10.5754/hge12283.

15. Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial [published December 2012]. J Clin Monit Comput. doi: 10.1007/s10877-012-9422-5.

16. Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132(6):1817-1824.

16 17

References

1. Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118.

2. Cecconi M, Fasano N, Langiano N, et al. Goal directed haemodynamic therapy during elective total hip arthrosplasty under regional anaesthesia. Crit Care. 2011;15(3):R132.

3. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176-1186.

4. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hyperperfusion during cardiac surgery. Arch Surg. 1995;130(4):423-429.

5. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315(7113):909-912.

6. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88(1):65-71.

7. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820-826.

8. Conway D, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57(9):845-849.

9. McKendry M, McGloin H, Saberi D, Caudwell L, Brady A, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258.

10. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler-guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95(5):634-642.

11. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076.

12. Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care. 2007;11(1):R24.

13. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011;342:d3016.

14. Ping W, Hong-Wei W, Tai-Di Z. Effect of stroke volume variability- guided intraoperative fluid restriction on gastrointestinal functional recovery [published online ahead of print]. Hepatogastroenterology. 2012;59(120). doi:10.5754/hge12283.

15. Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial [published December 2012]. J Clin Monit Comput. doi: 10.1007/s10877-012-9422-5.

16. Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132(6):1817-1824.

16 17

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