Letters to the Editor: Letter to the Editor
Thank you for the opportunity to reply to the letter from Dr. Zhang.1 In fact, Dr. Zhang reemphasizes the several arguments we posed in our editorial regarding the lack of firm documentation of the benefits of goal-directed fluid therapy (GDFT) as essential component of enhanced recovery protocol.2 This includes poor agreement among monitors used in the studies assessing GDFT. In addition, the recent meta-analysis published after the acceptance of our editorial strengthens our point of view that the benefits of GDFT are mitigated in the context of enhanced recovery protocols.3
The recent meta-analysis3 weakens the argument that GDFT is an essential element of an enhanced recovery protocol.4 Also, reduced intraoperative and postoperative fluid administration, which has been observed in recent years,3 may have contributed to the improved perioperative outcome. Thus, it is not “…foolish to believe that crystalloid restriction alone can achieve this goal.”4 Interestingly, Cannesson and Gan4 actually strengthen our point of view by emphasizing that implementation of a clinical pathway (ie, enhanced recovery protocol) reduces variability, which may be one of the reasons for the limited documentation of benefits of GDFT during enhanced recovery protocol. We agree, “variability is the enemy of quality.”4
However, we do want to emphasize that hemodynamic monitoring is an appropriate component of optimal anesthesia care for patients with significant comorbidities undergoing major invasive surgical procedures. Furthermore, there is an urgent need to highlight compliance with enhanced recovery protocols and to define the specific indications and effects of GDFT.
Girish P. Joshi, MBBS, MD, FFARCSI
Department of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center
Henrik Kehlet, MD, PhD
Section for Surgical Pathology
Rigshospitalet Copenhagen University
1. Zhang C. Does the device matter in goal-directed fluid therapy? Anesth Analg. 2016;123:1061–1062.
2. Joshi GP, Kehlet H. CON: Perioperative goal-directed fluid therapy is an essential element of an enhanced recovery protocol? Anesth Analg. 2016;122:1261–1263.
3. Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg. 2016;263:465–476.
4. Cannesson M, Gan TJ. PRO: perioperative goal-directed fluid therapy is an essential element of an enhanced recovery protocol. Anesth Analg. 2016;122:1258–1260.