ISICEM 2016 Day 3

The 3rd instalment in the quadrumvirate of oxicm blogs by Dr Wong from Brussels. JS

Principles of triage of ICU admission (Gomersall)


  • Only when necessary
  • Fair
  • Transparent

Balancing supply and demand

Maximising supply

  • Cut staff ratio
  • Temporary increase in beds; but can increase in adjusted odds ratio as needs to be staffed e.g. temporary staff; quality vs quantity

Decreased demand

Ethics – mainly beneficence and distributive justice. No role for autonomy in triage?

Triage – Egalitarian (first come first serve vs utilitarian (benefit most)

Benefit = probability of survival in ICU – without ICU. Effects of ICU may be overestimated.

ELDICUS study –

Risk factors for death – >60, refereral location, dependent on ADLs, cirrhosis, AKI

BUT equation needs to also factor in Life expectancy (quality adjusted) – old ppl have a lower life expectancy!


Improving the ICU Environment (Curley)

Hospitals are dangerous places

Post-hospital syndrome –

What can we do?

Change paradigm

Restore resilience (R2)


Circadian rhythm assessment

Align family with care plan – decision making and care

Noise contamination and thus containment is good for patients and staff

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure


ICU diaries Crit care 2010 14 r168 –

Nurses and pts/families knowing each other – synergy and continuity


Optimal Alarms (JD Chiche)

Alarms in the ICU – why do much noise?

Nurse Crit Care 2007 12 188 Noise levels in a general intensive care unit –


Crit Care Med 2016 44 147 Noise levels in Surgical ICU are consistently above recommended standards –

Alarms are the main cause of noise

We are not very good at identifying them –

Bad alarm – desensitisation, disruption of workflow, sleep disruption

72-99% of alarm false or non-clinically significant

Alarm fatigue –

Smarter alarm algorithm – adaptive time-delays e.g. derangement needs to be sustained to trigger alarm –


False Alarm Identification and Reduction (FAIR Study)



Evaluating the risk state of the ICU (Talmor)

Traditional approach to safety – checklist e.g. CLABSI, VAP

Openness and transparency

Root-cause-analysis for all preventable harm

Safety in Healthcare – traditional vs systems (pic)


Reengineering the ICU (Brown)


  • Medical errors
  • Communication poor
  • Respect and dignity threatened
  • Fragmentation of information

Developing a comprehensive model of intensive care unit processes –

Technology – Accelerometers to document pt mobility or agitation?

Observations of respect and dignity in the intensive care unit. –

Emotional harm from disrespect: the neglected preventable harm –

ISICEM 2016 Day 2

Adrian strikes again with a neat summary of his second day in Brussels JS

How we decide

Protocols and guidelines: misaligned and misdistributed (Kavanagh)

Do protocols work in CCM?

Sevransky Crit Care Med 2015: Protocols and hospital mortality in critically ill pts

They don’t help – no difference in outcomes BUT not related to protocol compliance


Protocols surely do some good in some settings but overall the net impact is nil… therefore protocols must do harm in some settings!!



  1. Protocols misattribution

Hayes et al NEJM 2009 Surgical Safety Checklist to Reduce Mortality and Morbidity – 1/3 less complications which was attributed to implementation of key ‘processes’

BUT did increase implementation cause improved outcome?

NO concordance, almost perfect discordance – no ‘cause and effect’


2) Protocols misalignment

Variation in hospitals settings e.g. basics vs advanced, primary vs tertiary

  1. Could sophisticated setting work in rudimentary setting? NO e.g. FEAST trial.
  2. Could rudimentary protocol work in sophisticated setting i.e. dumbdown? NO

Standardized Intensive Care. Protocol Misalignment and Impact Misattribution


Situation where good

  • non-Tacit knowledge: difficult to put into words, demands talent, requires practice e.g. playing flute
  • Issue is simple and explicit
  • Reduce variability e.g. ECMO (caveat no variability = no health care research)
  • Research

In research, protocols need to be followed exactly. BUT expert clinicians nee to be more flexible.



  • Avoid misattribution
  • Avoid misalignments
  • Understand limitations of protocols
  • Assess protocols as drug
  • Understand need for protocol in research
  • Understand why you need protocol IF you need protocol because of lack of staffing or expertise, address this first!


Why don’t all ICUs use SDD? (A Gordon)

WHO Report on burden of healthcare infections

Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth

Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis

Use of SDDT in UK ICU Bastin and Ryanna – 192 UK ICUs only 10 did

Decontamination of the digestive tract and oropharynx in ICU patients.


SDD does require consensus amongst my colleagues – you need a champion

New evidence R-GNOSIS RCT in 12 European ICUs –


How personal biases influence decisions (Funk)

Illustrated by case of misdiagnsosis

Cognitive biases

Two modes of thinking (Kahnemann)

  • Fast – automatic and effortless, associations and heuristic
  • Slow – active reasoning and effort, calculations and probability

Dunning Kruger effect – unskilled doctors overestimating their ability; very skilled doctors underestimating their ability

Status quo bias – slow to change. Ignore new evidence in favour of current practice e.g. sedation, SDD

Sunk cost fallacy – when you’ve invested so much, you keep going

Omission bias – someone starts unnecessary drug (in case), and another who fails to stop it

Omission bias and decision making in pulmonary and critical care medicine CHEST 2005 128 1497

Bias blind spot – we think are not bias

De-biasing is possible

Protocols promote familiarity and hence development the clinicians’ “gut-feeling”


The influence of human factors: Looking into the mirror (Brett)

Humans are variables

Thought outside the box: ICU freakonomics and decision making in ICU (reference)

Rationale economics doesn’t make sense – if we have an emotional attachment or bias, we make foolish decisions

A lot of what we do is pattern recognition


Different ppl in teams may not see/hear the same thing – FEEDBACK/READ BACK AT END OF ROUND IS IMPORTANT


The therapeutic conflict: When each of your decisions may cause harm (Perel)

Therapeutic conflicts are common especially in pts with MOF. E.g. septic pts with ARDS, how do you manage fluids. 30mls/kg advocated by SSC

Marik and Bellomo: A rational approach to fluid therapy BJA 2015 – most septic pts are not fluid responders


How to approach?

  1. Recognise there is a conflict – ask if the pt can afford the mistake your decision might result in?
  2. Gain more information – Acting in the Face of Uncertainty: Annals Int Med 2014. Combine and integrate parameters
  3. Identify the most critical problem
  4. Choose the least potentially harmful option
  5. Make decision and closely follow its results
  6. Repeat steps from the top


Changing strategies at the right time (Hall)




How to implement changes (Stelfox)

Research should inform changes to clinical practice (discover new rx, replace current rx or reverse current rx)

BUT there is a 17 year journey from bench to clinical practice

  • Limited knowledge on implement science
  • Inefficient dissemination method
  • Inadequate assessment of cost and societal values
  • Science and clinical communities operating in isolation

The story of tight BM control on ICU; LEUVEN 1 (good) à NICE-SUGAR (bad)

Predictors of adoption – teaching vs non-teaching hospital, medical vs surgical admission



ICU Nurses: A physician’s perspective

So important and respected (especially by patients)

The nurses role 4Cs – convening, checking, caring and continuing

Developing a model of interprofessional shared clinical decision making in the ICU Crit Care Med 2016 –


The forgotten family: caregivers (Herridge)

Informal caregivers are given very little support

Caring for Caregivers of the Chronically Critically Ill –

Post-ICU Syndrome –

Mortality after the Hospitalization of a Spouse –

RECOVER Programme



Burnout and Moral Distress

Increasing problem


Burnout Syndrome in Critical Care Nursing Staff –

High Level of Burnout in Intensivists: Prevalence and Associated Factors –

Causes of moral distress theme : EoLC, communication, complex pts, bed capacity strain

Intervention (pic)

Summary (pic)



Vasoactive drugs in septic shock

Noradrenaline (JL Teboul)

Early NA increases cardiac preload and CO – crit care 2010 14 R

Due to redistributive effect from unstressed to stressed volume

OK as unstressed volume is abnormally increased during sepsis and further overfilled by volume

5 reasons to start NA


Start it when diastolic BP is low


High high should we go? (Martin)

NE: not too much, too long –


Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials


Beyond 1mcg/kg/min do not switch to other catecholamine


Vasopressin (Gordon)

Cochrane review:

The cardiopulmonary effects of vasopressin compared with norepinephrine in septic shock.

VASST Trial –

Anthony Gordon presenting the VANISH Trial @ICSmeetings #icssoa2016…

Vasopressin not superior to Norad

Alternative inotropes

  • Levosimendan: calcium channel sensitiser, K-ATP activator
  • LEOPARDS trial


Vasopressin analogues in septic shock (Russell)

Norad doses vary widely between RCTs

Selepressin Evaluation Programme for Sepsis-Induced Shock – Adaptive Clinical Trial (SEPSIS-ACT) –

Kanji et al J Crit Care 2014 Echocardiography guided care –

Selepressin in septic shock –


  • NE doses vary widely between RCTs
  • Excessive NE associated with organ dysfunction and mortality
  • Vasopressin and selepressin decrease NE requirement
  • Selepressin also moderates permeability injury more than vasopressin

Angiotensin 2 (Chawla)

Intravenous angiotensin II for the treatment of high-output shock (ATHOS trial): a pilot study –



Vasodilators (Bakker)

Vasodilators are counterintuitive in hypotensive pts

Effects of thoracic epidural anesthesia on survival and microcirculation in severe acute pancreatitis: a randomized experimental trial –

Nitroglycerin reverts clinical manifestations of poor peripheral perfusion in patients with circulatory shock –

Testing a conceptual model on early opening of the microcirculation in severe sepsis and septic shock: a randomised controlled pilot study –


  • Vasodilation optimizes venous pressure in pts with hypotension.
  • Nitroglycerin infusion improves microcirculation and lowers CVP


Nitric Oxide (De Bakker)

NO has a role in regulating microvasculature

NO synthase enzyme has several forms – constitutive and inducible

Non-selective NO inhibitors in pts with septic shock and are unlikely to be of value



Beta-blockers in sepsis (Singer)

Some sympathetic activation is necessary and good. BUT too much of a good thing, or if it persists for too long, is bad.

Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress –

Catecholamine treatment for shock–equally good or bad? –

Nonselective beta-blockade enhances pressor responsiveness to epinephrine, norepinephrine, and angiotensin II in normal man. –

Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock –





ISICEM 2016 Day 1

Adrian Wong is at The International Symposium on Intensive Care and Emergency Medicine, which is often affectionately known as “Brussels”.  He has written a mega blog covering the talks he attended today – if you are there he would love you to come up to him, say hello and tell him what you think of his blog! JS

Opening plenary

Personalised Intensive Care Medicine (JL Vincent)

3Ps pyramid – population-based/broad definitions –> personalised. We need to move from population-based to precision medicine.

Failure of large RCTs in ICM can be in part be explained by the sheer heterogeneity of population being studied.

Medicine has always been personalised (Osler)

Genomics – does survival rely solely on the individual’s genetic makeup?

                        e.g. response to vasopressin is different in population

The host response to inflammation is variable


            ARTISAN study which looks at THROMBOMODULIN

Wong et al – Developing a clinically feasible personalized medicine approach to pediatric septic shock.

“SIRS is a hiccup in history”

Report of round table meeting re: recovery after critical illness (Azoulay/Herridge)

3rd round table meeting – 2002 and 2009

2002 – Angus: Surviving Intensive Care

2009 – Griffiths and Hall: Exploring ICU-acquired weakness

Broached the idea of extending rehabilitation outside ICU but also focussed on the long-term effects on patients beyond ICU

Opportunities to improve care

  • Critical care is a disease continuum
  • Patient and family centred and engagement
  • Sound biological plausibility
  • Pts are heterogeneous
  • Role of rehabilitation in changing outcome

Long term cognitive impairment after critical illness (BRAIN-ICU study)

Depressive symptoms in patients and spouses are common

The Impact of High Versus Low Sedation Dosing Strategy on Cognitive Dysfunction in Survivors of Intensive Care Units: A Systematic Review and Meta-Analysis.

Early intensive care sedation predicts long-term mortality in ventilated critically ill patients.

The longer MV, the greater the weakness

NICE guidelines on rehabilitation after critical illness (2009)

Patient-centred outcomes/spiritual care – independent life, cognitive function, ability to work, absence of chronic pain, etc

            These may not be the same as what the doctor is aiming for

Intensive care may need to integrate with palliative care

  • Relieve distress
  • Support person
  • Manage uncertainties
  • Elicit values
  • Help caregivers

10 recommendations:

  • Look outside the ICU and embrace continuum including pre-ICU trajectory/recovery/adaptation
  • Patient and family engagement and personalised care
  • Heterogeneity risk stratification
  • Open the ICU doors
  • Addressing pain
  • Understand role, timing, indication and duration of rehabilitation
  • Comprehensive understand of neuroendocrine derangements
  • Role of long germ follow up
  • Adoption of proven strategies from other clinical settings
  • Development a comprehensive education agenda for all stakeholders

ICU-acquired infections (van der Poll)

Incidence, Risk Factors, and Attributable Mortality of Secondary Infections in the Intensive Care Unit After Admission for Sepsis

Host-response to sepsis: balance of pro- and anti-inflammatory response

Strategies = anti-inflammatory agents and immune stimulatory agents

Primary end-point – ICU-acquired infection (>48hrs after admission)

Patients who developed secondary infection where sicker (SOFA, APACHE2)

13.1% of patients admitted to ICU with sepsis will develop an ICU-AI (with attributable mortality of 10.9% by day 60)

15.1% of patients admitted to ICU with non-sepsis diagnosis will develop ICU-AI

Age isn’t a risk factor (with attributable mortality of 21.1% by day 60)

LOS with ICU-AI is significantly increased


DahLIA trial: Dexmedetomidine to lessen ICU agitation (Reade)

Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium

We don’t know how to treat delirium

Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study.

Mechanism of dexmedetomodine – sedative a2-agonist (substantially less hypotentive than clonidine)

Inclusion – pts who remain intubated only because of their degree of agitation require such a high dose of sedative medication

Intervention dex 0.5ug/kg/hr (0-1.5) or placebo

Primary end-point: ventilator-free hours after extubation

74 patients randomised (96 target)

Fewer pts in dex group required additional sedative drugs

Dex group had significantly more ventilator-free hours: 144.8 vs 127.5

Nurses thought patient was ready for extubation quicker

Time to extubation faster

Dex patients had less time CAM-ICU positive

Adding dex to standard care is likely to be a cost-effective intervention


Early vs late parenteral nutrition in critically ill children (PEPaNIC) Van der Berghe

Early versus Late Parenteral Nutrition in Critically Ill Children

Critically ill patients unable to be fed by mouth

Cochrane collaborative (2009) Nutritional support in critically ill children

Nutritional practice in PICUs varies

  • 70% start EN within 24-48hrs
  • 50% start PN within 24-48hrs
  • Adult trials question the benefit of early PN

This trial looked at early PN to supplement EN compared to EN alone

PN initiated within 24hrs after PICU admission

Both groups had early EN

End point – new infections and duration of PICU stay

1440 randomised

No difference in mortality (hint that early PN might be harmful)

Early PN associated with more infection

Duration of ICU stay increased by PN

Early PN increased MV days

Withholding PN for 1 week superior to early PN


Hypoxaemia following major surgery – NIVAS study (Jabir)

Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery

Development and validation of a score or prediction of postop respiratory complications Brueckmann et al

A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery


Treatment of Acute Hypoxemic Nonhypercapnic Respiratory Insufficiency With Continuous Positive Airway Pressure Delivered by a Face Mask

This trial – primary outcome number of re-intubation within 7 days. Inclusion resp failure within 7 days of surgical procedure

300 pts randomised

NO HIGH-FLOW NASAL CANNULA. Only traditional NIV mask used

Re-intubation 46 (control) vs 33% (NIV)

NIV group had less lung infections within 30 days

NIV increased ventilator-free days


Post-extubation high-flow nasal cannula vs conventional oxygen therapy in low-risk pts

Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients

Would HFNO prevent reintubation in low risk pts within 72 hours

Low risk – <65, APACHE2<12, BMI<30, adequate secretion management, absence of heart failure, <1 co-morbidity, absence of airway patency problems

10347 screened; 527 randomised. Majority excluded as deemed high risk for intubation

HFNO had lower reintubation rate (4.9% vs 12.2%) – also less laryngeal oedema and stridor


Individualised management of ARDS (L Brochard)

Max Harry Weil Memorial Lecture

ARDS initially described in Lancet 1967


4499 pts with hypoxemic respiratory failure

3022 with ARDS

We don’t ventilate them very well – too much TV, PEEP variable etc.


ARDS – is not a single entity.

Comparisons of Berlin definition for ARDS with autopsy (Thille AW et al AJRCCM 2013)

Subphenotypes of ARDS (Calfee CS et al Lancet Resp Med 2014)

2 phenotypes identified – Phenotype 1 has better survival characteristics

Higher vs lower PEEP in ALI/ARDS Systematic Review (JAMA 2010)

PEEP induced lung volumes to predict alveolar recruitability (Dellamonica ICM)

Oxygenation response to PEEP predicts mortality in ARDS (Goligher EC et al)


ARDS management

The concept of the baby lung. Small lung does not mean stiff lung

Stress (pressure) and Strain (deformation)

Strain – increase in lung vol/FRC

Lung stress and strain during mechanical ventilation: any safe threshold?


Compliance = tidal volume/driving pressure

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome




Reducing VILI is still the most important possibility to improve survival post ARDS. Individualised ventilation should be based on

  • Recognising ARDS
  • Assessing severity
  • Individually titrating Vt (strain) and PEEP



SOSD Phases of fluid resuscitation

Circulatory Shock – JLV and De Backer

Four phases of intravenous fluid therapy: a conceptual model

Salvage (Shapiro)

  • Fluid management in sepsis has changed considerably despite it being a time critical diagnosis
  • Obtain a minimal acceptable BP

Perform lifesaving measures


During salvage, LIBERAL FLUID RESUSCITATION – 30mls/kg??


The Bottom Line – Fluid review section


  • Approximately 4-5l
  • Antibiotics
  • Ensure critical interventions
  1. Qns which fluid – anything you can swim in
  2. Qns diastolic dysfunction – becoming more important. BUT not in the salvage phase
  3. Qns what are your markers for success – multiple e.g. BP, HR, biochemistry. When you have a BP you can leave the bedside for a minute


Optimisation (De Backer)

  • Provide adequate oxygen availability
  • Optimise CO, SvO2, lactate

Why give fluids? Expect an increase in tissue perfusion

Delayed fluid is associated with greater activation of inflammation CCM 2012 40 2841

Improvement in microcirculation associated with improved organ function

Fluids and CO (Muller Anaesthesiology 2011) – not all improve CO

Why restrict fluids? Oedema deleterious – lung oedema and tissue oedema

A positive fluid balance is associated with a worse outcome in patients with acute renal failure

Sepsis in European intensive care units: results of the SOAP study.

The Adult Respiratory Distress Syndrome Cognitive Outcomes Study Long-Term Neuropsychological Function in Survivors of Acute Lung Injury

Fluid challenges in intensive care: the FENICE study A global inception cohort study

What DBD would do (pic)


Qns what markers? Lactate. Arterial Veno CO2 gradient



Stabilisation (Slama)

  • Provide organ support
  • Minimise complications

Aim for zero or negative balance during this phase

FINNAKI study –

A positive fluid balance is an independent prognostic factor in patients with sepsis

Chloride – Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS.

Meta-analysis of chloride – Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation.

RRT and diuretics to transition to de-escalation phase


De-escalation (Marshall)

  • Wean for vasoactive drugs
  • Achieve a negative fluid balance

Prefers the term de-resuscitation

How? Spontaneous, diuretics, RRT

Strategies – fluid restrict, initial resuscitation then restrict, active de-resuscitation

Who? >72 hrs in ICU and net fluid balance > 6l




Early resuscitation in sepsis

Arterial BP targets (JL Teboul)

Why do we use vasopressor?

When to initiate?

  • Early. May not have completely be fluid resuscitate yet.
  • Look at diastolic BP

Which MAP target in septic shock?




Lots of oxygen (P Rademacher)

Altered oxygen extraction in illness and sepsis

Understanding the benefits and harms of oxygen therapy

Hyperoxia in experimental sepsis CCM 2009 37 2465

  • In animals studies, hyperoxia is anti-inflammatory and improves hemodynamics/metabolism
  • And does not cause ALI

Eur J Emerg Med 2014 31 233 Stojmeijer et al.

Hyper2S – hyperoxia and hypertonic saline (2*2 trial)

BUT trials stopped early due to worse outcome in both intervention groups


  • Hyperoxia group had better PaO2 (obviously)
  • Hyperoxia group had better SOFA by D7
  • BUT adverse events noted. Hyperoxia had more weakness, atelectasis
  • Higher mortality in hyperoxia group at D28 and D90

Hyperoxia CANNOT be recommended in pts with septic shock


Should EGDT be abandoned (De Backer)

Varpula et al ICM 2005 31 1066

Rationale for EGDT – prevent development of tissue hypoperfusion achieving targets for  MAP, SvO2 and CVP

Rivers – more fluids, RBC, Dobutamine and vasodilatory agents, sedation and mechanical ventilation. BUT criticism – single centre, potential confounders, few pts made the difference….

PROCESS, ARISE, PROMISE all didn’t show a difference

EGDT: do we have a definitive answer – De Backer and JLV 


Difference with Rivers

High ScVO2 can mean anything!


How useful are changes in lactate levels? (Fries)

EGDT what do we do now? Levy

Serum lactate as predictor of mortality in patients with infections (ICM 2007)

Serial blood lactate levels can predict the development of MOF following septic shcok (Bakker 1996 Am J Surg) – time with high lactate probably more important than the initial lactate

Lactate clearance

EMShockNet investigators – lactate clearance vs non-lactate clearance groups

Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial

German Lactate in Severe Sepsis trial




How to interpret veno-arterial pCO2 (JLT)

Simplified Fick equation

High PCO2 difference is due to blood stagnation caused by low cardiac output state

6mmHg is the magic number


EtCO2 as a cardiac output monitor (Monnet)

Revision of physiology of etCO2

3 determinants of etCO2

  • Alveolar ventilation
  • Pulmonary blood flow
  • CO2 production

Provided production of CO2 is constant, etCO2 can be used to reflect CO

End-tidal CO2 pressure determinants during hemorrhagic shock –

Relationship between etCO2 and CO is not linear

Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study –

etCO2 can be used with fluid balances



Haemodynamic monitoring

Why (Perel)

Haemodynamic instability in sepsis –

Haemodynamic status of a critically ill patients is very complex

Clinical review: Update on hemodynamic monitoring – a consensus of 16 –

Getting the Full Diagnostic Picture in Intensive Care Medicine: A Plea for “Physiological Examination”

No evidence that any form of monitor improves outcome on the ICU

Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12


How (Biais)

  • PAC
  • Transpulmonary thermodilution
  • Pulse pressure analysis
  • Arterial line – calibrated vs non-calibrated
  • Oesophageal Doppler
  • Bio-reactance/bio-impedence


  • Many device available
  • Perfect device doesn’t exists
  • Know limitations
  • Will not improve outcome by itself


Who (Monnet)

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients

Choice of monitor in theatre depends on whether vascular resistance is going to be stable


Also see Robs trial summary: