• Morten Bundgaard-Nielsen, Øivind Jans, Rasmus G Müller, André Korshin, Birgitte Ruhnau, Peter Bie, Niels H Secher, and Henrik Kehlet.
• * Research Fellow, ‡ Research Assistant, Section of Surgical Pathophysiology, The Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, and Department of Anesthesiology, The Abdominal Center, Copenhagen University Hospital, Rigshospitalet. † Research Fellow, †† Professor, Section of Surgical Pathophysiology, The Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet. § Staff Anesthesiologist, ‖ Head of Department, ** Professor, Department of Anesthesiology, The Abdominal Center, Copenhagen University Hospital, Rigshospitalet. # Professor, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.
• Anesthesiology. 2013 Oct 1;119(4):813-23.

BackgroundEarly mobilization is important for postoperative recovery but is limited by orthostatic intolerance (OI) with a prevalence of 50% 6 h after major surgery. The pathophysiology of postoperative OI is assumed to include hypovolemia besides dysregulation of vasomotor tone. Stroke volume-guided fluid therapy, so-called goal-directed therapy (GDT), corrects functional hypovolemia, and the authors hypothesized that GDT reduces the prevalence of OI after major surgery and assessed this in a prospective, double-blinded trial.MethodsForty-two patients scheduled for open radical prostatectomy were randomized into standard fluid therapy (control group) or GDT groups. Both groups received a fixed-volume crystalloid regimen supplemented with 1:1 replacement of blood loss with colloid, and in addition, the GDT group received colloid to obtain a maximal stroke volume (esophageal Doppler). The primary outcome was the prevalence of OI assessed with a standardized mobilization protocol before and 6 h after surgery. Hemodynamic and hormonal orthostatic responses were evaluated.ResultsTwelve (57%) versus 15 (71%) patients in the control and GDT groups (P = 0.33), respectively, demonstrated OI after surgery, group difference 14% (CI, -18 to 45%). Patients in the GDT group received more colloid during surgery (1,758 vs. 1,057 ml; P = 0.001) and reached a higher stroke volume (102 vs. 89 ml; P = 0.04). OI patients had an increased length of hospital stay (3 vs. 2 days; P = 0.02) and impaired hemodynamic and norepinephrine responses on mobilization.ConclusionGDT did not reduce the prevalence of OI, and patients with OI demonstrated impaired cardiovascular and hormonal responses to mobilization.

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