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1. Anesthesiology 2008; 109:723–40
To the Editor:
The esophageal Doppler is an important part of Perioperative
Fluid Management.
Doctors Chappell, Jacob, Hofmann-Kiefer, Conzen, and Rehm are
to be commended for their excellent paper “A Rational Approach
to Perioperative Fluid Management” in Anesthesiology 2008;
109:723–40.
I would like to mention some aspects of rational approaches to
perioperative fluid management that may be helpful. As we know
the intravascular space is not a static one. In addition to fluid
shifting out of the intravascular space (type I and type II), which is
comprehensively dealt with in this paper, fluid shifting occurs
dynamically between various vascular beds. This fluid
shifting/shunting can mitigate against and obscure hypovolemia1
posing risks to the vascular beds that are being depleted.2
Additionally the vascular beds themselves can undergo dramatic
capacitance changes secondary to anesthetic agents and techniques,
various drugs and pathophysiologic states.
Given that “the principal goal of Perioperative Fluid Optimization
is to optimize cardiac preload” and that the compartments
contributing to preload are constantly changing, it is important that
the circulation be followed, understood and managed dynamically
with continuous, real time objective data. Understanding the
hemodynamic condition and making it acceptable in real time
helps to determine the amount and time of fluid administration.
Not only does the esophageal Doppler enable us to understand and
dynamically manage preload conditions, it also enables us to
understand and manage left ventricular (LV) contractility and the
effect of afterload impedance on LV performance.

2. Stroke volume optimization via esophageal Doppler-guided fluid
boluses not only “seems to” but does improve outcome, not only
“in elderly and frail patients”, but across a wide cross section of
the adult perioperative population.
The evidence base is strong. A technology assessment done by the
Agency for Healthcare Research and Quality reviewed over 1600
peer reviewed journals and 346 specific papers and concluded that
that “Doppler-guided fluid replacement during surgery leads to a
clinically significant reduction in major complications”, that
“Doppler-guided fluid replacement during surgery leads to a
clinically significant reduction in the total number of
complications”, and that “Doppler-monitored fluid replacement
leads to a reduction in hospital stay”3. Based on this, Centers for
Medicare and Medicaid Services (CMS) determined that use of
esophageal Doppler was “reasonable and necessary” and further
that its use be covered for “monitoring of cardiac output with the
esophageal Doppler for ventilated ICU patients and operative
patients requiring fluid optimization”4. CMS subsequently issued
instructions to its regional carriers on how to process claims for
professional reimbursement for the use of esophageal
Doppler5. We are currently receiving payments to monitor and
fluid optimize our patients.
There are currently not just two, but eight randomized controlled
trials that show improved outcomes using esophageal Doppler
guided fluid optimization678910111213. These outcomes include
decreased length of stay, ICU length of stay, unplanned ICU
admissions, use of and doses of vasopressors, lactate
levels, interleukin-6 levels, time to bowel sounds, time to taking
solid diet, nausea and vomiting and decreases in major
complications such as wound infection, pneumonia, respiratory
failure, ileus, impaired renal function, and severe PONV.

3. It is incorrect to conclude, as stated in their paper, “it [Esophageal
Doppler-guided fluid boluses] has up until now been compared
with only standard fluid handling, which revealed no large
differences between the total fluid volume of the two studied
groups. (30,42) Accordingly, assuming the worst case, the actual
message behind these data could also be that esophageal Doppler-
guided fluid overload is superior to uncontrolled fluid overload”.
The proper timing of fluid administration needs to be taken into
consideration. Certainly if a patient needs a specific amount of
volume resuscitation at the beginning of a procedure, giving this
amount at the end of the procedure would most likely be of limited
benefit and may be deleterious. The total amounts administered
may be the same but the outcomes would be, and are, as shown in
the randomized controlled trials, different.
It is time to stop bringing our patients to recovery areas with
acceptable blood pressures and heart rates at best, while totally
lacking any measurement or understanding of blood flow and
vascular resistance. Knowing all of these factors is essential for
proper fluid management and care of our patients and will help
minimize overloading the interstitial space and deteriorating the
endothelial glycocalyx.
Making the esophageal Doppler a part of Perioperative Fluid
Management is not only rational, it fixes an astonishing
fundamental flaw in our lack of hemodynamic understanding in the
35 million patients that we care for each year in the United States.
And most importantly, it will improve their outcomes.
Paul W. Corey, MD.
San Diego, California

4. 1
Price HL, Deutsch S, Marshall BE, Stephen GW, Behar MG,
Neufeld GR. Hemodynamic and metabolic effects of hemorrhage
in man, with particular reference to the splanchnic circulation. Circ
Res. 1966; 18(5):469-74.
2
Hamilton-Davies C, Mythen MG, Salmon JB, Jacobson D,
Shukla A, Webb AR. Comparison of commonly used clinical
indicators of hypovolaemia with gastrointestinal tonometry. Int
Care Med. 1997; 23(3):276-81
3
Agency for Healthcare and Research and Quality. Technology
Assessment. Esophageal Doppler Ultrasound-Based Cardiac
Output Monitoring for Real-Time Therapeutic Management of
Hospitalized Patients. January 16, 2007. 1-120
4
CMS Decision Memo for Ultrasound Diagnostic Procedures
Administrative File CAG-00309R, Final Coverage Decision
Memorandum for Ultrasound Diagnostic Procedures, May 22,
2007
5
Centers for Medicare and Medicare Services, Pub 100-03
Medicare National Coverage Determinations; Transmittal 76:
September 12 2007
6
Mythen M G, Webb A. R. Perioperative plasma volume
expansion reduces the incidence of gut mucosal hypoperfusion
during cardiac surgery. Arch Surg. 1995;130:423-429.

5. 7
Sinclair S, James S, Singer M, Intraoperative intravascular
volume optimization and length of hospital stay after repair of
proximal femoral fracture: randomized controlled trial BMJ 1997;
315:909-912
8
Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, and
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:
65-71.
9
Gan TJ , Soppitt A, Maroof M, El-Moalem H, Robertson K M,
Moretti E, Dwane P, Glass PSA., Goal-directed Intraoperative
Fluid Administration Reduces Length of Hospital Stay after Major
Surgery. Anesthesiology 2002; 97(4):820-826
Wakeling H. G, McFall M. R, Jenkins C. S, Woods W. G. A,
10
Miles W. F. A, Barclay G. R, and Fleming S. C. Intraoperative
esophageal Doppler guided fluid management shortens
postoperative hospital stay after major bowel surgery, BJA: British
Journal of Anesthesia 2005; 95(5): 634-642.
11
Noblett S. E, Snowden C. P, Shenton B. K, Horgan A. F.
Randomized clinical trial assessing the effect of Doppler-
optimized fluid management on outcome after elective colorectal
resection. BJS 2006; 93(9):1069-1076
12
McKendry M, McGloin H, Saberi D, Caudwell L, Brady A R,
Singer M. Randomized controlled trial assessing the impact of a
nurse delivered, flow monitored protocol for optimization of
circulatory status after cardiac surgery. BMJ 2004;329(7460):258.
E pub 2004
Chytra I, Pradl R, Bosman R, Pelnar P, Kasal E, Zidkova A.
13
Esophageal Doppler guided fluid management decreases blood

6. lactate levels in multiple trauma Patients: a randomized controlled
trial. Critical Care 2007, 11R24: 1-24