Do we need a dedicated hemodynamic control team?

Sir, The optimization of peri-operative haemodynamics is a key factor in decreasing the incidence of surgical complications and the length of hospital stay for high-risk patients. This is also important in critically ill patients, as presented in the recent Editorial in this journal from Wernerman and Sigurdsson. That is why several learned societies have issued guidelines on optimizing haemodynamic parameters. After an initial focus on the optimization of oxygen delivery, the concept has since been simplified to the maximization of stroke volume (while monitoring cardiac output) using fractionated fluid loading. Although this procedure is evidence-based, it is rarely used at the bedside. As has been described for the prescription of antibiotics, the implementation of a haemodynamic control team may help to improve the quality of care. Initially, a dedicated haemodynamic control team could work on adapting concepts and local dissemination and implementation of a peri-operative haemodynamic protocol, in the ‘perioperative surgical home’ model. Simple algorithms could be available in operating rooms, and postoperative care must be adapted to the patient surgical risk. Secondly, a hemodynamic control team would also be of value in complex hemodynamic situations. From determining the aetiology of acute hemodynamic instability with more complex tools (such as echocardiography techniques), this dedicated team could also assess the best treatment in each situation (inotropic agent, red blood cell transfusion and/or fluid loading in accordance with central venous oxygen saturation or lactate clearance, beta-blocker therapeutics according to the heart’s energy balance, or norepinephrine infusion). Optimizing veno-ventricular-arterial coupling is a complex task. These considerations emphasize the need for a dedicated team (Fig. 1). We are convinced that a hemodynamic control team is of value for implementing individualized, peri-operative, haemodynamic optimization in high-risk patients. Further studies are now required to validate this new concept and its implementation procedures.