These patients benefited from reduced vasopressor and inotrope requirement, reduced duration of mechanical ventilation and were ready for ICU discharge earlier than the control group [61].The Flotrac (Edwards, selleck chem inhibitor Irving, USA) is a blood flow sensor needing no calibration that attaches to the patient’s existing arterial line and, in conjunction with the processing and display unit (Vigileo monitor), provides non-invasive cardiac output monitoring that derives its values from the arterial blood pressure signal. Comparisons with other reference techniques have been inconsistent and, to date, it remains untested in a GDT algorithm [37].How to achieve the goalsThe aim of GDT is to prevent tissue oxygen debt by maintaining tissue perfusion. Many studies have tried to achieve this by augmenting DO2.

CO should be optimised in reference to preload, afterload, contractility and stroke volume whilst maintaining an adequate coronary perfusion pressure. There is an optimal haematocrit that is sufficient for oxygen transport but does not compromise rheology and, in general, haemoglobin should be kept above 7 g/dl (aiming higher in patients with ischaemic heart disease) [62]. In all studies patients have been kept well oxygenated and there is some evidence that the use of continuous positive airways pressure in the post-operative period is beneficial [63]. Fluid boluses alone may be sufficient to achieve goals of CO and DO2, and GDT using just fluids has been shown to improve outcome in certain groups of surgical patients [31,48,49].

Often fluids may not be sufficient to achieve these goals and, in addition, a positive inotrope or vasodilator is necessary. Lobo and co-workers [64] compared the use of fluids and dobutamine or fluids alone to achieve the goal of DO2I >600 ml/minute/m2 in high-risk surgical patients. The use of fluid and dobutamine conferred better post-operative outcomes with less cardiovascular complications than the fluid alone group. Those patients given dobutamine were more likely to achieve the goals. Dobutamine is also a positive inotrope and peripheral vasodilator. Dopexamine is a dopamine analogue with actions at beta adrenoreceptors and also at peripheral dopamine receptors. It is a positive inotrope and peripheral vasodilator that improves microcirculatory flow and splanchnic perfusion and oxygenation, which may reduce inflammation secondary to the tissue hypoxia and translocation of bacterial products or endotoxin.

This is probably the most extensively studied drug Entinostat in this setting and a recent meta-analysis has demonstrated it to be of considerable use, with low-dose infusion (��1 ��g/kg/minute) associated with survival benefit and reduction in hospital stay. A survival benefit has not been seen with doses higher than this [65].