Fifteen Eighty Four

When going to my hospital work, I pass a well-kept peaceful and quite large grass area surrounded by a fence. A memory stone declares that this is a mass grave of cholera victims from the 1850s. As a researcher in fluid balance, I sometimes think about how little doctors knew about this topic 175 years ago. Sadly, these deaths were preventable. Moreover, a religious detail did add to the tragedy. In those days, the hospital area was situated outside the city, which means that the victims were not buried in “sacred soil” close to the church.

For good, times have changed. Today we know a lot more, but we still don´t know all. Surgery and intensive care are settings in which the fluid balance is very complicated and challenging to handle. That is why I have chosen to focus my research on this topic. Early in my life, I was particularly troubled by the lack of useful methods to study fluid therapy. I invented a pharmacokinetic approach to study infusion fluids called “volume kinetics” in the late 1980s. This method has helped us to understand, for example, the differences between how the body handles commercially available infusion fluids in volunteers and during general anaesthesia.

Only since a couple of decades back we are aware of that infusion fluids can both save and hurt patients. The therapeutic window is still hard to define as outcome measures are multifactorial. However, the window is narrower in the sick and debilitated patients than in younger healthy individuals who still have physiological reserves that allow for missteps. Therefore, it is in the sickest patients undergoing major surgery that our skills are put on the toughest test.

Modern fluid therapy is based on knowledge about the pharmacokinetics and adverse effects of infusion fluids but also on hemodynamic monitoring. The latter topic has expanded greatly over the past 25 years along with the development of more refined equipment. Today, we may even regard fluid therapy and hemodynamic monitoring as an integrated topic.

I served as Editor for the 2011 and 2016 editions of the book “Clinical Fluid Therapy in the Perioperative Setting” at Cambridge University Press. I invited more than 30 world experts to provide overviews of their special field of fluid balance research. However, the time is now mature for including hemodynamic monitoring in the book. My idea was to merge the fluid book with an already existing book from Cambridge entitled “Perioperative Hemodynamic Monitoring and Goal Directed Therapy”. I asked my friend Maxime Cannesson about the idea, and he thought it was a good one. He also suggested Alexandre Joosten, a very successful front-line researcher in hemodynamics and fluid therapy, to join the team. I was more than happy that Alexandre accepted the challenge.

The result has been a completely new book “Hemodynamic Monitoring and Fluid Therapy during Surgery” in which Alexandre Joosten, Maxime Cannesson, and Robert Hahn serve as editors. The world´s best known researchers and specialists in the clinical use of hemodynamic measurements have contributed with chapters that provide the reader with a treasure of up-dated knowledge. 

Exciting development in recent years include closed-loop-arrangements where fluid is titrated based on feed-back from a hemodynamic monitor, guidance based on monitoring of the microcirculation, third-spacing of crystalloid fluid, and whether the perfusion index can be used to guide clinical decisions. Other chapters deal with predictive analytics and artificial intelligence, cerebral oximetry, and updated aspects on organ dysfunction.

I often think of the challenge of being a good doctor. What doctors do cannot only be based on large clinical trials that try to answer a simple question. Surgery and intensive care are too complicated for that. It is by learning how the body works and the behavior and limits of our equipment that we can guide sick patients through the most complicated surgical procedures. Experience and large clinical trials sail behind and should be used to support the decisions but the good doctor must be the manager, and that requires a lot. The insights needed to guide you is what this book gives you. I wrote an Editorial in Anesthesia & Analgesia in 2007 which I chose the entitle “fluid therapy might be more difficult than you think”. That is still true.

Title: Hemodynamic Monitoring and Fluid Therapy during Surgery

Author: Dr Alexandre Joosten, Dr Maxime Cannesson and Professor Robert Hahn

ISBN: 9781009226868