This topic was selected because an evidence synthesis beats a textbook on it: the trials disagree, or the guidance has moved recently.
THE EVIDENCE
What each source contributes, and how strong it is
Study design first — a cohort and a randomised trial do not carry the same weight.
Design
Year
Journal
What it found
Guideline
2025
British journal of anaesthesia
Goal-directed haemodynamic therapy is not recommended routinely for major elective
Cohort
2023
Acta anaesthesiologica Scandinavic
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke
Meta-analysis
2018
European journal of anaesthesiolog
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and
Randomised trial
2020
British journal of anaesthesia
In transthoracic oesophagectomy, goal-directed therapy targeting stroke volume
Review
2018
British journal of anaesthesia
Intraoperatively, maintain euvolemia using an individualized goal-directed therapy
Meta-analysis
2021
England)
Goal-directed therapy reduced overall postoperative complications regardless of the
6 resolved citations behind this deck; every point above traces to one of them.
WHERE THE GUIDANCE SITS
What the guidelines and pooled evidence say
3 findings, each on the slide that follows.
British journal of anaesthesia 2025
Goal-directed haemodynamic therapy is not recommended routinely for major elective
Goal-directed haemodynamic therapy is not recommended routinely for major elective abdominal surgery; consider it patient by patient in moderate- to…
European journal of anaesthesiology 2018
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and pneumonia, kidney injury and wound infection — but subgroup analysis…
England) 2021
Goal-directed therapy reduced overall postoperative complications regardless of the
Goal-directed therapy reduced overall postoperative complications regardless of the total volume infused
WHERE THE GUIDANCE SITS
Goal-directed haemodynamic therapy is not recommended routinely for major elective
Guideline · British journal of anaesthesia
Goal-directed haemodynamic therapy is not recommended routinely for major elective abdominal surgery; consider it patient by patient in moderate- to high-risk major noncardiac surgery, and do not use fixed low-dose inotrope infusions as part of the protocol.
Perioperative Quality Initiative Consensus Statement on Goal-Directed Haemodynamic Therapy, British journal of anaesthesia 2025 · PMID 40640043
WHERE THE GUIDANCE SITS
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and
Meta-analysis · European journal of anaesthesiolog
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and pneumonia, kidney injury and wound infection — but subgroup analysis found no mortality benefit for fluid-only protocols.
Does Goal-Directed Haemodynamic and Fluid Therapy Improve Peri-Operative Outcomes?: A Systematic Review and Meta-Analysis, European journal of anaesthesiology 2018 · PMID 29369117
WHERE THE GUIDANCE SITS
Goal-directed therapy reduced overall postoperative complications regardless of the
Meta-analysis · England)
Goal-directed therapy reduced overall postoperative complications regardless of the total volume infused, but did not reduce perioperative mortality or any single organ-specific complication.
Association Between Perioperative Fluid Administration and Postoperative Outcomes: A 20-Year Systematic Review and a Meta-Analysis of Randomized Goal-Directed Trials in Major Visceral/Noncardiac Surgery, Critical care (London, England) 2021 · PMID 33522953
WHAT THE TRIALS FOUND
In transthoracic oesophagectomy, goal-directed therapy targeting stroke volume
Randomised trial · British journal of anaesthesia
In transthoracic oesophagectomy, goal-directed therapy targeting stroke volume variation below 8% reduced death or major complications from 35% to 19%.
Impact of Intraoperative Goal-Directed Fluid Therapy on Major Morbidity and Mortality After Transthoracic Oesophagectomy: A Multicentre, Randomised Controlled Trial, British journal of anaesthesia 2020 · PMID 33092805
THE NUMBERS
Goal-directed therapy nearly halved major morbidity in oesophagectomy
A 15.9 percentage-point absolute reduction in a high-risk operation.
Impact of Intraoperative Goal-Directed Fluid Therapy on Major Morbidity and Mortality After Transthoracic Oesophagectomy: A Multicentre, Randomised Controlled Trial, British journal of anaesthesia 2020 · PMID 33092805
IN PRACTICE
What the cohorts and reviews add
2 findings, each on the slide that follows.
Acta anaesthesiologica Scandinavica 2023
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke volume by 10%
British journal of anaesthesia 2018
Intraoperatively, maintain euvolemia using an individualized goal-directed therapy
Intraoperatively, maintain euvolemia using an individualized goal-directed therapy plan based on patient and surgical risk, matching monitoring needs…
IN PRACTICE
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke
Cohort · Acta anaesthesiologica Scandinavic
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke volume by 10%, and the chance fell to near zero when stroke volume already exceeded 100 mL and had dropped less than 8% since the last optimisation.
Predicting Fluid Responsiveness Using Esophagus Doppler Monitoring and Pulse Oximetry Derived Pleth Variability Index; Retrospective Analysis of a Hemodynamic Study, Acta anaesthesiologica Scandinavica 2023 · PMID 37140405
THE NUMBERS
Most boluses during goal-directed therapy do nothing
Chance the next bolus raises stroke volume by ≥10%, by pre-bolus state.
Fluid responsiveness varied sharply with the pre-bolus state in this retrospective analysis; it describes an association, not a validated rule for withholding a bolus.
Predicting Fluid Responsiveness Using Esophagus Doppler Monitoring and Pulse Oximetry Derived Pleth Variability Index; Retrospective Analysis of a Hemodynamic Study, Acta anaesthesiologica Scandinavica 2023 · PMID 37140405
IN PRACTICE
Intraoperatively, maintain euvolemia using an individualized goal-directed therapy
Review · British journal of anaesthesia
Intraoperatively, maintain euvolemia using an individualized goal-directed therapy plan based on patient and surgical risk, matching monitoring needs with hemodynamic goals to reduce complications and length of stay.
Current Concepts of Fluid Management in Enhanced Recovery Pathways, British journal of anaesthesia 2018 · PMID 29406186
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Goal-directed haemodynamic therapy is not recommended routinely for major elective abdominal surgery; consider it patient by patient in moderate- to high-risk major noncardiac surgery, and do not use fixed low-dose inotrope infusions as part of the protocol.
2
2
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and pneumonia, kidney injury and wound infection — but subgroup analysis found no mortality benefit for fluid-only protocols.
3
3
Goal-directed therapy reduced overall postoperative complications regardless of the total volume infused, but did not reduce perioperative mortality or any single organ-specific complication.
4
4
In transthoracic oesophagectomy, goal-directed therapy targeting stroke volume variation below 8% reduced death or major complications from 35% to 19%.
5
5
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke volume by 10%, and the chance fell to near zero when stroke volume already exceeded 100 mL and had dropped less than 8% since the last optimisation.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
Goal-directed haemodynamic therapy is not recommended routinely for major elective
British journal of anaesthesia 2025
Only 44% of boluses given during goal-directed fluid therapy actually raised stroke
Acta anaesthesiologica Scandinavica 2023
Across 95 trials, goal-directed therapy reduced mortality (odds ratio 0.66) and
European journal of anaesthesiology 2018
In transthoracic oesophagectomy, goal-directed therapy targeting stroke volume
British journal of anaesthesia 2020
Goal-directed haemodynamic therapy is not recommended routinely for major elective
Questions I'll ask you in the room
How does your plan change if the patient is not optimised?
What is the physiology behind what we just did?
Talk me through the trade-off you made there.
What would make you abandon this plan and do something else?
Oral boards stem
A 70-year-old is three hours into an open pancreaticoduodenectomy. Estimated blood loss is 600 mL, urine output has been 15 mL/hr for two hours, and the resident wants to give a litre of crystalloid.
Board questions
1. Within an enhanced recovery pathway, state the intraoperative volume status you should aim for, how the fluid plan should be chosen, and the two outcomes this approach is intended to improve.
Show answer
Aim for euvolemia using an individualized goal-directed therapy plan based on patient and surgical risk, matching the monitoring to the hemodynamic goals. The stated aims are to reduce complications and length of stay.
Euvolemia is the target, and the monitoring you pick should match the haemodynamic goals for that patient and that operation.
Current Concepts of Fluid Management in Enhanced Recovery Pathways, British journal of anaesthesia 2018 · PMID 29406186
2. During goal-directed fluid therapy guided by stroke volume, what proportion of fluid boluses in a retrospective haemodynamic analysis actually raised stroke volume by 10%, and what two measured conditions identified boluses with essentially no chance of working?
Show answer
Only 44% of boluses raised stroke volume by 10%. The chance fell to near zero when stroke volume already exceeded 100 mL and had dropped less than 8% since the last optimisation.
More than half the boluses in that analysis did nothing to stroke volume - a high stroke volume that has barely fallen is a signal to stop giving fluid.
Predicting Fluid Responsiveness Using Esophagus Doppler Monitoring and Pulse Oximetry Derived Pleth Variability Index; Retrospective Analysis of a Hemodynamic Study, Acta anaesthesiologica Scandinavica 2023 · PMID 37140405
3. In a multicentre randomised controlled trial of transthoracic oesophagectomy, goal-directed therapy was titrated to one specific haemodynamic variable. State the target used and the effect on the trial's composite outcome, giving both event rates.
Show answer
The target was stroke volume variation below 8%. Death or major complications fell from 35% to 19%.
That 35% to 19% difference belongs to transthoracic oesophagectomy with a stroke volume variation target below 8% - that is the setting in which it was shown.
Impact of Intraoperative Goal-Directed Fluid Therapy on Major Morbidity and Mortality After Transthoracic Oesophagectomy: A Multicentre, Randomised Controlled Trial, British journal of anaesthesia 2020 · PMID 33092805
4. A meta-analysis of 95 trials of goal-directed therapy reports a mortality odds ratio of 0.66 along with reductions in pneumonia, kidney injury and wound infection. A resident asks whether this means running fluid by a stroke-volume protocol saves lives. Answer using what the subgroup analysis of that same meta-analysis showed.
Show answer
No. The overall pooled result was reduced mortality (odds ratio 0.66) and less pneumonia, kidney injury and wound infection, but subgroup analysis found no mortality benefit for fluid-only protocols, so the mortality signal did not hold for fluid alone.
The headline mortality odds ratio came from goal-directed therapy as a whole; the fluid-only subgroup showed no mortality benefit.
Does Goal-Directed Haemodynamic and Fluid Therapy Improve Peri-Operative Outcomes?: A Systematic Review and Meta-Analysis, European journal of anaesthesiology 2018 · PMID 29369117
The bottom lineGoal-directed haemodynamic therapy is not recommended routinely for major elective
Sources
[1] Perioperative Quality Initiative Consensus Statement on Goal-Directed Haemodynamic Therapy, British journal of anaesthesia 2025 · PMID 40640043 open
[2] Predicting Fluid Responsiveness Using Esophagus Doppler Monitoring and Pulse Oximetry Derived Pleth Variability Index; Retrospective Analysis of a Hemodynamic Study, Acta anaesthesiologica Scandinavica 2023 · PMID 37140405 open
[3] Does Goal-Directed Haemodynamic and Fluid Therapy Improve Peri-Operative Outcomes?: A Systematic Review and Meta-Analysis, European journal of anaesthesiology 2018 · PMID 29369117 open
[4] Impact of Intraoperative Goal-Directed Fluid Therapy on Major Morbidity and Mortality After Transthoracic Oesophagectomy: A Multicentre, Randomised Controlled Trial, British journal of anaesthesia 2020 · PMID 33092805 open
[5] Current Concepts of Fluid Management in Enhanced Recovery Pathways, British journal of anaesthesia 2018 · PMID 29406186 open
[6] Association Between Perioperative Fluid Administration and Postoperative Outcomes: A 20-Year Systematic Review and a Meta-Analysis of Randomized Goal-Directed Trials in Major Visceral/Noncardiac Surgery, Critical care (London, England) 2021 · PMID 33522953 open