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Doppler Monitoring Papers in BJA’s Top 25 Influencers

Last month saw World Anaesthesia Day and now this month we’re also celebrating the 25th anniversary of the Royal College of Anaesthetists, which received its Royal Charter as recently as 1992. TheBritish Journal of Anaesthesia has marked the events by selecting 25 papers it considers to have been its most influential. It published the earliest in 1954!

In recognition of the undoubted impact of oesophageal Doppler monitoring in recent years, of the 25 papers cited, two relate to the technology. The earlier (2002) paper* (Venn et al) compares conventional intraoperative fluid management with two methods of invasive monitoring (central venous pressure and oesophageal Doppler) and concludes that; “Invasive intraoperative haemodynamic monitoring with fluid challenges during repair of femoral fracture under general anaesthetic shortens time to being medically fit for discharge.”

The later (2005) paper** investigated the phenomenon of occult hypovolaemia during surgery. The authors discuss the idea that this common and often unrecognised state could lead to intraoperative gut hypoperfusion. This is associated with increased morbidity and longer postoperative hospital stay.

The study was undertaken by Wakeling et al and funded by an NHS Executive South East Research and Development grant. It was single centre, blinded and randomised to test the hypothesis that application of goal-directed intraoperative fluid management using oesophageal Doppler, would reduce complications associated with gut hypoperfusion in major bowel surgery. The paper concludes, “This study supports the hypothesis that intraoperative hypovolaemia is common and that the outcome from major surgery can be improved by following a simple dynamic oesophageal Doppler guided fluid algorithm.”

Dr Howard Wakeling, principle author of the 2005 study stated; “While the dangers of hypoperfusion were recognised before we undertook our study, this was the first time anyone had demonstrated the positive impact of guided fluid therapy in a blinded, randomised, single centre patient group.

“So not only was the risk recognised, we could actually do something about it that would result in undeniably better outcomes for patients… and significantly reduced costs!”

Dr Wakeling added; “The other major distinguishing point about my trial is that we used best conventional treatment to show the Doppler was better than anything else available. There are virtually no other studies which have controlled the control group to best treatment even now.”

Deltex Medical’s Managing Director, Andy Mears commented; “Despite the intervening years, these two papers still underpin everything we recognise in the power of intraoperative fluid management to deliver better patient outcomes. The fact that the BJA recognises them as two of their most important studies in the last 63 years is testament to the impact oesophageal Doppler monitoring has had. It remains the most accurate, real-time method of assessing haemodynamic status, direct from the aorta.”

*Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures: R. Venn A. Steele P. Richardson J. Poloniecki M. Grounds P. Newman
BJA: British Journal of Anaesthesia, Volume 88, Issue 1, 1 January 2002, Pages 65–71, https://doi.org/10.1093/bja/88.1.65

**Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery:
H. G. Wakeling M. R. McFall C. S. Jenkins W. G. A. Woods W. F. A. Miles G. R. Barclay S. C. Fleming BJA: British Journal of Anaesthesia, Volume 95, Issue 5, 1 November 2005, Pages 634–642, https://doi.org/10.1093/bja/aei223