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Clinical Evidence

Clinical Evidence

Deltex Medical has a large body of Clinical Evidence and Educational Resources to support any hospital education program.

As well as  a large number of clinical papers, available in our Library, we have a range of Randomized Controlled Trials and a Meta-Analysis. These provide an in-depth understanding of how Esophageal Doppler Monitoring, Fluid Management and Enhanced Recovery can improve patient outcomes.

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This Meta-Analysis has been prepared rigorously and objectively by Deltex Medical’s lead scientist. It is designed to be a valuable resource to everyone interested in the evidence for Intraoperative Fluid Management (IOFM) and may be downloaded and used without any need for permission.

Click here to download the full Meta-Analysis

This Meta-Analysis of published outcome evidence of fluid management using a Stroke Volume Optimization (SVO) strategy confirms that EDM is the only technology that can reduce both the incidence of complications and the length of hospital stay during surgery.

Studies of EDM-guided SVO for fluid management demonstrate a reduction in the incidence of postoperative complications, whereas studies using an arterial pressure based device (PPWA) to guide SVO for IOFM did not:

Comp 11.12

EDM-guided IOFM demonstrated a 1.1-day reduction in length of hospital stay, an outcome not obtained with PPWA technologies.

Deltex Medical plans to update the meta-analysis as it becomes aware of further studies newly published in peer reviewed journals to create a ‘living’ up to date meta-analysis.

LOS 11.12

Visitors to this page are invited to contact the author by email, should you wish to highlight any new or published studies which may merit inclusion:


A number of Randomized Controlled Trials (RCTs) have been conducted using the EDM to guide fluid management during surgery. See below for a summary of each, or the [Library] for a list of references.

Pillai, 2011 Summary

Clinical Application: Intraoperative

This double-blinded, randomized controlled trial compared routine intraoperative fluid management (fluids administered at the discretion of the anesthetist) with or without additional fluid guided by esophageal Doppler monitoring (EDM).


Sixty six patients undergoing radial cystectomy were randomly allocated into either the control or intervention group. Both groups received fluid management at the discretion of the anesthetist, however, the intervention group also received additional colloid guided by EDM. Outcome measures included markers of gastrointestinal morbidity, postoperative nausea and vomiting, wound infection, and intraoperative fluid volumes.


The intervention patients experienced less gastrointestinal morbidity; the number of patients experiencing ileus was reduced from 53% to 22% (P<0.001), the time flatus was reduced from 5.36 to 3.55 days (P<0.01), and the mean time to bowels opening was reduced from 9.79 to 6.53 days (P=0.02).

Postoperative nausea and vomiting (PONV) were significantly lower in the intervention group. Only 9% of the intervention patients experienced PONV at 24 hours postoperatively (vs. 32% of the control patients; P<0.01). At 48 hours postoperatively, 3% of the intervention and 38% of the control patients experienced PONV (P<0.0001). Both superficial and deep wound infections were also lower in the intervention group (6%) vs. the control (29%), P<0.01.

Mean length of hospital stay was reduced (non-significantly) by 4 days in the intervention patients (18 days vs. 22 days [control], P=0.12).

The intervention patients received more intraoperative fluid overall when compared with the control patients (0.23 mL/kg/min vs. 0.19 mL/kg/min; P<0.01). However, when total fluid administered was subdivided into that given during each hour of surgery, the volume administered was only different in the first hour of the procedure. During this time, the intervention group received ~50% more fluid than the control group (21 mL/kg vs. 14 mL/kg; P=0.0001).


This study demonstrates that using the EDM to guide fluid management during surgery significantly improves patient outcome when compared to fluid management guided by the anesthetist alone.

The patients in this study who had additional fluid management guided by the esophageal Doppler device, experienced less gastrointestinal morbidity, less postoperative nausea and vomiting, and less wound infections. These findings are comparable with previous randomised controlled trials that have used EDM to guide intraoperative fluid management, and demonstrated reductions in postoperative complications and length of hospital stay when compared with traditional care [1-6].

An interesting observation from this study is that the only intraoperative period where the intervention patients received more fluid than the control patients was in the first hour of surgery. This finding indicates that the important time for fluid administration during surgery may be early in the procedure, a concept supported by Noblett et al. [3]. Early fluid optimization ensures adequate circulating blood volume and may reduce the postoperative complications that can be attributed to hypovolemia.

  1. Gan, T.J.S., A.; Maroof, M.; el-Moalem, H.; Robertson, K. M.; Moretti, E.; Dwane, P.; Glass, P. S., Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology, 2002. 97(4): p. 820-6.
  2. Mythen, M.G.W., A. R., Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg, 1995. 130(4): p. 423-9.
  3. Noblett, S.E.S., C. P.; Shenton, B. K.; Horgan, A. F., Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg, 2006. 93(9): p. 1069-76.
  4. Sinclair, S.J., S.; Singer, M., Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ, 1997. 315(7113): p. 909-12.
  5. Venn, R.S., A.; Richardson, P.; Poloniecki, J.; Grounds, M.; Newman, P., Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth, 2002. 88(1): p. 65-71.Wakeling, H.G.M., M. R.; Jenkins, C. S.; Woods, W. G.; Miles, W. F.; Barclay, G. R.; Fleming, S. C., Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth, 2005. 95(5): p. 634-42.
  6. Wakeling, H.G.M., M. R.; Jenkins, C. S.; Woods, W. G.; Miles, W. F.; Barclay, G. R.; Fleming, S. C., Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth, 2005. 95(5): p. 634-42.

Challand, 2012 Summary

Clinical Application: Intraoperative

This double-blinded controlled trial compared goal-directed therapy (GDT; using esophageal Doppler monitoring (EDM) for intraoperative fluid management with that of routine care.


179 patients undergoing elective colorectal surgery underwent cardiopulmonary exercise testing prior to being categorized as aerobically ‘fit’ (anaerobic threshold >11 mL O2/kg/min; n=123) or ‘unfit’ (n=56). Within each fitness group, patients were randomly assigned to receive fluid management using GDT or based on routine care. Patients included those undergoing both open and laparoscopic procedures. Outcome measures included readiness for discharge, actual length of stay, and postoperative complications.


There was no difference in the amount of maintenance fluid given to the GDT and control groups (mean: 3849 mL vs. 4010 mL respectively). Approximately 90% of this maintenance fluid was crystalloid, infused at ~17 mL/kg/h. The GDT group received on average an additional 1360 mL of colloid (in the form of 200 mL boluses to optimise stroke volume (SV)). The GDT and control groups were 4179 mL and 4062 mL respectively in positive fluid balance at end of the day of their surgical procedure.

Time to readiness for discharge (6.8 [GDT] vs. 4.9 days [control]; P=0.09) and actual length of hospital stay (8.8 vs. 6.7 days; P=0.09) tended to be longer in the GDT group. This difference in length of stay became significant when analysis was performed on the aerobically ‘fit’ patients only. There were no significant differences in other outcome parameters including, gastrointestinal morbidity, serious postoperative complications, critical care admission or mortality between the GDT and control groups.


The authors conclude “Intraoperative SV optimization conferred no additional benefit over standard fluid therapy. In an aerobically fit subgroup of patients, GDT was associated with detrimental effects on the primary outcome.”


The results from this study are at odds with the previously published randomized controlled trials that use EDM to guide fluid management. The reasons for this may be related to the following:

  • Large volumes of maintenance crystalloid were administered to both patient groups. The authors aimed to target 10 mL/kg/h, but actually gave 17 mL/kg/h, an amount much higher than the recommended maintenance crystalloid rates of <2 mL/kg/h [1]. These high volumes of fluid may have placed the patients at risk of fluid overload.
  • The double-blinded nature of the study meant that during the procedure the anesthetist (infusing the maintenance fluid) and the investigator (administering the colloid boluses) were unable to correspond with each other. Therefore, even once the patient had an optimized SV (as deemed by the ODM), the anesthetist may still have been infusing high levels of maintenance crystalloid.
  • The poor randomization of the groups resulted in the GDT group having: fewer bowel preparations but more preoperative crystalloid loading, more epidurals, more blood transfusions and fewer laparoscopic procedures. These factors may have biased the GDT group towards a longer length of stay.
Summary of Responses

This study has generated responses from readers and the authors themselves, some of these are summarised as follows:

  • “The EDM data were only available to the investigator, who could, according to the algorithm, give boluses of colloid until no further increase in SV was recorded. At this point they would give no further fluid. The anesthetist without this information would continue to give maintenance and other fluid they felt necessary…It seems the study design led to more fluid being given than might have been if the ODM data were visible to the an esthetist.” Rivers, 2012 [2]
  • “This study provides a surprising result…which is in contrast to the large body of available data supporting the use of GDT in open surgery and the NICE technology appraisal… It is hard to see from the data presented exactly what led to the delayed readiness for discharge as tolerance of diet, bowel movement, flatus passed, renal complications, and postoperative complications did not show any significant difference between the two groups… As with many studies, it raises more questions than it directly answers.” Isherwood, 2012 [3]
  1. Mythen, M.G.S., M.; Acheson, N.; Crawford, R.; Jones, K.; Kuper, M.; McGrath, J. S.; Horgan, A. F., Perioperative fluid management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine, 2012. 1(2).
  2. Rivers, J., Intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth, 2012. 108(6): p. 1036; author reply 1037.
  3. Isherwood, P., Re: Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth, 2012. 108(6): p. 1036-7; author reply 1037.


Case Studies

Postoperative hypovolemia responding to fluid management


Sussex, UK

70 year old man, weight 87 kg, height 178 cm, BSA 2.06m2.

Postoperative cardiac surgery in cardiac recovery unit.

Patient remained ventilated and sedated.

BP adequate, patient warming up, urine output adequate, CVP 4mmHg.

Baseline Readings

CO/CI low.   HR not necessarily compensating CO/CI at this stage.

Baseline readings

SV low. Possible relative hypovolemia due to vasodilating with warming/sedation.

FTc low. Possible relative hypovolemia due to vasodilating with warming/sedation.

PV reduced. For a healthy individual at age 70, PV should be approximately 50-80cm/s.

The clinician suspected hypovolemia and a rapid 200ml fluid challenge was given.

Following a 200ml fluid challenge

Using the Frank-Starling mechanism and following a rapid fluid challenge, SV is expected to rise by 10% or more in a fluid responsive patient.

No increase in SV. CO, BP and HR unchanged. FTc increased slightly. The clinician believed that there was a sustained relative hypovolaemia because the patient was continuing to warm and therefore decided to give further fluid.

1st 200ml fluid challenge

Following a 2nd 200ml fluid challenge

SV now increased by more than 10% from 59ml to 76ml. Other ODM parameters also increasing. FTc increase is consistent with a reduction in the vasoconstriction associated with compensation therefore reducing afterload. The clinician believed that PV is increasing to match the increased preload. HR and BP are essentially unchanged. Since the SV has now increased appropriately, a further 200ml was given.

2nd 200ml fluid challenge

Following a 3rd 200ml fluid challenge

SV increased by more than 10% indicating the heart was still fluid responsive.

FTc, CO and PV also continue to increase. BP increased slightly. CVP increased to 8mmHg.

Following a 4th fluid challenge, the SV did not increase by 10% and since the flow parameters, BP and HR were all now acceptable; the clinician decided not to give further fluid and reassess within 15 minutes.

3rd Fluid Challenge


Despite no changes after the first challenge, a decision to try further fluid resulted in the appropriate response. This will depend on the clinical situation as to whether to give a second bolus or not. In this case scenario, the patient was dilating due to postoperative warming. This caused a relative hypovolemia where the circulating volume was inadequate. BP, CVP, HR and urine output did not indicate a hypovolemic situation and responded slower to the fluid. Without this type of monitoring, the appropriate resuscitation for covert hypovolemia would have been missed.

Effects of vasodilation, useful ectopics


Montreux, Switzerland

83 year old man, Wt 66kg. Ht 177 cm, BSA 1.82 m2. Intraoperative closure of colostomy. No cardiac history

Baseline at start of surgery

CO, SV and FTc may be acceptable for a healthy resting individual. CI and PV are on the lower end of normal A normal PV for this age is approximately 50-80cm/s. Although these parameters appear normal, vasodilation and therefore low resistance/afterload is usually expected with anaesthesia, but since FTc is ‘normal’, the vasodilation could be masked by a relatively low preload.

Baseline at start of surgery

After epidural top up

Before a fluid challenge was considered, a bolus of the epidural was given. This is likely to cause further dilation. SV, SVI and PV have reduced, which may indicate that preload may not be sufficient. CO/CI is similar, FTc has increased slightly. The clinician surmised that there may be relative hypovolemia present due to vasodilation, and two 200ml rapid fluid challenges were given to fill the dilated vascular space.

After epidural top up

Useful ectopic

All parameters have increased following the fluid and in particular the SV has increased by >10% indicating fluid responsiveness. Subsequently, isolated atrial ectopics were seen on the ECG. This can be useful when using EDM monitoring to determine fluid responsiveness. If the waveform after the ectopic is larger than a normal waveform, this indicates that the compensatory pause allows more filling and this larger waveform indicates fluid responsiveness.

Useful ectopic

Flow parameters reduced

Despite these indications of a possible reduction in circulating blood volume, no further fluid was given and 10 minutes later, SV and other parameters reduced. The clinician then gave three fluid challenges as per algorithm with good SV increases.

Flow parameters reduced

After 3rd fluid challenge. Abdomen now closed

SV increased by >10 %. Other flow parameters increased. These indicate good responses to fluid.

After 3rd fluid challenge, abdomen now closed


This case scenario describes how relative hypovolaemia can be missed. Since FTc is inversely related to resistance/afterload, it can be assumed that when the patient is dilated, that FTc should rise, however if the vascular space remains under filled (relative hypovolemia), the flow numbers may reduce initially until filling commences. It also describes how the presence of isolated ectopics could have helped the clinician to diagnose fluid responsiveness earlier. Both of these issues can be observed and corrected using the EDM monitors.


FTC – Flow Time corrected ECG – Electrocardiograph
CO – Cardiac Output/CI – Cardiac Index Wt – Weight
SV – Stroke Volume/SVI – Stroke Volume Index Ht – Height
PV – Peak Velocity BSA – Body Surface Area


BP – Blood Pressure CVP – Central Venous Pressure
CO – Cardiac Output HR – Heart Rate
SV – Stroke Volume Wt – Weight
FTc – Flow Time corrected Ht – Height
PV – Peak Velocity BSA – Body Surface Area



There is a large body of evidence to support the use of Deltex Medical’s technology. This includes an AHRQ Technology Assessment,  NICE recommendation, Randomized Controlled Trials (RCTs), published Audit studies, Reviews and Meta-Analyses, and Case Histories. Click here for a pdf version of the Deltex Medical Bibliography.


Intraoperative: EDM RCTs

Mythen, M.G. and Webb, A.R., Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg, 1995. 130(4): p. 423-9.

Sinclair, S., James, S., and Singer, M., Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ, 1997. 315(7113): p. 909-12.

Gan, T.J., Soppitt, A., Maroof, M., el-Moalem, H., Robertson, K.M., Moretti, E., Dwane, P., and Glass, P.S., Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology, 2002. 97(4): p. 820-6.

enn, R., Steele, A., Richardson, P., Poloniecki, J., Grounds, M., and Newman, P., Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth, 2002. 88(1): p. 65-71.

Wakeling, H.G., McFall, M.R., Jenkins, C.S., Woods, W.G., Miles, W.F., Barclay, G.R., and Fleming, S.C., Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth, 2005. 95(5): p. 634-42.

Noblett, S.E., Snowden, C.P., Shenton, B.K., and Horgan, A.F., Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. The Br J Surg, 2006. 93(9): p. 1069-76.

Senagore, A.J.E., Emery, T., Luchtefeld, M., Kim, D., Dujovny, N., Hoedema, R., Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum, 2009. 52(12): p. 1935-40.

Pillai, P.M., McEleavy, I., Gaughan, M., Snowden, C., Nesbitt, I., Durkan, G., Johnson, M., Cosgrove, J., Thorpe, A., A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol, 2011. 186(6): p. 2201-6.

Brandstrup, B., Svendsen, P.E., Rasmussen, M., Belhage, B., Rodt, S.A., Hansen, B., Moller, D.R., Lundbech, L.B., Andersen, N., Berg, V., Thomassen, N., Andersen, S.T., and Simonsen, L., Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth, 2012. 109(2): p. 191-9.

Challand, C.S., Struthers, R., Sneyd, J. R., Erasmus, P. D., Mellor, N., Hosie, K. B., Minto, G., Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth, 2012. 108(1): p. 53-62.

Srinivasa, S., Taylor, M.H., Singh, P.P., Yu, T.C., Soop, M., and Hill, A.G., Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg, 2013. 100(1): p. 66-74.

Zakhaleva, J., Tam, J., Denoya, P.I., Bishawi, M., and Bergamaschi, R., The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis, 2013. 15(7): p. 892-9.

McKenny, M., Conroy, P., Wong, A., Farren, M., Gleeson, N., Walsh, C., O’Malley, C., and Dowd, N., A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery. Anaesthesia, 2013.

El Sharkawy, O.A., Refaat, E.K., Ibraheem, A.E.M., Mahdy, W.R., Fayed, N.A., Mourad, W.S., Abd Elhafez, H.S., and Yassen, K.A., Transoesophageal Doppler compared to central venous pressure for perioperative hemodynamic monitoring and fluid guidance in liver resection. Saudi J Anaesth, 2013. 7(4): p. 378-86.

Intraoperative: EDM Audit

Kuper, M., Gold, S.J., Callow, C., Quraishi, T., King, S., Mulreany, A., Bianchi, M., and Conway, D.H., Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ, 2011. 342: p. d3016.

Feldheiser, A., Conroy, P., Bonomo, T., Cox, B., Ruiz Garces, T., and Spies, C., Development and feasibility study of an algorithm for intraoperative goal-directed haemodynamic management in noncardiac surgery. J Int Med Res, 2012. 40(4): p. 1227-41.

Chattopadhyay, S., Mittal, S., Christian, S., Terblanche, A.L., Patel, A., Biliatis, I., Kucukmetin, A., Naik, R., and Galaal, K., The role of intraoperative fluid optimization using the esophageal Doppler in advanced gynecological cancer: early postoperative recovery and fitness for discharge. Int J Gynecol Cancer, 2013. 23(1): p. 199-207.

Figus, A., Wade, R.G., Oakey, S., and Ramakrishnan, V.V., Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery. Ann Plast Surg, 2013. 70(3): p. 301-7.

Intraoperative: EDM Unpublished

Shi, C., Morse, L.S., Douning, L.K., Chi, L., and Jessen, M.E. Optimizing intraoperative volume management during coronary bypass surgery. American Society of Anesthesiologists, 2000: p. A-347.

Dodd, T.E.M., McCormack, R.N., Dorman, F., Green, R., Bromilow, J. Using the oesophageal Doppler monitor in elective colorectal surgery: is it worth it? [Poster]. in Annual Meeting of Wessex Anaesthetists in Training. 2004. Poole, UK.

McKenny, M., Dowd, N., and O’Malley, C. Oesophageal Doppler Monitor guided fluid management in laparoscopic gastrointesintal surgery. in Anaesthesia & Perioperative Medicine. 2011. Dingle, Ireland.

Munoz, C.A.F., Rojas, J.L.T., Bermudez, O.I.G., Rios, D.E.M., Escobar, E.M. Intraoperative oesophageal Doppler during emergency abdominal surgery [Abstract #966]. in World Congress of Anaesthesiologists. 2012. Buenos Aires.

Intraoperative: Other EDM

Conway, D.H., Mayall, R., Abdul-Latif, M.S., Gilligan, S., Tackaberry, C., Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia, 2002. 57(9): p. 845-9.

Mannova, J.H., Silhart, Z., Sevcik, P., and Prokes, A., Perioperative haemodynamic monitoring by oesophageal Doppler improves outcome of patients with abdominal aortic aneurysm repair. Bratislavske lekarske listy, 2013. 114(2): p. 78-83.

Postoperative/ICU: EDM RCTs

McKendry, M., McGloin, H., Saberi, D., Caudwell, L., Brady, A.R., and Singer, M., Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ, 2004. 329(7460): p. 258.

El Sharkawy, O.A., Refaat, E.K., Ibraheem, A.E.M., Mahdy, W.R., Fayed, N.A., Mourad, W.S., Abd Elhafez, H.S., and Yassen, K.A., Transoesophageal Doppler compared to central venous pressure for perioperative hemodynamic monitoring and fluid guidance in liver resection. Saudi J Anaesth, 2013. 7(4): p. 378-86.

Postoperative/ICU: ODM Unpublished

van Dellen, J., McCorkell, S., and Williams, A., Randomised controlled trial of extended post-operative goal-directed fluid therapy using oesophageal doppler within an enhanced recovery programme for elective colorectal patients [Abstract P056]. Colorectal Dis, 2013. 15(Suppl 1): p. 30.

Postoperative/ICU: Other ODM

Chytra, I., Pradl, R., Bosman, R., Pelnar, P., Kasal, E., Zidkova, A., Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care, 2007. 11(1): p. R24.

Systematic Reviews & Meta Analysis

Abbas, S.M., Hill, A. G., Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia, 2008. 63(1): p. 44-51.

Phan, T.D., Ismail, H., Heriot, A. G., Ho, K. M., Improving perioperative outcomes: fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. J Am Coll Surg, 2008. 207(6): p. 935-41.

Walsh, S.R., Tang, T., Bass, S., and Gaunt, M.E., Doppler-guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis. Int J Clin Pract, 2008. 62(3): p. 466-70.

Giglio, M.T., Marucci, M., Testini, M., and Brienza, N., Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth, 2009. 103(5): p. 637-46.

Mowatt, G., Houston, G., Hernandez, R., de Verteuil, R., Fraser, C., Cuthbertson, B., Vale, L., Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients. Health Technol Assess, 2009. 13(7): p. iii-iv, ix-xii, 1-95.

Dalfino, L., Giglio, M.T., Puntillo, F., Marucci, M., and Brienza, N., Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care, 2011. 15(3): p. R154.

Hamilton, M.A., Cecconi., M., Rhodes, A., A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg, 2011. 112(6): p. 1392-402.

Maeso, S., Callejo, D., Hernandez, R., Blasco, J.A., and Andradas, E., Esophageal Doppler monitoring during colorectal resection offers cost-effective improvement of hemodynamic control. Value Health, 2011. 14(6): p. 818-26.

Giglio, M., Dalfino, L., Puntillo, F., Rubino, G., Marucci, M., and Brienza, N., Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis. Interact Cardiovas Thorac Surg, 2012. 15(5): p. 878-87.

Grocott, M.P., Dushianthan, A., Hamilton, M.A., Mythen, M.G., Harrison, D., and Rowan, K., Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database Syst Rev, 2012. 11: p. CD004082.


Singer, M., Clarke, J., Bennett, E. D., Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med, 1989. 17(5): p. 447-52.

Singer, M. and Bennett, E.D., Noninvasive optimization of left ventricular filling using esophageal Doppler. Crit Care Med, 1991. 19(9): p. 1132-7.

Klotz, K.F., Klingsiek, S., Singer, M., Wenk, H., Eleftheriadis, S., Kuppe, H., and Schmucker, P., Continuous measurement of cardiac output during aortic cross-clamping by the oesophageal Doppler monitor ODM 1. Br J Anaesth, 1995. 74(6): p. 655-60.

Keyl, C., Rodig, G., Lemberger, P., and Hobbhahn, J., A comparison of the use of transoesophageal Doppler and thermodilution techniques for cardiac output determination. Eur J Anaesthesiol, 1996. 13(2): p. 136-42.

Krishnamurthy, B., McMurray, T.J., and McClean, E., The peri-operative use of the oesophageal Doppler monitor in patients undergoing coronary artery revascularisation. A comparison with the continuous cardiac output monitor. Anaesthesia, 1997. 52(7): p. 624-9.

Colbert, S., O’Hanlon, D.M., Duranteau, J., and Ecoffey, C., Cardiac output during liver transplantation. Can J Anaesth, 1998. 45(2): p. 133-8.

Lefrant, J.Y., Bruelle, P., Aya, A.G., Saissi, G., Dauzat, M., de La Coussaye, J.E., and Eledjam, J.J., Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients. Intensive Care Med, 1998. 24(4): p. 347-52.

Valtier, B., Cholley, B.P., Belot, J.P., de la Coussaye, J.E., Mateo, J., and Payen, D.M., Noninvasive monitoring of cardiac output in critically ill patients using transesophageal Doppler. Am J Respir Crit Care Med, 1998. 158(1): p. 77-83.

Baillard, C., Cohen, Y., Fosse, J.P., Karoubi, P., Hoang, P., and Cupa, M., Haemodynamic measurements (continuous cardiac output and systemic vascular resistance) in critically ill patients: transoesophageal Doppler versus continuous thermodilution. Anaesth Intensive Care, 1999. 27(1): p. 33-7.

DiCorte, C.J., Latham, P., Greilich, P.E., Cooley, M.V., Grayburn, P.A., and Jessen, M.E., Esophageal Doppler monitor determinations of cardiac output and preload during cardiac operations. Ann Thorac Surg, 2000. 69(6): p. 1782-6.

Penny, J.A., Anthony, J., Shennan, A.H., De Swiet, M., and Singer, M., A comparison of hemodynamic data derived by pulmonary artery flotation catheter and the esophageal Doppler monitor in preeclampsia. Am J Obstet Gynecol, 2000. 183(3): p. 658-61.

Leather, H.A. and Wouters, P.F., Oesophageal Doppler monitoring overestimates cardiac output during lumbar epidural anaesthesia. Br J Anaesth, 2001. 86(6): p. 794-7.

Su, N.Y., Huang, C.J., Tsai, P., Hsu, Y.W., Hung, Y.C., Cheng, C.R., Cardiac output measurement during cardiac surgery: esophageal Doppler versus pulmonary artery catheter. Acta Anaesthesiol Sin, 2002. 40(3): p. 127-33.

Jaeggi, P., Hofer, C.K., Klaghofer, R., Fodor, P., Genoni, M., and Zollinger, A., Measurement of cardiac output after cardiac surgery by a new transesophageal Doppler device. J Cardiothorac Vasc Anesth, 2003. 17(2): p. 217-20.

Roeck, M., Jakob, S.M., Boehlen, T., Brander, L., Knuesel, R., and Takala, J., Change in stroke volume in response to fluid challenge: assessment using esophageal Doppler. Intensive Care Med, 2003. 29(10): p. 1729-35.

Seoudi, H.M., Perkal, M.F., Hanrahan, A., and Angood, P.B., The esophageal Doppler monitor in mechanically ventilated surgical patients: does it work? J Trauma, 2003. 55(4): p. 720-5; discussion 5-6.

Dark, P.M., Singer, M., The validity of trans-esophageal Doppler ultrasonography as a measure of cardiac output in critically ill adults. Intensive Care Med, 2004. 30(11): p. 2060-6.

Monnet, X., Rienzo, M., Osman, D., Anguel, N., Richard, C., Pinsky, M.R., and Teboul, J.L., Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med, 2005. 31(9): p. 1195-201.

Chew, H.C., Devanand, A., Phua, G.C., and Loo, C.M., Oesophageal Doppler ultrasound in the assessment of haemodynamic status of patients admitted to the medical intensive care unit with septic shock. Ann Acad Med Singapore, 2009. 38(8): p. 699-703.

Phan, T.D., Kluger, R., Wan, C., Wong, D., and Padayachee, A., A comparison of three minimally invasive cardiac output devices with thermodilution in elective cardiac surgery. Anaesth Intensive Care, 2011. 39(6): p. 1014-21.

Guinot, P.G., de Broca, B., Abou Arab, O., Diouf, M., Badoux, L., Bernard, E., Lorne, E., and Dupont, H., Ability of stroke volume variation measured by oesophageal Doppler monitoring to predict fluid responsiveness during surgery. Br J Anaesth, 2013. 110(1): p. 28-33.

Monnet, X., Robert, J.M., Jozwiak, M., Richard, C., and Teboul, J.L., Assessment of changes in left ventricular systolic function with oesophageal Doppler. Br J Anaesth, 2013.


Tibby, S.M., Hatherill, M., and Murdoch, I.A., Use of transesophageal Doppler ultrasonography in ventilated pediatric patients: derivation of cardiac output. Critical care medicine, 2000. 28(6): p. 2045-50.

Tibby, S.M., Hatherill, M., Durward, A., and Murdoch, I.A., Are transoesophageal Doppler parameters a reliable guide to paediatric haemodynamic status and fluid management? Intensive care medicine, 2001. 27(1): p. 201-5.

Mohan, U.R., Britto, J., Habibi, P., de, M.C., and Nadel, S., Noninvasive measurement of cardiac output in critically ill children. Pediatr Cardiol, 2002. 23(1): p. 58-61.

Knirsch, W., Kretschmar, O., Tomaske, M., Stutz, K., Nagdyman, N., Balmer, C., Schmitz, A., Bettex, D., Berger, F., Bauersfeld, U., and Weiss, M., Cardiac output measurement in children: comparison of the Ultrasound Cardiac Output Monitor with thermodilution cardiac output measurement. Intensive Care Med, 2008. 34(6): p. 1060-4.

Schubert, S., Schmitz, T., Weiss, M., Nagdyman, N., Huebler, M., Alexi-Meskishvili, V., Berger, F., and Stiller, B., Continuous, non-invasive techniques to determine cardiac output in children after cardiac surgery: evaluation of transesophageal Doppler and electric velocimetry. J Clin Monit Comput, 2008. 22(4): p. 299-307.

Fleck, T., Schubert, S., Stiller, B., Redlin, M., Ewert, P., Nagdyman, N., and Berger, F., Capability of a new paediatric oesophageal Doppler monitor to detect changes in cardiac output during testing of external pacemakers after cardiac surgery. J Clin Monit Comput, 2011. 25(6): p. 419-25.

Raux, O., Spencer, A., Fesseau, R., Mercier, G., Rochette, A., Bringuier, S., Lakhal, K., Capdevila, X., and Dadure, C., Intraoperative use of transoesophageal Doppler to predict response to volume expansion in infants and neonates. Br J Anaesth, 2012. 108(1): p. 100-7.

Comparison with Other Technologies

Meng, L., Tran, N.P., Alexander, B.S., Laning, K., Chen, G., Kain, Z.N., Cannesson, M., The impact of phenylephrine, ephedrine, and increased preload on third-generation Vigileo-FloTrac and esophageal doppler cardiac output measurements. Anesth Analg, 2011. 113(4): p. 751-7.

Conway, D.H., Hussain, O.A., and Gall, I., A comparison of noninvasive bioreactance with oesophageal Doppler estimation of stroke volume during open abdominal surgery: An observational study. Eur J Anaesthesiol, 2013. 30(8): p. 501-8.

Nordstrom, J., Hallsjo-Sander, C., Shore, R., and Bjorne, H., Stroke volume optimization in elective bowel surgery: a comparison between pulse power wave analysis (LiDCOrapid) and oesophageal Doppler (CardioQ). Br J Anaesth, 2013. 110(3): p. 374-80.

Davies, S.J., Minhas, S., Wilson, R.J., Yates, D., and Howell, S.J., Comparison of stroke volume and fluid responsiveness measurements in commonly used technologies for goal-directed therapy. J Clin Anesth, 2013.

Relevant Review Studies

Laupland, K.B. and Bands, C.J., Utility of esophageal Doppler as a minimally invasive hemodynamic monitor: a review. Can J Anaesth, 2002. 49(4): p. 393-401.

Cholley, B.P. and Singer, M., Esophageal Doppler: noninvasive cardiac output monitor. Echocardiography, 2003. 20(8): p. 763-9.

King, S.L. and Lim, M.S., The use of the oesophageal Doppler monitor in the intensive care unit. Crit Care Resusc, 2004. 6(2): p. 113-22.

Grocott, M.P., Mythen, M.G., and Gan, T.J., Perioperative fluid management and clinical outcomes in adults. Anesth Analg, 2005. 100(4): p. 1093-106.

Roche, A.M., Miller, T.E., and Gan, T.J., Goal-directed fluid management with trans-oesophageal Doppler. Best Pract Res Clin Anaesthesiol, 2009. 23(3): p. 327-34.

Schober, P., Loer, S.A., and Schwarte, L.A., Perioperative hemodynamic monitoring with transesophageal Doppler technology. Anesth Analg, 2009. 109(2): p. 340-53.

Schober, P., Loer, S.A., and Schwarte, L.A., Transesophageal Doppler devices: A technical review. J Clin Mon Comput, 2009. 23(6): p. 391-401.

Singer, M., Oesophageal Doppler. Curr Opin Crit Care, 2009. 15(3): p. 244-8.

Singer, M., Oesophageal Doppler monitoring: should it be routine for high-risk surgical patients? Curr Opin Anaesthesiol, 2011. 24(2): p. 171-6.

Marik, P.E., Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth, 2013. 27(1): p. 121-34.


Sun, J.X., Reisner, A.T., Saeed, M., and Mark, R.G., Estimating Cardiac Output from Arterial Blood Pressure Waveforms: a Critical Evaluation using the MIMIC II Database, Harvard-MIT Division of Health Sciences and Technology, MIT: Cambridge, MA, USA.

Sun, J.X., Cardiac output estimation using aterial blood pressure waveforms, in Electrical Engineering and Computer Science 2006, Massachusettes Institute of Technology.

Sun, J.X., Reisner, A.T., Saeed, M., Heldt, T., and Mark, R.G., The cardiac output from blood pressure algorithms trial. Crit Care Med, 2009. 37(1): p. 72-80.

Caillard, A., Dubreuil, G., M’Bakulu, E., Tantot, A., Bart, F., Gayat, E., Madadaki, C., Vallee, F., and Mebazaa, A., Comparaison du débit cardiaque mesuré par doppler œsophagien et par 9 algorithmes d’analyse du contour de l’onde de pouls au cours d’épreuves thérapeutiques. Ann Fr Anesth Reanim, 2013. 32(S1): p. A389.

Monge Garcia, M.I., Gracia Romero, M., Gil Cano, A., Rhodes, A., Grounds, R.M., and Cecconi, M., Impact of arterial load on the agreement between pulse pressure analysis and esophageal Doppler. Crit Care, 2013. 17(3): p. R113.


Ghosh, S., Arthur, B., and Klein, A.A., NICE guidance on CardioQ(TM) oesophageal Doppler monitoring. Anaesthesia, 2011. 66(12): p. 1081-3. [and responses]

Campbell, B., Innovation, NICE, and CardioQ. Br J Anaesth, 2012. 108(5): p. 726-9.

Pinsky, M.R., O’Brien, T., Green, D., and Jonas, M., Technology comparison studies require precise reference controls to be valid [Letter]. Br J Anaesth, 2012. [and response]

Morris, C., Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change. Anaesthesia, 2013.

Physiology & the Need for Fluid Optimization

Fiddian-Green, R.G., Splanchnic ischaemia and multiple organ failure in the critically ill. Ann R Coll Surg Engl, 1988. 70(3): p. 128-34.

Deitch, E.A., The role of intestinal barrier failure and bacterial translocation in the development of systemic infection and multiple organ failure. Arch Surg, 1990. 125(3): p. 403-4.

Shoemaker, W.C.A., Apple, P. L.; Kram, H. B., Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest, 1992. 102(1): p. 208-15.

Hamilton-Davies, C., Mythen, M.G., Salmon, J.B., Jacobson, D., Shukla, A., and Webb, A.R., Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Intensive Care Med, 1997. 23(3): p. 276-81.

Khuri, S.F.H., W. G.; DePalma, R. G.; Mosca, C.; Healey, N. A.; Kumbhani, D. J., Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg, 2005. 242(3): p. 326-41; discussion 41-3.

Kimberger, O., Arnberger, M., Brandt, S., Plock, J., Sigurdsson, G.H., Kurz, A., and Hiltebrand, L., Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology, 2009. 110(3): p. 496-504.

Bundgaard-Nielsen, M.J., C. C.; Secher, N. H.; Kehlet, H., Functional intravascular volume deficit in patients before surgery. Acta Anaesthesiol Scand, 2010. 54(4): p. 464-9.

Enhanced Recovery

Kehlet, H., Multimodal approach to control postoperative pathophysiology and rehabilitation. British journal of anaesthesia, 1997. 78(5): p. 606-17.

Fearon, K.C., Ljungqvist, O., Von Meyenfeldt, M., Revhaug, A., Dejong, C.H., Lassen, K., Nygren, J., Hausel, J., Soop, M., Andersen, J., Kehlet, H., Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr, 2005. 24(3): p. 466-77.

Lassen, K., Soop, M., Nygren, J., Cox, P.B., Hendry, P.O., Spies, C., von Meyenfeldt, M.F., Fearon, K.C., Revhaug, A., Norderval, S., Ljungqvist, O., Lobo, D.N., and Dejong, C.H., Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg, 2009. 144(10): p. 961-9.

Ramirez, J.M., Blasco, J.A., Roig, J. V., Maeso-Martinez, S., Casal, J.E., Esteban, F., Lic, D.C., Enhanced recovery in colorectal surgery: a multicentre study. BMC Surg, 2011. 11: p. 9.

Mythen, M.G., Swart, M., Acheson, N., Crawford, R., Jones, K., Kuper, M., McGrath, J. S., Horgan, A.F., Perioperative fluid management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine, 2012. 1(2).

NHS Enhanced Recovery Partnership Programmme. Fulfilling the potential: A better journey for patients and a better deal for the NHS, 2012.  NHS Improvement


NHS Technology and Adoption Centre (NTAC). ‘How to why to’ guide – Doppler Guided Intraoperative Fluid Management. NTAC

Powell-Tuck, J., Gosling, P., Lobo, D. N., Allison, S.P., Carlson, G.L., Gore, M., Lewington, A.J., Pearse, R.M., Mythen, M.G., British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.

National Institute for Health and Clinical Excellence (NICE). CardioQ-ODM Oesophageal Doppler Monitor. NICE MTG3, 2011.

Innovation Health and Wealth: Accelerating Adoption and Diffusion in the NHS., 2011.