Perioperative goal directed haemodynamic therapy--do it, bin it, or finally investigate it properly?

The literature concerning the use of goal directed haemodynamic therapy (GDHT) in high risk surgical patients has been importantly increased by the study of Lopes and colleagues. Using a minimally invasive assessment of fluid status and pulse pressure variation monitoring during mechanical ventilation, improvements were seen in post-operative complications, duration of mechanical ventilation, and length of hospital and intensive care unit (ICU) stay. Many small studies have shown improved outcome using various GDHT techniques but widespread implementation has not occurred. Those caring for perioperative patients need to accept the published evidence base or undertake a larger, multi-centre study.     

CPR: is it cruel or is it kind?

When people have a cardiac arrest, whether in hospital or the community, there is a presumption is that cardiopulmonary resuscitation should be attempted in all but exceptional circumstances. This is based on ethical, legal, political and cultural principles. However, few patients leave hospital with their faculties intact following CPR, which often simply postpones death for a short time. The authors argue that this represents a poor use of public resources and condemns many patients to severe debilitation. They suggest that the focus should move towards preventing cardiac arrest, so that scarce resources can be redirected to interventions with proven benefits.