Please select the eligibility criteria that correspond to the clinical trial below.
Title: Intraoperative Fluid Management Based on Arterial Pulse Pressure Variation During High-Risk Surgery
Brief Summary: Hypovolaemia and tissue hypoperfusion can pass undetected during and after major surgery. The resulting systemic inflammatory response and organ dysfunction, often not clinically apparent for several days, may lead to increased morbidity and mortality and prolonged hospital stay.

In this regard, intraoperative optimization of circulatory status by volume loading has been shown to improve the outcome of patients undergoing high-risk surgery.

Indeed, several reports (1-7) have shown that monitoring and maximizing stroke volume by volume loading (until stroke volume reaches a plateau, actually the plateau of the Frank-Starling curve) during high-risk surgery decreases the incidence of post-operative complications and the length of hospital stay.

Unfortunately, this strategy has required so far the measurement of stroke volume by a cardiac output monitor, as well as a specific training period for the operators (8), and hence is not applicable in many institutions as well as in many countries.

The arterial pulse pressure variation (∆PP) induced by mechanical ventilation is known to be a very accurate predictor of fluid responsiveness, i.e. of the position on the preload/stroke volume relationship (Frank-Starling curve) (9).

By increasing cardiac preload, volume loading induces a rightward shift on the preload/stroke volume relationship and hence a decrease in ∆PP. Patients who have reached the plateau of the Frank-Starling relationship can be identified as patients in whom ∆PP is low (9).

Therefore, the clinical and intraoperative goal of "maximizing stroke volume by volume loading" can be achieved simply by minimizing ∆PP.

We designed the present study to investigate whether monitoring and minimizing ∆PP by volume loading during high-risk surgery may improve post-operative outcome and decrease the duration of post-operative hospital stay.


Options:
A: Inclusion Criteria:

* To provide high generalizability and representativeness the high number of patients with laparotomy and major surgical trauma is included into this study. - Therefore, open visceral, urological, and gynecological surgery is covered by this study.
* Expected duration of surgery must be ≥ 120 minutes and requirement of volume therapy needs to be expected ≥ 2 liters.
* Risk for any postoperative complications needs to be ≥10% assessed by the ACS (American College of Surgery)- NSQUIP (National Surgical Quality Improvement Program) risk calculator.

Exclusion Criteria:

* Patients \<18 years,
* laparoscopic approach,
* patients not having sinus rhythm,
* patients having highly impaired left ventricular function (ejection fraction \<30%) or severe aortic valve stenosis (aortic valve area \<1 cm2, mean gradient \>40 mmHg),
* pregnant women,
* emergency surgeries (surgery required within 24 hours),
* primarily vascular surgery,
* patients suffering from septic shock,
* patients having phaeochromocytoma,
* patients suffering from non-cardiac chest pain,
* refusal of consent,
* patients receiving palliative treatment only (likely to die within 6 months) and patients suffering from acute myocardial ischemia (within 30 days before randomization) are excluded from the study.
* Further, in case that clinicians intended to use cardiac output monitoring for clinical reasons patients should also not be included in the study.
B: Inclusion Criteria:

* Medico-surgical pre-operative decision of post-operative ICU admission (because of co-morbidities or/and the surgical procedure)
* Age \> 18 yr
* Elective surgery

Exclusion criteria:

* No informed consent
* Cardiac arrhythmias
* Body mass index \> 40
* Patients undergoing surgery with an open thorax
* Patients undergoing neurosurgery
* Enrolment in any other protocol
C: Inclusion Criteria:

* Major intraabdominal surgery

Exclusion Criteria:

* Age \< 18 years
* Pregnancy
* Body mass index \> 35 kg/m2
* Emergency surgery
* Coagulopathy
* Sepsis or Systemic inflammatory response syndrome (SIRS)
* Hepatic failure (prothrombin ratio \< 50%, factor V \< 50%)
* Contraindication for epidural analgesia
D: Inclusion Criteria:

* age greater than 18 years
* signed informed consent
* listed for deceased donor transplantation.

Exclusion Criteria:

* esophageal surgery or cancer
* esophageal stricture, varices or diverticulum
* upper airway surgery
* coarctation of the aorta
* significant valvular heart disease
* clinically significant cardiac arrhythmias
* patient randomized to other trials with an outcome variable of delayed graft function or early graft function will also be excluded

Answer: B