Overview of the new 2025 ESAIC Guidelines on Intra-operative Haemodynamic Monitoring and Management of Adults Having Noncardiac Surgery

Introduction

Intra-operative haemodynamic management is a cornerstone of safe and effective surgical care. The 2025 guidance from the European Society of Anaesthesiology and Intensive Care (ESAIC) provides updated, evidence-informed recommendations for clinicians managing adult patients undergoing noncardiac surgery. This article distils the key points from the new guidelines, offering a practical overview for healthcare professionals.

Core Principles of the Guidelines

The ESAIC panel, comprising 25 international experts, focused on seven key areas:

1. Arterial Pressure
2. Heart Rate
3. Stroke Volume and Cardiac Output
4. Cardiac Preload and Fluid Responsiveness
5. Echocardiography
6. Microcirculation
7. Depth of Anaesthesia and Cerebral Oximetry

1. Arterial Pressure Management

• Primary Target: Maintain mean arterial pressure (MAP) above 60 mmHg.
• Measurement: Continuous invasive monitoring in high-risk patients is preferred; otherwise, oscillometric methods with proper technique are used.
• Individualisation: Consider patient-specific baseline pressures, especially in those with chronic hypertension.
• New Technologies: Continuous non-invasive monitoring (e.g., finger-cuff systems) is promising but not yet standard.

Key Takeaway: MAP is the most reliable indicator for guiding intra-operative blood pressure management.

2. Heart Rate Monitoring

• No Universal Thresholds: Bradycardia (<60 bpm) and tachycardia (>100 bpm) should be treated based on clinical context.
• Treatment Strategy: Intervene if abnormal heart rates cause hypotension or compromise perfusion.

Key Takeaway: Focus on the haemodynamic impact of heart rate changes rather than fixed numerical thresholds.

3. Stroke Volume and Cardiac Output

• Monitoring: Recommended in high-risk patients or high-risk surgeries.
• Avoid Routine Maximisation: Do not aim to maximise cardiac output universally; tailor targets to individual needs.
• Goal-Directed Therapy: Should be personalised and based on clinical and metabolic signs of perfusion.

Key Takeaway: Cardiac output monitoring is useful but must be linked to meaningful therapeutic decisions.

4. Fluid Management and Responsiveness

• Assessment Tools: Use dynamic indicators like pulse pressure variation (PPV) and stroke volume variation (SVV) with caution.
• Fluid Challenges: Should be guided by stroke volume or cardiac output changes.
• Avoid Overuse: Do not administer fluids solely based on fluid responsiveness; look for signs of hypovolaemia or hypoperfusion.

Key Takeaway: Fluid therapy should be judicious, evidence-based, and responsive to real-time physiological needs.

5. Echocardiography

Echocardiography provides real-time imaging of the heart, enabling clinicians to assess cardiac anatomy and function. It is particularly valuable for diagnosing the causes of haemodynamic instability during or after surgery and can help identify conditions such as:

• Hypovolaemia
• Left or right ventricular dysfunction
• Cardiac tamponade
• Valvular dysfunction
• Pulmonary embolism

Key Takeaway: Recommend performing focused transthoracic or transoesophageal echocardiography as a diagnostic tool for patients developing haemodynamic instability during or after surgery,

6. Microcirculation

• Current Limitations: Sublingual microcirculation monitoring is not recommended for routine use due to technical and interpretive challenges.
• Surrogate Markers: Use lactate levels and central venous oxygen saturation to infer tissue perfusion.

Key Takeaway: Focus on global indicators of perfusion until more practical microcirculatory tools are validated.

7. Depth of Anaesthesia and Cerebral Oximetry

• Processed EEG: Helps titrate anaesthetic depth and reduce haemodynamic side effects.
• Cerebral Oximetry: Not recommended for routine use but may be helpful in high-risk patients.

Key Takeaway: Neuromonitoring supports haemodynamic stability and may reduce postoperative complications like delirium.

Conclusion

The 2025 ESAIC guidelines emphasise a personalised, evidence-informed approach to intra-operative haemodynamic management. These guidelines aim to improve patient outcomes by promoting thoughtful, individualised care during surgery.

This guideline marks a shift toward personalised, evidence-based intra-operative haemodynamic care. It encourages clinicians to:

• Move beyond traditional metrics
• Use dynamic, patient-specific data
• Apply advanced monitoring tools thoughtfully
• Focus on outcomes like organ protection and recovery

For any further information on these guidelines, you can visit the European Society of Anaesthesiology and Intensive Care website here: https://esaic.org/

Reference:

[1] Saugel, B., Buhre, W., Chew, M. S., Cholley, B., Coburn, M., Cohen, B., … & Zarbock, A. (2025). Intra-operative haemodynamic monitoring and management of adults having noncardiac surgery: A statement from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology, 42(7), 543–556. https://doi.org/10.1097/EJA.0000000000002174