This survey of 1067 anaesthetists from the UK, AUS/NZ and the USA reveals important differences in practice with regards to intraoperative fluid therapy and GDFT specifically. The response rates were moderate or low, especially in the USA, and it is likely that the present data represents views of a self-selected group among the anaesthetists who were randomly invited to participate. Such selection could be based on strong positive or negative views on GDFT. Nevertheless, certain observations can be made and hypotheses generated regarding the interest in and barriers to GDFT in the UK and AUS/NZ. The poor response rate from the USA limits the validity of any statements regarding practice in this region except to speculate that there is comparatively lesser interest in this topic.
The use of GDFT seems to be significantly less prevalent in AUS/NZ compared to the UK amongst respondents in this survey. The majority of the respondents were involved in major abdominal surgery and orthopaedic surgery and used GDFT in patients with significant comorbidities. The ODM is the most commonly utilised instrument in the UK with significant variation in preferences in other regions. The most significant barriers to conducting GDFT were either a lack of availability of monitoring tools or a lack of experience with instruments. Even though a proportion of respondents from all regions remain unconvinced of the benefits of GDFT, there was significant enthusiasm overall towards trialling GDFT if barriers were to be removed.
The use of GDFT was most common in the UK which may have been made possible by governmental endorsement and funding of the ODM specifically with demonstrated cost-effectiveness
[15, 16]. Nationally-driven implementation may also potentially overcome the problems associated with silo budgeting as GDFT represents an anaesthetic intervention- thereby adding cost to clinical departments of anaesthesia- to provide financial benefits for surgical services such as decreased hospital length of stay. This represents a potential blueprint for other regions to follow. For clinicians, the recently published GIFTASUP guidelines which recommend mandatory use of GDFT in major abdominal surgery may have also provided further impetus
Moreover, a significant portion of the evidence supporting GDFT originates from the UK
[9, 11, 29]. The recent guidelines from the European Enhanced Recovery After Surgery (ERAS) group have also shown enthusiasm towards GDFT and the ODM and, as ERAS protocols are instituted across the UK, GDFT has been integrated into practice as well
[19, 30, 31]. This has likely led to the emergence of the ODM as the preferred tool to conduct GDFT in the UK. In contrast, the principles of optimised perioperative care have shown reduced penetrance in AUS/NZ with persisting scepticism regarding benefits
[32, 33]. In AUS/NZ, there appears to be no clear preference with regards to tools for GDFT.
The barriers identified to the use of GDFT appear eminently solvable especially if the observed benefits from trials are replicated in clinical practice
. Many of the instruments used to conduct GDFT are simple to use and the learning curve for the ODM can be overcome after 12 insertions
. However, it should be noted that in the context of abdominal surgery, restrictive fluid regimens have also shown similar benefits to GDFT and the majority of the trials investigating GDFT have not been conducted in an environment of standardised, optimised perioperative care
A proportion of people from all the regions surveyed remain sceptical regarding the proposed benefits of GDFT. To an extent, this is justified as important questions remain unanswered, such as efficacy in settings where fluid restriction has been shown to be beneficial
[21–23]. Nonetheless, it is interesting to note that in the absence of barriers, a high proportion of respondents would be willing to consider GDFT into their practice. This suggests that future randomised trials or selective clinical implementation of GDFT remain feasible and are required.
Whilst the use of intraoperative crystalloids was largely homogeneous between the regions, there were interesting differences in practice between the three regions with regards to colloid use. There are considerable differences between individual classes of colloids as well as between the individual colloid products themselves
[35, 36]. Succinylated gelatin solutions were favoured in the UK and AUS/NZ with the latter showing a wide variation in practice. This may be a reflection of the variable availability and cost of these solutions.
There are important limitations to this study which need to be considered alongside the results. The survey was designed on the basis of questions of clinical importance but was not developed with a focus group nor with redundant questions to validate its methodology. Moreover, since the survey aimed towards an overview of GDFT, specifics could not be elucidated regarding any one aspect (e.g. specific barriers). Any barriers identified were the opinion of the respondent and may not be reflective of the institution or the region in its entirety. The number of individuals to be surveyed was limited by the respective professional associations. The colleges facilitated selection of individuals with no author input allowed regarding this. The only selection criterion was to prevent administration of the survey to individuals who had previously replied to other college-led surveys to minimise responder fatigue. In the context of a low-moderate response rate, it cannot be assumed with certainty that it is representative of the anaesthetic community in its entirety.