In spite of numerous studies about fluid management and hemodynamic monitoring in thoracic anesthesia, the heterogeneity of the results has led to the fact that there is still no strong evidence on this topic. The historical recommendation of restricted fluid management has been replaced by normovolemia, but there are still many unsolved problems. Most importantly, not only the amount of the fluid, but also its indication, timing, the addition of a vasopressor and/or inotrope, its dosage, protection of glycocalyx layer and several other parameters play a role in the relationship of fluid strategy and overall outcome. Regarding the postoperative outcome, fluid management in its extensive form should be considered as an important part of a strategy.

Goal-directed therapy (GDT) is associated with certain limitations, mainly because “open thorax” can affect the cardiopulmonary interaction. Still, it can give objective hints to achieve stable hemodynamics, protection of glycocalyx, prevention of pulmonary edema and avoidance of postoperative organ injury.

Estimation of intravascular volume status by clinical examination and static measurements such as central venous pressure and pulmonary capillary wedge pressure do not predict fluid responsiveness. Current evidence indicates that dynamic monitoring of arterial pressure and derived indices are the most sensitive and specific means of determining fluid responsiveness, especially in mechanically ventilated patients. Several monitors that automate and embellish this approach, a few of which are noninvasive, are now commercially available and they are gradually being incorporated into intensive and perioperative care practice. This chapter reviews the physiologic underpinnings of how and why the arterial pressure waveform can be used to determine fluid responsiveness and gives an overview of the devices incorporating these principles.