This web-based survey among ÖGARI members provides valuable insights into current hemodynamic monitoring and management practices during non-cardiac surgery in Austria. The findings suggest that respondents largely follow international recommendations, particularly concerning general blood pressure thresholds, measurement intervals, and indications for advanced hemodynamic monitoring. However, hemodynamic and blood pressure management appear to be only partially standardized, with decisions primarily left to the discretion of the anesthetist.

The results also indicate a certain level of awareness of the recently published German guideline on ‘Intraoperative hemodynamic monitoring and management in adults undergoing non-cardiac surgery’ within the Austrian anesthesiology community [2]. A notable proportion of respondents reported familiarity with its content just a few months after its release, suggesting increasing recognition and engagement with this topic.

In most patients, blood pressure monitoring during surgery is performed using intermittent oscillometric measurements. During anesthesia induction, many respondents measure blood pressure every two to three minutes [5,6,7]. However, during surgery, the most commonly reported measurement intervals are longer, usually three or five minutes, likely due to anesthetists’ experience that induction of anesthesia is often accompanied by hypotension [7]. In the PACU, measurement intervals are often extended beyond five minutes, presumably due to greater hemodynamic stability [8].

When intra-arterial blood pressure monitoring is indicated, more than one-third of the respondents insert arterial catheters only after anesthesia induction, possibly to enhance patient comfort. However, pre-induction arterial catheter placement reduces the incidence of hypotension and potentially prevents organ injury [9].

Moreover, similar procedures, such as arterial access during cardiac catheterization, are routinely performed in awake patients, suggesting that pre-induction placement may be a feasible and beneficial approach. The findings indicate a strong preference for direct arterial cannulation as the primary method for invasive blood pressure monitoring, while the Seldinger technique is used only occasionally. However, studies in neonates, infants, and adults suggest that the guidewire-assisted technique (Seldinger technique) achieves higher first-attempt success rates and lower complication rates, particularly in challenging anatomical conditions [10, 11]. This discrepancy suggests that the choice of technique is influenced by clinician expertise and patient-specific factors, with direct puncture remaining a cost-effective standard option. Compared to their Austrian counterparts, German clinicians more frequently perform arterial cannulation using Seldinger technique into routine practice [3].

Ultrasound devices were generally available for advanced hemodynamic monitoring. However, this availability did not consistently translate into the use of ultrasound guidance for arterial catheter placement. This discrepancy underscores a relevant gap between technological availability and its routine clinical application, despite well-established benefits of ultrasound-guided arterial access [12, 13].

Assessing arterial pressure waveform quality is crucial, particularly in the context of pulse wave analysis [14, 15]. While approximately 75% of respondents rely on visual inspection to detect damping phenomena in the blood pressure curve, only 19% employ standardized tests [14, 16]. These findings indicate that visual assessment remains the predominant method for evaluating arterial pressure waveforms. Given the critical role of waveform accuracy in pulse wave analysis, implementing standardized testing methods, such as the fast-flush test, may enhance the reliability of hemodynamic monitoring in clinical practice.

In addition to continuous invasive blood pressure measurement, continuous non-invasive monitoring via finger cuff technology may contribute to reducing intraoperative hypotension [17, 18]. However, more than half of the respondents reported lacking access to such monitoring systems, and only 4% indicated frequent use of this technology. These findings suggest that finger cuff technology is not yet routinely integrated into clinical practice among the respondents. Compared to survey data from Germany, finger cuff monitoring appears less frequently adopted in Austrian hospitals, although its overall utilization remains limited in both countries [3].

Furthermore, participants were asked about the use of standardized protocols for the treatment of intraoperative hypotension. With only one in ten respondents following such protocols, blood pressure management appears largely unstandardized, which may lead to variability and reduced reproducibility [19]. Although protocol-based approaches may help improve blood pressure stability and [20], when combined with machine learning tools, significantly reduce the incidence and duration of hypotension [21], robust evidence for improved patient outcomes remains limited [22, 23]. Standardized protocols, tailored to local clinical structures and resources, may represent a pragmatic approach to improving consistency and quality in blood pressure management. Compared to the Austrian results, the German survey data indicate greater adherence to standardized treatment pathways, with less reliance on individualized clinical decision-making in the management of intraoperative hypotension [3].

Large database studies have demonstrated an association between perioperative hypotension and postoperative organ injury [6, 24,25,26]. Although no universally accepted definition of hypotension exists [27, 28], it is commonly defined as a MAP below 60–65 mmHg – a threshold associated with an increased risk of acute kidney and myocardial injury [28, 29]. Consistent with these findings, a substantial proportion of respondents manage blood pressure based on MAP and consider a MAP of 60–65 mmHg critically low. Raising alarm thresholds to reflect these critical MAP values may help reduce hypotension episodes and support timely intervention. This simple adjustment represents a pragmatic and easily implementable strategy to enhance intraoperative blood pressure management in everyday practice [30].

The survey results also reflect the availability of standard vasoactive agents for intraoperative hypotension management in Austria. Phenylephrine and ephedrine were the most frequently used agents, consistent with the findings of Baekgaard et al., who identified both substances among the most commonly employed vasoactive drugs in clinical trials for hypotension treatment [31]. Cafedrine/Theodrenaline (Akrinor®), available to only 25% of respondents, was the third most frequently used agent, despite its limited availability outside Germany [32].

According to current recommendations [33], respondents select advanced hemodynamic monitoring based on patient comorbidities, surgical risk, and expected blood loss. While these considerations appear appropriate, studies consistently indicate that advanced hemodynamic monitoring remains underutilized in surgical patients, including those at high risk [34, 35].

To identify potential barriers to implementation, respondents were asked to specify contributing factors. A substantial proportion of respondents perceived the added value of advanced hemodynamic monitoring as too low, while more than half reported a lack of experience in interpreting hemodynamic parameters. Despite the widespread availability of pulse wave analysis in clinical settings, only a minority of respondents reported regular use. These findings highlight a considerable gap between the availability and clinical utilization of advanced hemodynamic monitoring, aligning with findings from a recent survey among German anesthesiologists [3].

The limited uptake may reflect ongoing uncertainty regarding appropriate indications, therapeutic targets, and the lack of compelling outcome evidence. Recent meta-analyses have shown that goal-directed hemodynamic therapy (GDHT) using parameters such as stroke volume variation or cardiac output can reduce postoperative complications in high-risk patients undergoing major non-cardiac surgery [36,37,38]. In contrast, large randomized trials, specifically the iPEGASUS trial by Funcke et al. and the OPTIMISE II trial conducted by the OPTIMISE II Trial Group, found no benefit in actively maintaining an optimized postinduction cardiac index [22, 23]. Notably, both studies reported an increased incidence of adverse cardiac events. These conflicting findings likely contribute to clinician skepticism regarding the routine use of advanced monitoring.

The frequently reported insufficient familiarity with advanced hemodynamic parameters underscores the need for structured training and continuous education. A solid grasp of cardiovascular physiology and monitoring principles is essential for accurate interpretation [39], as misinterpretation may lead to inappropriate treatment and compromise patient safety [40, 41]. Several clinical studies have investigated educational strategies to improve competency in this area.

High-fidelity simulators combined with advanced monitoring systems have proven effective in teaching cardiovascular physiology to anesthesia providers [42, 43]. Simulation-based models have also been successfully used to train critical care physicians in advanced ventilation and hemodynamic management [44]. Notably, medical learners who observed their own real-time hemodynamic parameters during personalized simulation scenarios demonstrated a significant improvement in understanding complex physiological concepts [45]. These methods allow realistic clinical training without exposing patients to risk. To further enhance clinical application, structured interpretation tools such as validity checklists have been proposed to support clinical decision-making and promote appropriate use of advanced hemodynamic parameters [46].

A follow-up study is planned for late 2026. It will revisit the present key findings, including the use and further development of local protocols, potential improvements in the interpretation of advanced hemodynamic parameters, and the clinical application of continuous non-invasive monitoring. To broaden the perspective, an international extension via the European Society of Anaesthesiology and Intensive Care is being considered.

This study is based on 177 fully completed responses, providing a differentiated view of current hemodynamic monitoring and management practices during non-cardiac surgery in Austria. The sample was exclusively composed of medical professionals, with negligible participation from non-physician staff. A high proportion of respondents held senior clinical positions, enhancing the clinical validity and interpretability of the findings. In addition to structural parameters, the survey assessed clinical decision-making with regard to indication thresholds, hemodynamic targets and pharmacological interventions. Many key findings of this survey among Austrian anesthesiologists are consistent with the results of the nationwide German survey and reveal comparable trends and barriers in clinical routine in both countries.

The study is not without limitations.

First, the response rate was 11% of all contacted ÖGARI members. While this figure is consistent with other anonymous online surveys conducted without incentives or reminders, it limits generalizability. ÖGARI includes not only anesthesiologists but also nursing staff, associate members, and physicians working solely in intensive care. These groups may not have felt addressed by a survey on intraoperative hemodynamic management, potentially contributing to limited participation.

A comparable survey on advanced hemodynamic monitoring among members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), also with a limited response rate, was recently published by our group [3]. While the response rate was acknowledged as a limitation, publication in a peer-reviewed journal underlined that scientific value is primarily determined by the relevance of the research question, methodological transparency and the professional qualification of respondents.

Furthermore, Austria’s healthcare system is characterized by a high degree of centralization, in contrast to more decentralized systems such as Germany. Specialized services, such as advanced hemodynamic monitoring, are typically concentrated in high-capacity university or tertiary hospitals. This may have also contributed to the limited participation rate.

Second, voluntary participation may have led to a predominance of respondents with a specific interest in hemodynamic monitoring and access to advanced technologies. This introduces the risk of selection bias and may lead to an overestimation of the frequency of advanced monitoring modalities.

Third, the survey exclusively captured physician perspectives. The views of critical care nurses - particularly relevant in intensive care settings - were not included. Anesthetists working in outpatient or day-case settings, where advanced monitoring is less commonly applied, may have been underrepresented.

Fourth, as with all self-reported data, discrepancies between stated practices and actual clinical behavior must be considered. This applies in particular to questions regarding protocol adherence and monitoring indications.

Fifth, although technical measures (e.g., cookie-based response blocking) were employed to prevent multiple submissions, repeated participation by individual respondents cannot be ruled out entirely.

Sixth, due to the anonymous nature of the survey, it cannot be determined whether multiple respondents originated from the same hospital. This could potentially lead to an overrepresentation of local clinical standards in the results, particularly if these respondents followed the same standardized protocols. We acknowledge that hospital-specific protocols might contribute to response variability. However, the data indicate that intraoperative blood pressure management was predominantly guided by individual clinical judgment rather than by institutional protocols. Therefore, the influence of potential institutional clustering on the overall findings is likely limited.

Despite these methodological constraints, the present survey provides a robust and clinically relevant snapshot of perioperative hemodynamic monitoring and management practices in Austria - particularly within tertiary care centers and highly specialized surgical environments.