A substantial number of patients are at high-risk of intra- or post-operative complications or both. Most perioperative deaths are represented by patients who present insufficient physiological reserve to meet the demands of major surgery. Recognition and management of critical high-risk surgical patients require dedicated and effective teams, capable of preventing, recognize, start treatment with adequate support in time to refer patients to the satisfactory ICU level provision. The main task for health-care planners and managers is to identify and reduce this severe risk and to encourage patient’s safety practices. Inadequate tissue perfusion and decreased cellular oxygenation due to hypovolemia, heart dysfunction, reduced cardiovascular reserve, and concomitant diseases are the most common causes of perioperative complications. Hemodynamic, respiratory and careful sequential monitoring have become essential aspects of the clinical practice both for surgeons and intensivists. New monitoring techniques have changed significantly over the past few years and are now able to rapidly identify shock states earlier, define the etiology, and monitor the response to different therapies. Many of these techniques are now minimally invasive or non-invasive. Advanced hemodynamic and respiratory monitoring combines invasive, non-invasive monitoring skills. Non-invasive ultrasound has emerged during the last years as an essential operative and perioperative evaluation tool, and its use is now rapidly growing. Perioperative management guided by appropriate sequential clinical evaluation combined with respiratory and hemodynamic monitoring is an established tool to help clinicians to identify those patients at higher risk in the attempt to reduce the complications rate and potentially improve patient outcomes. This review aims to provide an update of currently available standard concepts and evolving technologies of the various respiratory and hemodynamic monitoring systems for the high-risk surgical patients, highlighting their potential usefulness when integrated with careful clinical evaluation.
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