At first glance, the recent 447-patient randomized controlled trial in major orthopedic surgery with new goal-directed fluid management methodology may revitalize the debate, although no effect was demonstrated. Importantly, the concept of goal-directed fluid management has been discussed for more than a decade and, although initially promising, still remains debatable.2,3 

However, a closer look on the methodology of the study again shows that the gold standard of an randomized controlled trial in perioperative medicine may not always be the “gold standard” when it is performed in a clinical setup that limits the potential interaction between the intervention and the outcome. Thus, the trial had a primary outcome on length of stay which was similar between the groups (about 6 days), which is very far from common practice in many international centers...

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