In light of the growing proportion of illness in the general population, the complexity of modern surgery requires precise perioperative hemodynamic monitoring. Echocardiography has emerged over the past 15 years as an especially valuable diagnostic instrument for intensive medicine. No other monitoring technique provides in such a short time, with so little invasiveness, so much additional anatomic information for determining the cause of acute hemodynamic instability. There is of course the possibility of proceeding transthoracally at first, with poor imaging quality but noninvasively, or transesophageally. However, perioperative hemodynamic monitoring allows even less experienced operators to detect the various differential diagnoses of acute hemodynamic instability with an easily managed number of standard images. Starting from the first standard settings, depending on pathology the imaging should continue selectively with transthoracal echocardiography in the short parasternal axis or transesophageal echocardiography in the transgastral short midpapillary axis.