[Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis]
Javier Ripollés1, Angel Espinosa2, Eugenio Martínez-Hurtado1
1Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Espanha.
Insights
Intraoperative goal-directed hemodynamic therapy significantly reduces postoperative complications in noncardiac surgery. However, this meta-analysis did not find a significant decrease in mortality rates.
Area of Science:
- Anesthesiology and Critical Care Medicine
- Surgical Outcomes Research
- Hemodynamic Monitoring
Context:
- Goal-directed hemodynamic therapy (GDHT) optimizes tissue perfusion and oxygen delivery using cardiac output parameters.
- Intraoperative GDHT is increasingly explored to improve surgical outcomes.
- Postoperative complications remain a significant concern in noncardiac surgery.
Purpose:
- To evaluate the impact of intraoperative goal-directed hemodynamic therapy on postoperative complication rates.
- To assess the effect of GDHT on mortality following noncardiac surgery.
Summary:
- A meta-analysis of 29 randomized clinical trials (2654 patients) compared intraoperative GDHT with conventional fluid management.
- GDHT demonstrated a significant reduction in postoperative complications (RR: 0.70, 95% CI: 0.62-0.79).
- No significant difference in mortality rates was observed (RR: 0.76, 95% CI: 0.45-1.28).
Impact:
- Intraoperative GDHT, particularly with minimally invasive monitoring, effectively decreases postoperative complications in noncardiac surgery.
- The study highlights the potential of GDHT to enhance patient recovery.
- Further research may be needed to explore its impact on mortality reduction.
Background:
The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates.
Methods:
A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis.
Results:
51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results.
Conclusions:
Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.
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