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, Spain.
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
- Critical Care Medicine
- Surgical Outcomes
Background:
- Goal directed hemodynamic therapy optimizes tissue perfusion using cardiac output parameters.
- It aims to improve oxygen delivery through fluid and drug management.
- This study investigates its impact on postoperative complications.
Purpose of the Study:
- To evaluate the effects of intraoperative goal directed hemodynamic therapy on postoperative complication rates.
- To assess the impact on mortality as a secondary outcome.
Main Methods:
- A meta-analysis of randomized clinical trials (RCTs) adhering to PRISMA guidelines.
- Systematic searches in Medline, PubMed, Embase, and Cochrane Library up to October 2014.
- Included adult noncardiac surgery RCTs comparing goal directed hemodynamic therapy with conventional fluid management; excluded trauma, pediatric, and pulmonary artery catheter studies.
Main Results:
- 29 RCTs involving 2654 patients were analyzed.
- A significant reduction in postoperative complications was observed with goal directed hemodynamic therapy (RR: 0.70, 95% CI: 0.62-0.79).
- No significant decrease in mortality was found (RR: 0.76, 95% CI: 0.45-1.28).
Conclusions:
- Intraoperative goal directed hemodynamic therapy, particularly with minimally invasive monitoring, reduces postoperative complications in noncardiac surgery.
- The therapy did not demonstrate a significant reduction in mortality rates.
- Further research may be needed to clarify mortality benefits.
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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