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Published on: November 20, 2016
Classification and differential effectiveness of goal-directed hemodynamic therapies in surgical patients: A network
Xu Zhao1, Li Tian2, Alexandria Brackett3
1Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, United States of America.
Insights
Goal-directed hemodynamic therapy (GDHT) effectively reduces mortality and acute kidney injury in surgical patients. Optimizing intravascular volume, stroke volume, and cardiac output offers the best outcomes.
Area of Science:
- Critical Care Medicine
- Surgical Oncology
- Anesthesiology
Background:
- Goal-directed hemodynamic therapy (GDHT) is crucial for optimizing patient outcomes in surgical settings.
- Understanding the relative effectiveness of different GDHT strategies is essential for clinical decision-making.
- Previous research has yielded varied results regarding the efficacy of specific GDHT protocols.
Purpose of the Study:
- To systematically investigate and rank the effectiveness of various goal-directed hemodynamic therapies (GDHTs) in surgical patients.
- To identify the most effective GDHT strategies for reducing key postoperative complications such as mortality and acute kidney injury (AKI).
- To provide evidence-based recommendations for GDHT implementation in surgical care.
Main Methods:
- A network meta-analysis was conducted on 101 randomized controlled trials (RCTs) involving surgical patients receiving GDHT.
- GDHTs were categorized based on their optimization targets: intravascular volume, preload, stroke volume, cardiac output, oxygen delivery, systemic oxygenation, or tissue oxygenation.
- The Surface Under the Cumulative Ranking Curve (SUCRA) was used to rank the relative effectiveness of different GDHT strategies.
Main Results:
- GDHTs targeting intravascular volume and cardiac output optimization significantly reduced 30-day mortality (OR 0.40; low quality evidence).
- GDHTs targeting intravascular volume optimization significantly reduced acute kidney injury (AKI) (OR 0.26; moderate quality evidence).
- No significant reduction in arrhythmia was observed with any GDHT strategy. GDHT for intravascular volume and stroke volume optimization showed high likelihood of reducing mortality (SUCRA = 78.8%), while GDHT for intravascular volume, stroke volume, and cardiac output optimization showed high likelihood of reducing AKI (SUCRA = 85.4%).
Conclusions:
- The effectiveness of GDHTs in surgical patients is outcome-dependent.
- GDHTs focusing on optimizing intravascular volume, stroke volume, and cardiac output appear to be the most effective overall.
- These findings support the tailored application of GDHT to achieve specific patient outcomes and improve surgical care quality.
Purpose:
To investigate the most effective goal-directed hemodynamic therapy (GDHT) in surgical patients.
Methods:
GDHTs were classified as methods for intravascular volume, preload, stroke volume, cardiac output, oxygen delivery, systemic oxygenation, or tissue oxygenation optimization, alone or in combination. Their relative effectiveness and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA), respectively.
Results:
101 randomized controlled trials investigating GDHT effectiveness in surgical patients were eligible. The most commonly reported outcomes were 30-day mortality, acute kidney injury (AKI), and arrhythmia. Mortality was significantly reduced by GDHTs aimed at intravascular volume and cardiac output optimization (OR 0.40; 95% CrI 0.14-0.997; low quality). AKI was significantly reduced by GDHT aimed at intravascular volume optimization (OR 0.26; 95% CrI 0.08-0.71; moderate quality). No GDHT significantly reduced arrhythmia. GDHT aimed at intravascular volume and stroke volume optimization was likely most effective for mortality reduction (SUCRA = 78.8%) while that aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for AKI reduction (SUCRA = 85.4%).
Conclusions:
Different GDHTs likely have different and outcome-dependent effectiveness in surgical patients. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective as per the overall evidence.
Systematic Review Registration:
PROSPERO registration number: CRD42020159978.
