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Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials

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Abstract

Background and aims

Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients.

Material and methods

Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study.

Results

Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46–1.08, p = 0.11) length of post-operative hospital stay (SMD −0.14; 95 % CI −0.28, 0.00; p = 0.05) and length of ICU stay (SMD −0.12; 95 % CI −0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure.

Conclusion

GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.

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References

  1. Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97:755–7.

    Article  CAS  PubMed  Google Scholar 

  2. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Powell-Tuck J, Gosling P, Lobo DN, Carlson GL, Gore M, Lewington AJ, Pearse RM, Mythen MG. British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP). London: NHS National Library of Health; 2009. http://www.ics.ac.uk/EasysiteWeb/getresource.axd?AssetID=466&type=full&servicetype=Attachment. Accessed 20 March 2015.

  4. Miller TE, Roche AM, Gan TJ. Poor adoption of hemodynamic optimization during major surgery: are we practicing substandard care? Anesth Analg. 2011;112:1274–6.

    Article  PubMed  Google Scholar 

  5. Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care. 2014;18:584.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Feldheiser A, Hunsicker O, Krebbel H, Weimann K, Kaufner L, Wernecke KD, Spies C. Oesophageal Doppler and calibrated pulse contour analysis are not interchangeable within a goal-directed haemodynamic algorithm in major gynaecological surgery. Br J Anaesth. 2014;113:822–31.

    Article  CAS  PubMed  Google Scholar 

  7. Arulkumaran N, Corredor C, Hamilton MA, Ball J, Grounds RM, Rhodes A, Cecconi M. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth. 2014;112:648–59.

    Article  CAS  PubMed  Google Scholar 

  8. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114:640–51.

    Article  PubMed  Google Scholar 

  9. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637–46.

    Article  CAS  PubMed  Google Scholar 

  10. Gurgel ST, do Nascimento P Jr. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg. 2011;112:1384–91.

  11. Brienza N, Giglio MT, Marucci M, Fiore T. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med. 2009;37:2079–90.

    Article  PubMed  Google Scholar 

  12. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 112:1392–402.

  13. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–9.

    Article  PubMed  Google Scholar 

  14. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Bartha E, Arfwedson C, Imnell A, Fernlund ME, Andersson LE, Kalman S. Randomized controlled trial of goal-directed haemodynamic treatment in patients with proximal femoral fracture. Br J Anaesth. 2013;110:545–53.

    Article  CAS  PubMed  Google Scholar 

  16. Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14:R118.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bisgaard J, Gilsaa T, Rønholm E, Toft P. Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Acta Anaesthesiol Scand. 2013;57:189–98.

    Article  CAS  PubMed  Google Scholar 

  18. Bisgaard J, Gilsaa T, Rønholm E, Toft P. Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial. Acta Anaesthesiol Scand. 2013;57:178–88.

    Article  CAS  PubMed  Google Scholar 

  19. Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SÅ, Hansen B, Møller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth. 2012;109:191–9.

    Article  CAS  PubMed  Google Scholar 

  20. Buettner M, Schummer W, Huettemann E, Schenke S, van Hout N, Sakka SG. Influence of systolic-pressure-variation-guided intraoperative fluid management on organ function and oxygen transport. Br J Anaesth. 2008;101:194–9.

    Article  CAS  PubMed  Google Scholar 

  21. Cecconi M, Fasano N, Langiano N, Divella M, Costa MG, Rhodes A, Della Rocca G. Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care. 2011;15:R132.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G. Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 2012;108:53–62.

    Article  CAS  PubMed  Google Scholar 

  23. Colantonio L, Claroni C, Fabrizi L, Marcelli ME, Sofra M, Giannarelli D, Garofalo A, Forastiere E. A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. J Gastrointest Surg. 2015;19:722–729.

  24. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57:845–9.

    Article  CAS  PubMed  Google Scholar 

  25. Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg. 2010;111:910–4.

    PubMed  Google Scholar 

  26. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–26.

  27. Harten J, Crozier JE, McCreath B, Hay A, McMillan DC, McArdle CS, Kinsella J. Effect of intraoperative fluid optimisation on renal function in patients undergoing emergency abdominal surgery: a randomised controlled pilot study. Int J Surg. 2008;6:197–204.

    Article  CAS  PubMed  Google Scholar 

  28. Van der Linden PJ, Dierick A, Wilmin S, Bellens B, De Hert SG. A randomized controlled trial comparing an intraoperative goal-directed strategy with routine clinical practice in patients undergoing peripheral arterial surgery. Eur J Anaesthesiol. 2010;27:788–93.

    Article  PubMed  Google Scholar 

  29. Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care. 2007;11:R100.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Mayer J, Boldt J, Mengistu AM, Röhm KD, Suttner S. Goal-directed intraoperative therapy based on auto calibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care. 2010;14:R18.

    Article  PubMed  PubMed Central  Google Scholar 

  31. McKenny M, Conroy P, Wong A, Farren M, Gleeson N, Walsh C, O’Malley C, Dowd N. A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery. Anaesthesia. 2013;68:1224–31.

    Article  CAS  PubMed  Google Scholar 

  32. Moppett IK, Rowlands M, Mannings A, Moran CG, Wiles MD, NOTTS Investigators. LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. Br J Anaesth. 2015;114:444–59.

    Article  CAS  PubMed  Google Scholar 

  33. Bundgaard-Nielsen M, Jans Ø, Müller RG, Korshin A, Ruhnau B, Bie P, Secher NH, Kehlet H. Does goal-directed fluid therapy affect postoperative orthostatic intolerance?: a randomized trial. Anesthesiology. 2013;119:813–23.

    Article  PubMed  Google Scholar 

  34. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069–76.

    Article  CAS  PubMed  Google Scholar 

  35. Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, Grocott MP, Ahern A, Griggs K, Scott R, Hinds C, Rowan K, OPTIMISE Study Group. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311:2181–90.

    Article  CAS  PubMed  Google Scholar 

  36. Peng K, Li J, Cheng H, Ji FH. Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Med Princ Pract. 2014;23:413–20.

    Article  PubMed  Google Scholar 

  37. Pestaña D, Espinosa E, Eden A, Nájera D, Collar L, Aldecoa C, Higuera E, Escribano S, Bystritski D, Pascual J, Fernández-Garijo P, de Prada B, Muriel A, Pizov R. Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth Analg. 2014;119:579–87.

    Article  PubMed  Google Scholar 

  38. Phan TD, D’Souza B, Rattray MJ, Johnston MJ, Cowie BS. A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an enhanced recovery after surgery program. Anaesth Intensive Care. 2014;42:752–60.

    CAS  PubMed  Google Scholar 

  39. Pösö T, Winsö O, Aroch R, Kesek D. Perioperative fluid guidance with transthoracic echocardiography and pulse-contour device in morbidly obese patients. Obes Surg. 2014;24:2117–25.

    Article  PubMed  Google Scholar 

  40. Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. J Clin Monit Comput. 2013;27:249–57.

    Article  PubMed  Google Scholar 

  41. Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG, Reuter DA. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care. 2013;17:R191.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Scheeren TW, Wiesenack C, Gerlach H, Marx G. Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. J Clin Monit Comput. 2013;27:225–33.

    Article  PubMed  Google Scholar 

  43. Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum. 2009;52:1935–40.

    Article  CAS  PubMed  Google Scholar 

  44. Srinivasa S, Taylor MH, Singh PP, Yu TC, Soop M, Hill AG. Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg. 2013;100:66–74.

    Article  CAS  PubMed  Google Scholar 

  45. Szakmany T, Toth I, Kovacs Z, Leiner T, Mikor A, Koszegi T, Molnar Z. Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial. Intensive Care Med. 2005;31:656–63.

    Article  PubMed  Google Scholar 

  46. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71.

    Article  CAS  PubMed  Google Scholar 

  47. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–42.

    Article  CAS  PubMed  Google Scholar 

  48. Yu Y, Dong J, Xu Z, Shen H, Zheng J. Pleth variability index-directed fluid management in abdominal surgery under combined general and epidural anesthesia. J Clin Monit Comput. 2015;29:47–52.

    Article  PubMed  Google Scholar 

  49. Zeng K, Li Y, Liang M, Gao Y, Cai H, Lin C. The influence of goal-directed fluid therapy on the prognosis of elderly patients with hypertension and gastric cancer surgery. Drug Des Devel Ther. 2014;8:2113–9.

    PubMed  PubMed Central  Google Scholar 

  50. Zhang J, Qiao H, He Z, Wang Y, Che X, Liang W. Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Clinics (Sao Paulo). 2012;67:1149–55.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Zhang J, Chen CQ, Lei XZ, Feng ZY, Zhu SM. Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study. Clinics (Sao Paulo). 2013;68:1065–70.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Zheng H, Guo H, Ye JR, Chen L, Ma HP. Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. World J Surg. 2013;37:2820–9.

    Article  PubMed  Google Scholar 

  53. Funk DJ, HayGlass KT, Koulack J, Harding G, Boyd A, Brinkman R. A randomized controlled trial on the effects of goal-directed therapy on the inflammatory response open abdominal aortic aneurysm repair. Crit Care. 2015;19:247.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Jammer I, Tuovila M, Ulvik A. Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial. Perioper Med (Lond). 2015;4:6.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care. 2005;9:R687–93.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Jhanji S, Vivian-Smith A, Lucena-Amaro S, Watson D, Hinds CJ, Pearse RM. Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Crit Care. 2010;14:R151.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Ackland GL, Iqbal S, Paredes LG, Toner A, Lyness C, Jenkins N, Bodger P, Karmali S, Whittle J, Reyes A, Singer M, Hamilton M, Cecconi M, Pearse RM, Mallett SV, Omar RZ, POM-O (PostOperative Morbidity-Oxygen delivery) study group. Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial. Lancet Respir Med. 2015;3:33–41.

    Article  CAS  PubMed  Google Scholar 

  58. Correa-Gallego C, Tan KS, Arslan-Carlon V, Gonen M, Denis SC, Langdon-Embry L, Grant F, Kingham TP, DeMatteo RP, Allen PJ, D'Angelica MI, Jarnagin WR, Fischer M. Goal-directed fluid therapy using stroke volume variation for resuscitation after low central venous pressure-assisted liver resection: a randomized clinical trial. J Am Coll Surg. 2015;221:591–601.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103:419–28.

    Article  PubMed  Google Scholar 

  60. Pearse RM, Belsey JD, Cole JN, Bennett ED. Effect of dopexamine infusion on mortality following major surgery: individual patient data meta-regression analysis of published clinical trials. Crit Care Med. 2008;36:1323–9.

    Article  CAS  PubMed  Google Scholar 

  61. Zarychanski R, Abou-Setta AM, Turgeon AF, Houston BL, McIntyre L, Marshall JC, Fergusson DA. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA. 2013;309:678–88.

    Article  CAS  PubMed  Google Scholar 

  62. Serpa Neto A, Veelo DP, Peireira VG, de Assunção MS, Manetta JA, Espósito DC, Schultz MJ. Fluid resuscitation with hydroxyethyl starches in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy: a systematic review and meta-analysis of the literature. J Crit Care. 2014;29:185.e1–7.

  63. Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, Grounds RM, Bennett ED. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10:R81.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Suehiro K, Tanaka K, Mukai A, Joosten A, Desebbe O, Alexander B, Cannesson M, Nishikawa K. Hemodynamic monitoring and management in high-risk surgery: a survey among Japanese anesthesiologists. J Anesth. 2016;30:526–9.

    Article  PubMed  Google Scholar 

  65. Opperer M, Poeran J, Rasul R, Mazumdar M, Memtsoudis SG. Use of perioperative hydroxyethyl starch 6 % and albumin 5 % in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis. BMJ. 2015;350:h1567.

    Article  PubMed  PubMed Central  Google Scholar 

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Som, A., Maitra, S., Bhattacharjee, S. et al. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials. J Anesth 31, 66–81 (2017). https://doi.org/10.1007/s00540-016-2261-7

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