A systematic review of goal directed fluid therapy: Rating of evidence for goals and monitoring methods

Abstract

Purpose

To review the literature on goal directed fluid therapy and evaluate the quality of evidence for each combination of goal and monitoring method.

Materials and Methods

A search of major digital databases and hand search of references was conducted. All studies assessing the clinical utility of a specific fluid therapy goal or set of goals using any monitoring method were included. Data was extracted using a pre-determined pro forma and papers were evaluated using GRADE principles to assess evidence quality.

Results

Eighty-one papers met the inclusion criteria, investigating 31 goals and 22 methods for monitoring fluid therapy in 13 052 patients. In total there were 118 different goal/method combinations. Goals with high evidence quality were central venous lactate and stroke volume index. Goals with moderate quality evidence were sublingual microcirculation flow, the oxygen extraction ratio, cardiac index, cardiac output, and SVC collapsibility index.

Conclusions

This review has highlighted the plethora of goals and methods for monitoring fluid therapy. Strikingly, there is scant high quality evidence, in particular for non-invasive G/M combinations in non-operative and non-intensive care settings. There is an urgent need to address this research gap, which will be helped by methodologies to compare utility of G/M combinations.

Introduction

Almost 40 years ago, Shoemaker and colleagues published a landmark study introducing the use of physiological goals to guide fluid therapy [1]. They demonstrated that mortality could be reduced by titrating fluid therapy to pre-determined cardiorespiratory variables. This was the birth of ‘goal directed fluid therapy’ (GDFT).

Since then many goals have been promoted to direct fluid therapy, both invasive and non-invasive [2]. Despite evidence demonstrating the potential benefit of GDFT in a number of disease states [3], there remains no consensus about the most effective goals for fluid therapy or the most appropriate monitoring methods. As such, GDFT remains a well-accepted concept that has not yet translated to an established standard of care. Formal evaluation of the different goal/method (G/M) combinations for GDFT has been hampered by the many different goals, the number of methods to monitor fluid therapy, the variation in study design, and the lack of comparable controls. A new approach to evaluating G/M combinations is required so that the leading options can be formally studied to establish an evidence based standard of care for GDFT.

The aim of this study was to conduct a systematic review of the literature and evaluate the quality of evidence for each G/M combination using the established GRADE methodology [4], [5], [6], [7], [8], [9].