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Meta-Analysis
. 2016 Mar 14;3(3):CD003004.
doi: 10.1002/14651858.CD003004.pub4.

Perioperative fluid volume optimization following proximal femoral fracture

Sharon R Lewis  1 , Andrew R Butler, Andrew Brammar, Amanda Nicholson, Andrew F Smith
Affiliations
Meta-Analysis

Perioperative fluid volume optimization following proximal femoral fracture

Sharon R Lewis et al. Cochrane Database Syst Rev. .

Abstract

Background: Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear.

Objectives: To compare the safety and effectiveness of the following methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered in other reviews.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9); MEDLINE (October 2012 to September 2015); and EMBASE (October 2012 to September 2015) without language restrictions. We ran forward and backward citation searches on identified trials. We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published originally in 2004 and updated first in 2013 and again in 2015. Original searches were performed in October 2003 and October 2012.

Selection criteria: We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF that compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status.

Data collection and analysis: Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, time to medical fitness, whether participants were able to return to pre-fracture accommodation at six months, participant mobility at six months and adverse events in-hospital. We pooled data using risk ratio (RR) or mean difference (MD) for dichotomous or continuous data, respectively, on the basis of random-effects models.

Main results: We included in this updated review five RCTs with a total of 403 participants, and we added two new trials identified during the 2015 search. One of the included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found two trials for which data are awaited for classification and one ongoing trial.Three studies compared advanced haemodynamic monitoring with a protocol using standard measures; three compared advanced haemodynamic monitoring with usual care; and one compared a protocol using standard measures with usual care. Meta-analyses for the two advanced haemodynamic monitoring comparisons are consistent with both increased and decreased risk of mortality (RR Mantel-Haenszel (M-H) random-effects 0.41, 95% confidence interval (CI) 0.14 to 1.20; 280 participants; RR M-H random-effects 0.45, 95% CI 0.07 to 2.95; 213 participants, respectively). The study comparing a protocol with usual care found no difference between groups for this outcome.Three studies comparing advanced haemodynamic monitoring with usual care reported data for length of stay and time to medical fitness. There was no statistically significant difference between groups for these outcomes in the two studies that we were able to combine (MD IV fixed 0.63, 95% CI -1.70 to 2.96); MD IV fixed 0.01, 95% CI -1.74 to 1.71, respectively) and no statistically significant difference in the third study. One study reported reduced time to medical fitness when comparing advanced haemodynamic monitoring with a protocol, and when comparing protocol monitoring with usual care.The number of participants with one or more complications showed no statistically significant differences in each of the two advanced haemodynamic monitoring comparisons (RR M-H random-effects 0.83, 95% CI 0.59 to 1.17; 280 participants; RR M-H random-effects 0.72, 95% CI 0.40 to 1.31; 173 participants, respectively), nor any differences in the protocol and usual care comparison.Only one study reported the number of participants able to return to normal accommodation after discharge with no statistically significant difference between groups.There were few studies with a small number of participants, and by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach, we judged the quality of the outcome evidence as low. We had included one study with a high risk of bias, but upon applying GRADE, we downgraded the quality of this outcome evidence to very low.

Authors' conclusions: Five studies including a total of 403 participants provided no evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Further research powered to test some of these outcomes is ongoing.

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Conflict of interest statement

Andrew Brammar: none known.

Andrew F Smith: none known.

Sharon R Lewis: none known

Andrew R Butler: none known.

Amanda Nicholson (AN): From June 2015, AN has worked for Q Medical Technology Limited, a firm that markets and distributes a range of medical devices. AN made no substantial contribution to the review while working at Q Medical Technologies Limited. None of the company's products are directly relevant to the subject of this review. AN's husband has small direct holdings in several drug and biotech companies as part of a wider balanced share portfolio.

Figures

1
1
Study flow diagram. Updated search October 2012 to January 2015.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Advanced haemodynamic monitoring versus protocol using standard measures, Outcome 1 All‐cause mortality.
1.2
1.2. Analysis
Comparison 1 Advanced haemodynamic monitoring versus protocol using standard measures, Outcome 2 Adverse outcomes.
2.1
2.1. Analysis
Comparison 2 Advanced haemodynamic monitoring versus usual care, Outcome 1 All‐cause mortality.
2.2
2.2. Analysis
Comparison 2 Advanced haemodynamic monitoring versus usual care, Outcome 2 Total length of hospital stay.
2.3
2.3. Analysis
Comparison 2 Advanced haemodynamic monitoring versus usual care, Outcome 3 Days until medically fit for discharge.
2.4
2.4. Analysis
Comparison 2 Advanced haemodynamic monitoring versus usual care, Outcome 4 Adverse outcomes.
See this image and copyright information in PMC

Update of

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