Impact of hemodynamic goal-directed resuscitation on mortality in adult critically ill patients: a systematic review and meta-analysis

Abstract

The effect of hemodynamic optimization in critically ill patients has been challenged in recent years. The aim of the meta-analysis was to evaluate if a protocolized intervention based on the result of hemodynamic monitoring reduces mortality in critically ill patients. We performed a systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions. The study was registered in the PROSPERO database (CRD42015019539). Randomized controlled trials published in English, reporting studies on adult patients treated in an intensive care unit, emergency department or equivalent level of care were included. Interventions had to be protocolized and based on results from hemodynamic measurements, defined as cardiac output, stroke volume, stroke volume variation, oxygen delivery, and central venous-or mixed venous oxygenation. The control group had to be treated without any structured intervention based on the parameters mentioned above, however, monitoring by central venous pressure measurements was allowed. Out of 998 screened papers, thirteen met the inclusion criteria. A total of 3323 patients were enrolled in the six trials with low risk of bias (ROB). The mortality was 22.4% (374/1671 patients) in the intervention group and 22.9% (378/1652 patients) in the control group, OR 0.94 with a 95% CI of 0.73-1.22. We found no statistically significant reduction in mortality from hemodynamic optimization using hemodynamic monitoring in combination with a structured algorithm. The number of high quality trials evaluating the effect of protocolized hemodynamic management directed towards a meaningful treatment goal in critically ill patients in comparison to standard of care treatment is too low to prove or exclude a reduction in mortality.

Keywords: Critical care; Fluid therapy; Hemodynamic monitoring; Meta-analysis; Mortality; Protocol.

Fig. 1

PRISMA flow diagram Fig. 1 Legend: PRISMA flow diagram on literature search and study selection

Fig. 2

Risk of bias assessment for included studies Fig. 2 Legend: Assessment of validity of included studies according to the cochrane collaborative tool for risk of bias assessment. Low risk of bias +, high risk of bias −, unclear risk of bias?

Fig. 3

Meta-analysis of effectiveness of hemodynamic monitoring combined with protocolized interventions to reduce mortality, low risk of bias trials Fig. 3 Legend: Meta-analysis of effectiveness of hemodynamic monitoring combined with protocolized interventions to reduce mortality, low risk of bias trials. Weight is the relative contribution of each study to the overall treatment effect (odds risk ratio and 95% confidence interval) on a log scale assuming Mantel–Haenszel random effects model

Fig. 4

Meta-analysis of effectiveness of hemodynamic monitoring combined with protocolized interventions to reduce mortality, all included trials Fig. 4 Legend: Meta-analysis of effectiveness of hemodynamic monitoring combined with protocolized interventions to reduce mortality, all included trials. Weight is the relative contribution of each study to the overall treatment effect (odds risk ratio and 95% confidence interval) on a log scale assuming Mantel–Haenszel random effects model