Effects of perioperative goal-directed fluid therapy combined with the application of alpha-1 adrenergic agonists on postoperative outcomes: a systematic review and meta-analysis

Abstract

Background: Past studies have demonstrated that goal-directed fluid therapy (GDFT) may be more marginal than previously believed. However, beneficial effects of alpha-1 adrenergic agonists combined with appropriate fluid administration is getting more and more attention. This study aimed to systematically review the effects of goal-directed fluid therapy (GDFT) combined with the application of alpha-1 adrenergic agonists on postoperative outcomes following noncardiac surgery.

Methods: This meta-analysis included randomized controlled trials (RCTs) on GDFT combined with the application of alpha-1 adrenergic agonists in patients undergoing noncardiac surgery. The primary outcomes included the postoperative mortality rate and length of hospital stay (LOS). The secondary outcome indexes were the incidence of postoperative complications and recovery of postoperative gastrointestinal (GI) function. The traditional pairwise meta-analysis was conducted to compare the effect of fluid therapy. The quality of included RCTs was evaluated according to the Cochrane Collaboration's risk-of-bias tool. Also, the publication bias was detected using funnel plots, Egger's regression test, and Begg's adjusted rank correlation test. The meta-analysis was conducted using the RevMan 5.3 and Stata 14.0 software.

Results: Thirty-two eligible RCTs were included in this meta-analysis. Perioperative GDFT combined with the application of alpha-1 adrenergic agonists was associated with a significant reduction in LOS (P = 0.002; I² = 69%), and overall complication rates (P = 0.04; I² = 41%). It facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 6.30 h (P < 0.00001; I² = 91%) and the time to toleration of solid food by 1.69 days (P < 0.00001; I² = 0%). Additionally, there was no significant reduction in short-term mortality in the GDFT combined with alpha-1 adrenergic agonists group (P = 0.05; I² = 0%).

Conclusion: This systematic review of available evidence suggested that the use of perioperative GDFT combined with alpha-1 adrenergic agonists might facilitate recovery in patients undergoing noncardiac surgery.

Keywords: Alpha-1 adrenergic agonists; Anesthesia management; Goal-directed fluid therapy; Length of hospital stay; Morbidity; Mortality; Noncardiac surgery.

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram of study selection. RCTs, Randomized controlled trials

Fig. 2

Review authors’ judgments about each risk-of-bias item presented as percentages across all included studies

Fig. 3

Meta-analysis and pooled risk ratio (RR) of the effect of goal-directed fluid therapy (GDFT) combined with alpha-1 adrenergic agonists on the short-term mortality after noncardiac surgery

Fig. 4

Meta-analysis and pooled risk ratio (RR) of the effect of goal-directed fluid therapy (GDFT) combined with alpha-1 adrenergic agonists on the length of hospital stay (LOS) after noncardiac surgery

Fig. 5

Forest plot comparing the length of hospital stay (LOS) for patients receiving GDFT combined with alpha-1 adrenergic agonists versus control divided by the (a) type of surgery: abdominal surgery, thoracic surgery, orthopedic surgery, or other surgery and (b) type of alpha-1 adrenergic agonists: norepinephrine, phenylephrine, norepinephrine combined with phenylephrine, or metaraminol

Fig. 6

Meta-analysis and pooled risk ratio (RR) of the effect of goal-directed fluid therapy (GDFT) combined with alpha-1 adrenergic agonists on gastrointestinal (GI) function recovery after noncardiac surgery and the influence analysis of individual studies on the pooled RR. Forest plots for (a) time to first flatus and (b) time to toleration of solid food

Fig. 7

Meta-analysis and pooled risk ratio (RR) of the effect of goal-directed fluid therapy (GDFT) combined with alpha-1 adrenergic agonists on overall complication rates after noncardiac surgery and the influence analysis of individual studies on the pooled RR

Fig. 8

Meta-analysis and pooled risk ratio (RR) of the effect of goal-directed fluid therapy (GDFT) combined with alpha-1 adrenergic agonists on postoperative complications after noncardiac surgery and the influence analysis of individual studies on the pooled RR. Forest plots for (a) postoperative myocardial ischemia, (b) postoperative respiratory infection, (c) postoperative respiratory support, (d) postoperative nausea and vomiting (PONV), and (e) wound infection