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Meta-Analysis
. 2019 Dec 12;12(12):CD012767.
doi: 10.1002/14651858.CD012767.pub2.

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery

Anna Wrzosek  1   2 , Joanna Jakowicka-Wordliczek  3 , Renata Zajaczkowska  1 , Wojciech T Serednicki  1 , Milosz Jankowski  3   4 , Malgorzata M Bala  5 , Mateusz J Swierz  6 , Maciej Polak  7 , Jerzy Wordliczek  1
Affiliations
Meta-Analysis

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery

Anna Wrzosek et al. Cochrane Database Syst Rev. .

Abstract

Background: Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization.

Objectives: To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery.

Search methods: We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified.

Selection criteria: We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery.

Data collection and analysis: Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person.

Main results: From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment.

Authors' conclusions: Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.

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Conflict of interest statement

Anna Wrzosek is employed as an Assistant in the Department of Interdisciplinary Intensive Care. Dr Wrzosek has no known conflicts of interest.

Maciej Polak is an Assistant in the Department of Epidemiology and Population Studies in the Institute of Public Health. Dr Polak has no known conflicts of interest.

Malgorzata M Bała is acting head of the Chair of Epidemiology and Preventive Medicine and the Head of the Department of Hygiene and Dietetics. Prof Bala has no known conflicts of interest.

Mateusz J Swierz is an Assistant in the Department of Surgery of a Specialist Hospital in Gorlice and a PhD student at the Department of Hygiene and Dietetics. Dr Swierz has no known conflicts of interest.

Joanna Jakowicka‐Wordliczek is employed as a Specialist in Anaesthesiology and Intensive Care. Dr Jakowicka‐Wordliczek has no known conflicts of interest.

Renata Zajaczkowska is employed as a Specialist in Anaesthesiology and Intensive Care. Dr Zajaczkowsk has no known conflicts of interest.

Milosz Jankowski is employed as a Specialist in Anaesthesiology and Intensive Care. He receives honoraria (as a freelancer) from a publishing company that draws its revenue from pharmaceutical companies in unrelated indications. He is not aware of any direct conflict of interest.

Jerzy Wordliczek is a Head of the Department of Interdisciplinary Intensive Care. Prof Wordliczek has no known conflicts of interest.

Wojciech T Serednicki is employed as a Consultant in Anaesthesia and Critical Care. Dr Serednicki has no known conflicts of interest.

Figures

1
1
Study flow diagram.
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.
4
4
Forest plot of comparison: 1 Restrictive versus goal‐directed fluid therapy, outcome: 1.1 Major complications.
5
5
Forest plot of comparison: 1 Restrictive versus goal‐directed fluid therapy, outcome: 1.2 All‐cause mortality.
6
6
Forest plot of comparison: 1 Restrictive versus goal‐directed fluid therapy, outcome: 1.3 Peto OR all‐cause mortality.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012767

References

References to studies included in this review

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Correa‐Gallego 2015 {published data only}
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Dhawan 2018 {published data only}
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Johnson 2011 {published data only}
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Joosten 2018 {published data only}
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Kumar 2016 {published data only}
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Li 2011 {published data only}
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Liang 2017 {published data only}
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Lilot 2018 {published data only}
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Lobo 2011 {published data only}
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Lopes 2007 {published data only}
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Minkovich 2012 {published data only}
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Minto 2011 {published data only}
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Park 2016 {published data only}
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Peng 2014 {published data only}
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References to ongoing studies

ChiCTR1800014777 {published data only}
    1. Comparison of three different liquid therapies in colorectal surgery. Ongoing study February 2018.
NCT02625701 {unpublished data only}
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NCT03039946 {unpublished data only}
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NCT03519165 {unpublished data only}
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References to other published versions of this review

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