Non-invasive goal-directed fluid therapy with the pleth variability index (PVI): a systematic review and meta-analysis

Abstract

Optimal intraoperative fluid management is essential to improve surgical outcomes and reduce complications. The Pleth Variability Index (PVI), a dynamic and non-invasive indicator of fluid responsiveness, has been proposed as a tool for goal-directed fluid management. This systematic review and meta-analysis aimed to evaluate the effectiveness of PVI-guided fluid therapy compared to conventional fluid management (CFM) in non-cardiac surgeries. A comprehensive search of PubMed, Embase, and Cochrane databases up to January 2024 identified eligible studies. Primary outcomes included total intraoperative fluid volume and crystalloid administration. Secondary outcomes included hemodynamic parameters, renal function markers, acid-base balance, and hospital length of stay (LOS). Random-effects models were applied, and subgroup and sensitivity analyses were performed. Nine studies comprising 1,105 patients were included. Compared to conventional fluid management, PVI-guided therapy significantly reduced total fluid volume (mean difference [MD] - 761.23 mL; 95% CI - 1267.42 to - 255.03) and crystalloid administration (MD - 655.05 mL; 95% CI - 1096.48 to - 213.62), without significant differences in colloid use, urine output, norepinephrine requirement, arterial pressure, acid-base balance, or LOS. Subgroup analysis of abdominal surgeries confirmed the observed reduction in fluid volumes. PVI-guided fluid management allows for a more restrictive and individualized approach without compromising hemodynamic or metabolic stability. While the heterogeneity across studies limits generalizability, these findings support the clinical value of PVI as a non-invasive tool for perioperative fluid optimization, especially in settings where invasive monitoring is not feasible. Further trials are needed to evaluate its impact on long-term outcomes.

Keywords: Goal-directed fluid therapy; Meta-analysis; Perioperative fluid management; Pleth Variability Index (PVI); Systematic review.

Fig. 1

PRISMA flow diagram detailing the study selection process, including identification, screening, and inclusion of studies in the meta-analysis

Fig. 2

Meta-analysis comparing total fluid infused (a), total crystalloids infused (b), and total colloids infused (c) between the Pleth Variability Index (PVI) group and the standard management group. Mean differences (MD) and 95% confidence intervals (CI) were analyzed using a random-effects model

Fig. 3

Meta-analysis evaluating the impact of the Pleth Variability Index (PVI) versus standard management on norepinephrine requirement (a), mean arterial blood pressure (b), and urine output (c). Results are presented as risk ratios (RR) or mean differences, with 95% confidence intervals (CI), using a random-effects model

Fig. 4

Meta-analysis comparing the effects of using the Pleth Variability Index (PVI) versus standard management on acid-base parameters (a), serum bicarbonate (b), and postoperative blood lactate (c). Mean differences and 95% confidence intervals (CI) were analyzed using a random-effects model

Fig. 5

Meta-analysis evaluating blood loss (a), length of hospital stay (LOS) (b), and postoperative creatinine levels (c) in patients managed with the Pleth Variability Index (PVI) versus standard management. Results are presented as mean differences (MD) with 95% confidence intervals (CI) using a random-effects model

Fig. 6

Subgroup analysis comparing total fluid infused (a) and total crystalloids infused (b) in abdominal surgeries between the intervention and control groups. Mean differences (MD) and 95% confidence intervals (CI) were analyzed using a random-effects model