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Review
. 2021 Dec 15;1(1):26.
doi: 10.1186/s44158-021-00026-3.

Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis

Mariateresa Giglio  1 , Giandomenico Biancofiore  2 , Alberto Corriero  3 , Stefano Romagnoli  4 , Luigi Tritapepe  5 , Nicola Brienza  6 , Filomena Puntillo  6
Affiliations
Review

Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis

Mariateresa Giglio et al. J Anesth Analg Crit Care. .

Abstract

Background: Goal-directed therapy (GDT) aims to assure tissue perfusion, by optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications. However, all recent evidences focused on high-risk patients and on major abdominal surgery.

Objectives: The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications (defined as number of patients with a least one postoperative complication) in different kind of surgical procedures.

Data sources: Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. A subgroup-analysis was performed considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery. and so on.

Study appraisal and synthesis methods: Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs).

Results: In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49-0.72. The sensitivity analysis confirmed the main result. The analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59-0.87, p = 0.0007, 31 RCTs, 4203 patients), both in high- and low-risk patients. A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35-0.80, p = 0.002, 7 RCTs, 650 patients. Also neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21-0.78, p = 0.008, 2 RCTs, 208 patients). In both major abdominal and orthopedic surgery, a strategy adopting fluids and inotropes yielded significant results. The total volume of fluid was not significantly different between the GDT and the control group.

Conclusions and implications of key findings: The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, suggests that GDT can reduce postoperative complication rate. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. Several well-designed RCTs are needed to further explore the effect of GDT in different kind of surgeries.

Keywords: Cardiac output; Fluid therapy; Meta-analysis; Postoperative complications.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow chart summarizing the studies selection procedure for the meta-analysis. RCT, andomized controlled trial
Fig. 2
Fig. 2
Rates of postoperative complications in subgroups defined according to risk of bias (see text for details) with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI
Fig. 3
Fig. 3
Rates of postoperative complications in patients undergoing abdominal surgery, with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI
Fig. 4
Fig. 4
Rates of postoperative complications in patients undergoing orthopedic surgery, with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI
Fig. 5
Fig. 5
Rates of postoperative complications in patients undergoing neurosurgery, with Odds Ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI
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