Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial

Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review

Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.

Impact of Goal-Directed Fluid Therapy on Postoperative Outcomes in Colorectal Surgery: An Evidence-Based Review

PURPOSE

To investigate the effects of goal-directed fluid therapy (GDFT) or conventional fluid therapy (CFT) in improving postoperative outcomes in patients undergoing colorectal surgeries.

DESIGN

Evidence-Based Review.

METHODS

Following the guidelines outlined in the PRISMA statement, a comprehensive search was conducted using PubMed, Elsevier ScienceDirect, Oxford Academic, EBSCO, Google Scholar, Cochrane Library, and gray literature. Only randomized controlled studies and pre-appraised evidence such as systematic review with meta-analysis examining the effects of GDFT and CFT in colorectal surgery were included. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide.

FINDINGS

Two systematic reviews with meta-analyses and four randomized controlled trials (RCT) involving 2018 patients were included in this review. Overall, the use of GDFT did not shorten the hospital length of stay (LOS), reduce 30-day mortality, lower overall morbidity rates, or decrease incidence of postoperative ileus. Additionally, the return of bowel function was not improved using GDFT or CFT. However, when GDFT was implemented within enhanced recovery after surgery (ERAS) programs, there was a significant reduction in hospital LOS. . When GDFT was used in a non-ERAS patient care setting, there was a significant reduction in overall morbidity rate and faster time to first flatus. All studies included in the review were categorized as Level I and rated Grade A, implying strong confidence in the true effects of GDFT on all outcome measures in the review.

CONCLUSIONS

The benefits of GDFT in colorectal surgery are still unclear. Considerable heterogeneity based on the types of GDFT devices, patient outcome parameters, and fluid protocols limit the application to clinical practice. Furthermore, there was limited data on the effects of GDFT in high-risk patients for colorectal surgery.

Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis

BACKGROUND

During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes.

METHODS

Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence.

CONCLUSIONS

Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.

Goal-Directed Fluid Therapy and Postoperative Outcomes in an Enhanced Recovery Program for Colorectal Surgery: A Propensity Score-Matched Multicenter Study

INTRODUCTION

Goal-directed fluid therapy (GDFT) has increasingly been utilized in major surgery as a key component to ensure fluid optimization and adequate tissue perfusion, showing improvements in the rate of morbidity and mortality under conventional care. It is unclear if patients derive similar benefit as part of an enhanced recovery program (ERP). Our group sought to assess the association between GDFT and postoperative outcomes within an ERP for colorectal surgery.

METHODS

A propensity score-matched analysis, based upon demographic characteristics, comorbidities, and ERP components, was utilized to assess the association between GDFT and outcomes in a multicenter prospective ERP for colorectal surgery cohort study. Outcomes included pulmonary edema, acute kidney injury (AKI), ileus, surgical site infection (SSI), and anastomotic dehiscence. The calipmatch module was used to match patients who received GDFT to non-GDFT in a 1-to-1 propensity score fashion.

RESULTS

A total of 151 matched pairs were included in the analysis (n = 302, 23%). Both groups had comparable baseline demographics, as well as similar rates of compliance with enhanced recovery after surgery (ERAS) components. Goal-directed fluid therapy patients received significantly more colloid (237 ± 320 mL vs. 140 ± 245 mL, P < .01) than non-GDFT counterparts. Goal-directed fluid therapy was not associated with improved rates of postoperative AKI (odds ratios (OR) 1.00, 95% confidence intervals (CI) .39-2.59, P = 1.00), ileus (OR 1.40, 95% CI .82-2.41, P = .22), SSI (OR 1.06, 95% CI .54-2.08, P = .86), or length of hospital stay (LOS) (10.8 ± 8.9 vs. 11.1±13.2 days, P = .84).

CONCLUSIONS

There was no associated between GDFT and major postoperative outcomes within an ERAS program for colorectal surgery. Additional large-scale or pragmatic randomized trials are necessary to determine whether GDFT has a role in ERP for colorectal surgery.

Goal-directed haemodynamic therapy (GDHT) in surgical patients: systematic review and meta-analysis of the impact of GDHT on post-operative pulmonary complications

Background

Perioperative goal-directed haemodynamic therapy (GDHT), defined as the administration of fluids with or without inotropes or vasoactive agents against explicit measured goals to augment blood flow, has been evaluated in many randomised controlled trials (RCTs) over the past four decades. Reported post-operative pulmonary complications commonly include chest infection or pneumonia, atelectasis, acute respiratory distress syndrome or acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema. Despite the substantial clinical literature in this area, it remains unclear whether their incidence is reduced by GDHT. This systematic review aims to determine the effect of GDHT on the respiratory outcomes listed above, in surgical patients.

Methods

We searched the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, and clinical trial registries up until January 2020. We included all RCTs reporting pulmonary outcomes. The primary outcome was post-operative pulmonary complications and secondary outcomes were specific pulmonary complications and intra-operative fluid input. Data synthesis was performed on Review Manager and heterogeneity was assessed using I² statistics.

Results

We identified 66 studies with 9548 participants reporting pulmonary complications. GDHT resulted in a significant reduction in total pulmonary complications (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections, reported in 45 studies with 6969 participants, was significantly lower in the GDHT group (OR 0.72, CI 0.60 to 0.86). Pulmonary oedema was recorded in 23 studies with 3205 participants and was less common in the GDHT group (OR 0.47, CI 0.30 to 0.73). There were no differences in the incidences of pulmonary embolism or acute respiratory distress syndrome. Sub-group analyses demonstrated: (i) benefit from GDHT in general/abdominal/mixed and cardiothoracic surgery but not in orthopaedic or vascular surgery; and (ii) benefit from fluids with inotropes and/or vasopressors in combination but not from fluids alone. Overall, the GDHT group received more colloid (+280 ml) and less crystalloid (−375 ml) solutions than the control group. Due to clinical and statistical heterogeneity, we downgraded this evidence to moderate.

Conclusions

This systematic review and meta-analysis suggests that the use of GDHT using fluids with inotropes and/or vasopressors, but not fluids alone, reduces the development of post-operative pulmonary infections and pulmonary oedema in general, abdominal and cardiothoracic surgical patients. This evidence was graded as moderate.

PROSPERO registry reference: CRD42020170361

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Introduction

Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.

Aim

To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.

Methods

Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.

Results

Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.

Conclusions

There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Meta-analysis of goal-directed fluid therapy using transoesophageal Doppler monitoring in patients undergoing elective colorectal surgery

Background

Intraoperative goal-directed fluid therapy (GDFT) is recommended in most perioperative guidelines for intraoperative fluid management in patients undergoing elective colorectal surgery. However, the evidence in elective colorectal surgery alone is not well established. The aim of this meta-analysis was to compare the effects of GDFT with those of conventional fluid therapy on outcomes after elective colorectal surgery.

Methods

A meta-analysis of RCTs examining the role of transoesophageal Doppler-guided GDFT with conventional fluid therapy in adult patients undergoing elective colorectal surgery was performed in accordance with PRISMA methodology. The primary outcome measure was overall morbidity, and secondary outcome measures were length of hospital stay, time to return of gastrointestinal function, 30-day mortality, acute kidney injury, and surgical-site infection and anastomotic leak rates.

Results

A total of 11 studies were included with a total of 1113 patients (556 GDFT, 557 conventional fluid therapy). There was no significant difference in any clinical outcome measure studied between GDFT and conventional fluid therapy, including overall morbidity (risk ratio (RR) 0·90, 95 per cent c.i. 0·75 to 1·08, P = 0·27; I ² = 47 per cent; 991 patients), 30-day mortality (RR 0·67, 0·23 to 1·92, P = 0·45; I ² = 0 per cent; 1039 patients) and length of hospital stay (mean difference 0·01 (95 per cent c.i. -0·92 to 0·94) days, P = 0·98; I ² = 34 per cent; 1049 patients).

Conclusion

This meta-analysis does not support the perceived benefits of GDFT guided by transoesophageal Doppler monitoring in the setting of elective colorectal surgery.

Early Acute Kidney Injury Within an Established Enhanced Recovery Pathway: Uncommon and Transitory

BACKGROUND

The present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long-term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP).

METHODS

Retrospective analysis of consecutive patients from a prospectively maintained ERP database (2011-2015) is performed. Pre- and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.5), injury (×2), failure (×3), loss of kidney function and end-stage kidney disease (RIFLE) criteria. Risk factors for early AKI were identified through logistic regression analysis, and long-term outcome in patients with AKI was assessed.

RESULTS

Out of 7103 patients, 4096 patients (58%) with pre- and postoperative creatinine levels were included. Of these, 104 patients (2.5%) presented postoperative AKI. AKI patients received higher amounts of POD 0 fluids (3.8 ± 2.4 vs. 3.2 ± 2 L, p = 0.01) and had increased postoperative weight gain at POD 2 (6 ± 4.9 vs. 3 ± 2.7 kg, p = 0.007). Independent risk factors for AKI were high ASA score (ASA ≥ 3: OR 1.7; 95% CI 1.1-2.5), prolonged operating time (>180 min: OR 1.9; 95% CI 1.3-2.9) and diabetes mellitus (OR 2.5; 95% CI 1.5-4), while minimally invasive surgery was a protective factor (OR 0.6; 95% CI 0.4-0.9). Five patients (0.1%) developed chronic kidney disease, and two of them needed dialysis after a mean follow-up of 33.7 ± 22.4 months.

CONCLUSIONS

Early AKI was very uncommon in the present cohort of colorectal surgery patients treated within an ERP, and long-term sequelae were exceptionally low.

Perioperative goal-directed therapy: A systematic review without meta-analysis

BACKGROUND

Perioperative goal-directed therapy aims to optimise haemodynamics by titrating fluids, vasopressors and/or inotropes to predefined haemodynamic targets. Perioperative goal-directed therapy is a complex intervention composed of several independent component interventions. Trials on perioperative goal-directed therapy show conflicting results. We aimed to conduct a systematic review and meta-analysis to investigate the benefits and harms of perioperative goal-directed therapy.

METHODS

PubMED, EMBASE, Web of Science and Cochrane Library were searched. Trials were included if they had a perioperative goal-directed therapy protocol. The primary outcome was all-cause mortality. The first secondary outcome was serious adverse events excluding mortality. Risk of bias was assessed, and GRADE was used to evaluate quality of evidence.

RESULTS

One hundred and twelve randomised trials were included of which one trial (1%) had low risk of bias. Included trials varied in patients: types of surgery which was expected due to inclusion criteria; in intervention and comparison: timing of intervention, monitoring devices, haemodynamic variables, target values, use of fluids, vasopressors and/or inotropes as well as combinations of these within protocols; and in outcome: mortality was reported in 87 trials (78%). Due to substantial clinical heterogeneity also within the various types of surgery a meta-analysis of data, including subgroup analyses, as defined in our protocol was considered inappropriate.

CONCLUSION

Clinical heterogeneity in patients, interventions and outcomes in perioperative goal-directed therapy trials is too large to perform meta-analysis on all trials. Future trials and meta-analyses highly depend on universally agreed definitions on aspects beyond type of surgery of the complex intervention and its evaluation.

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

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.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0564-y) contains supplementary material, which is available to authorized users.