Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery

Abstract

Background Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients’ hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid). Results The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively]. Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = − 0.10 (− 0.14, − 0.07); Chi2 = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = − 0.016 (− 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications. Conclusions Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality. Trial Registration CRD42020168866; Registration: February 2020 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866

Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery

“…Interestingly, this approach was incorporated into the intraoperative protocol of 5 studies [ 16 , 25 , 27 – 29 ], including the study of Myles et al who assessed central venous pressure and stroke volume variation in case of intraoperative hypotension to guide resuscitation (supplementary appendix of the trial [ 16 ]). Moreover, a recent metanalysis showed a trend towards the reduction of postoperative complications when a goal-directed therapy is used in patients receiving large amounts of perioperative fluids [ 45 ]. Thus, rather than choosing between a fixed-volume regimen and a goal-directed concept, an alternative approach could be to combine the two strategies.…”

Study of relation of type of fracture with amount of postoperative fluid therapy and duration of hospital stay after surgery

“…27,28 A meta-analysis has also concluded that appropriate preoperative fluid therapy strategy reduces postoperative complications, but not perioperative mortality, irrespectively of perioperative overall amount of fluids infused. 29 Makaryus et al also mentioned that preoperative as well as intra operative fluid therapy is important to decrease overall morbidities and mortalities but, in the postoperative period, patients Count should be encouraged to start per oral hydration early, and excessive IV fluid administration should be avoided. 30 Postoperative hospital stay is defined as the time from the date of the index operation to the date of discharge, transfer to a subacute service, or death, whichever came first.…”

Perioperative hemodynamic optimization: from guidelines to implementation—an experts’ opinion paper

“…3 Département de Médecine Périopératoire, Anesthésie-Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France. 4 Université Clermont Auvergne, CNRS; Inserm U1103, 63000 Clermont-Ferrand, France. 5 Service D' Anesthésie-Réanimation, Hôpital Timone, AP-HM, Marseille, France.…”

“…Hemodynamic optimization (goal-directed therapy or GDT) has been recommended by several international guidelines because it has been shown consistently to improve outcomes [2]. However, the implementation of guidelines on GDT remains limited in routine practice [3,4]. The explanations for absent/poor implementation of the guidelines are numerous [5][6][7] but it is possible that the current guidelines on perioperative GDT are on the one hand not explicit enough to allow a reproducible decision-making process, and on the other hand not suited to manage uncertainty [8].…”