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

Abstract

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 ratio¼0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference¼e0.72 days; 95% CI, e1.10 to e0.35) 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.

Fraction of inspired oxygen during general anesthesia for non‐cardiac surgery: Systematic review and meta‐analysis

“…This review is part of a series of reviews of clinical trials assessing various respiratory and hemodynamic targets or strategies for patients undergoing general anesthesia for non‐cardiac surgery. This part of the review focuses on FiO 2 settings or oxygenation targets (PaO 2 or oxygen saturation), and findings for other targets (i.e., goal‐directed hemodynamic therapy, 11 blood pressure, and ventilation) are reported separately. As no trials on oxygenation targets were identified, we focus on FiO 2 in the remainder of the manuscript.…”

Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery

“…Both excessive (1-3) and insufficient fluid infusion (4,5) are related to poor outcomes including the development of organ dysfunction or death in patients undergoing abdominal surgery. The benefit of hemodynamic parameters such as cardiac output (CO) or stroke volume (SV)guided fluid infusion on mortality or postoperative complication such as surgical site infection, acute kidney injury, has been demonstrated in recent meta-analyses (6,7). However, this benefit seems to be limited in high-risk surgical patients (8,9).…”

Intraoperative respiratory and hemodynamic strategies for reducing nausea, vomiting, and pain after surgery: Systematic review and meta‐analysis

“…This paper is part of a larger systematic review project including clinical trials assessing various respiratory and hemodynamic interventions and targets for patients undergoing non‐cardiac surgery under general anesthesia. Previous manuscripts from this review project have focused on the outcomes mortality, length of stay, and postoperative complications 4–7 . In this manuscript, we focus on the outcomes of postoperative pain, nausea, and vomiting.…”

“…Pre‐, intra‐, and postoperatively, various medical interventions are used to minimize pain, nausea, and vomiting in the postoperative setting and avoid severe complications 3 . Recent reviews have shown limited effects of specific intra‐operative respiratory and hemodynamic interventions on “hard” endpoints such as hospital length of stay and mortality 4–7 . However, identification of intraoperative respiratory and hemodynamic interventions and specific targets that can influence the development and intensity of postoperative pain, nausea, and vomiting would be valuable additions in a multimodal approach.…”