Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials

Abstract

Postoperative gastrointestinal (GI) dysfunction is one of the most frequent complications in surgical patients. Most cases are associated with episodes of splanchnic hypoperfusion due to hypovolaemia or cardiac dysfunction. It has been suggested that perioperative haemodynamic goal-directed therapy (GDT) may reduce the incidence of these complications in cardiac surgery, and other surgery, but clear evidence is lacking. We have undertaken a meta-analysis of the effects of GDT on postoperative GI and liver complications. A systematic search, using MEDLINE, EMBASE, and The Cochrane Library databases, was performed. Sixteen randomized controlled trials (3410 participants) met the inclusion criteria. Data synthesis was obtained using odds ratio (OR) with 95% confidence interval (CI) by random-effects model. Statistical heterogeneity was assessed by Q and I2 statistics. GI complications were ranked as major (required radiological or surgical intervention or life-threatening condition) or minor (no or only pharmacological treatment required). Major GI complications were significantly reduced by GDT when compared with a control group (OR, 0.42; 95% CI, 0.27-0.65). Minor GI complications were also significantly decreased in the GDT group (OR, 0.29; 95% CI, 0.17-0.50). Treatment did not reduce hepatic injury rate (OR, 0.54; 95% CI, 0.19-1.55). Quality sensitive analyses confirmed the main overall results. In patients undergoing major surgery, GDT, by maintaining an adequate systemic oxygenation, can protect organs particularly at risk of perioperative hypoperfusion and is effective in reducing GI complications.

Simplified Intraoperative Goal-Directed Therapy Using the FloTrac/Vigileo System: An Analysis of Its Usefulness and Safety

“…Many reports indicate that intraoperative management based on GDT improves patient outcomes [2] [3] [4]. GDT reduces the incidence of postoperative complications and mortality; therefore, the benefit of GDT seems to be established.…”

“…In 2001, a randomized controlled trial (RCT) in patients with severe sepsis demonstrated that the mortality rate was significantly reduced in patients receiving GDT [1]. This approach has also been applied to the management of surgical patients under general anesthesia, and it has been reported that GDT may improve patient outcomes by reducing the length of hospital stay (LOS) and the incidence of complications [2] [3] [4].…”

“…However, the reported algorithms of intraoperative GDT are considerably complicated [2] [3] [4]. For patients without any comorbid systemic diseases who are undergoing elective routine surgery, GDT needs to be simplified as much as possible.…”

Disfunção do trato gastrointestinal prolongada em pacientes admitidos na terapia intensiva

“…(24)(25)(26) On the other hand, in high-risk patients, target driven post-operative hemodynamic optimization has shown improved gastric mucosa acidosis, and reduced post-operative gastrointestinal complications. (31)(32)(33)(34) In view of the GID impact on the clinical outcomes and costs, studies should be encouraged on this subject. Multi-modal approaches, including measures to reduce the mechanic trauma, early mobilization and enteral feeding, more accurate volume replacement and treatment of shock with visceral region monitoring should be investigated in prospective multicenter trials.…”

Perioperative Haemodynamic Optimisation

“…More recently, a meta-analysis of 26 RCT on patients undergoing major surgery demonstrated that GDT initiated in the perioperative period confirmed the reduced risk of post-operative infections (6). Likewise, early initiation of haemodynamic optimization reduces the risk of postoperative acute renal injury and gastrointestinal complications following major surgery (3,4).…”