Methodology in systematic reviews of goal-directed therapy: improving but not perfect

Abstract

High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial.

Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome

“…An accompanying editorial has analysed in detail some methodological issues related to this and other systematic reviews, but has not challenged its conclusions. 2 In fact, the editorial expanded these conclusions claiming that this systematic review provides us with the best currently available evidence on this topic. Although these conclusions seem logical, and may even be true, a more careful examination of this meta-analysis leads me to believe that its conclusions should be very different.…”

“…In spite of this, the accompanying editorial claims that "although the accuracy of uPC devices has been questioned, this systematic review shows that they are clinically useful when used in combination with a GDT therapy protocol". 2 This conclusion is misleading as the CO accuracy of these devices did play a minimal role, if any, in the results of the meta-analysis. Similarly, the editorial's claim that this meta-analysis shows that SV and CO optimization do not lead to excessive fluid administration 2 is questionable as only a minority of the included studies have used the SV or CO as a goal.…”

“…1 Usually, non-significant trends in efficacy in the absence of harm prompt authors to recommend further research. [2][3][4][5] The final statement of Serraino and Murphy, however, appears inconsistent: "further large trials are unlikely to demonstrate clinical benefits for current viscoelastic point-of-care tests. Research should now focus on development of new techniques to identify important and treatable causes of coagulopathy in cardiac surgery."…”

Goal-directed therapy: hit early and personalize!

“…Such heterogeneity might limit the usefulness of pooling data [5]. The authors explicitly excluded studies with ICU patients in whom GDT was started "before or in the operating room", i.e., before or during general anesthesia or surgical trauma.…”

“…A GDT approach can only be as good as the algorithm used to guide administration of fluids and vasoactive agents. This has been discussed many times before [5,8,9] and it is impossible to agree on a "universal treatment algorithm". The challenge is to combine two concepts that seem to be contradictory at first sight: personalized hemodynamic treatment for the individual patient and protocolized care [10].…”