Goal directed hemodynamic therapy based in esophageal Doppler flow parameters: A systematic review, meta-analysis and trial sequential analysis

Abstract

Background

Numerous studies have compared perioperative esophageal Doppler monitoring (EDM) guided intravascular volume replacement strategies with conventional clinical volume replacement in surgical patients. The use of the EDM within hemodynamic algorithms is called ‘goal directed hemodynamic therapy’ (GDHT).

Methods

Meta-analysis of the effects of EDM guided GDHT in adult non-cardiac surgery on postoperative complications and mortality using PRISMA methodology. A systematic search was performed in Medline, PubMed, EMBASE, and the Cochrane Library (last update, March 2015). Inclusion criteria: Randomized clinical trials (RCTs) in which perioperative GDHT was compared to other fluid management. Primary outcomes: Overall complications. Secondary outcomes: Mortality; number of patients with complications; cardiac, renal and infectious complications; incidence of ileus. Studies were subjected to quantifiable analysis, pre-defined subgroup analysis (stratified by surgery, type of comparator and risk); pre-defined sensitivity analysis and trial sequential analysis (TSA).

Results

Fifty six RCTs were initially identified, 15 fulfilling the inclusion criteria, including 1368 patients. A significant reduction was observed in overall complications associated with GDHT compared to other fluid therapy (RR = 0.75; 95% CI: 0.63–0.89; p = 0.0009) in colorectal, urological and high-risk surgery compared to conventional fluid therapy. No differences were found in secondary outcomes, neither in other subgroups. The impact on preventing the development of complications in patients using EDM is high, causing a relative risk reduction (RRR) of 50% for a number needed to treat (NNT) = 6.

Conclusions

GDHT guided by EDM decreases postoperative complications, especially in patients undergoing colorectal surgery and high-risk surgery. However, no differences versus restrictive fluid therapy and in intermediate-risk patients were found.

Resumen

Introducción

Numerosos estudios han comparado la monitorización perioperatoria guiada por Doppler esofágico (ODM) para establecer estrategias de reemplazo de volumen intravascular. El uso del ODM con algoritmos hemodinámicos se denomina terapia hemodinámica guiada por objetivos (THGO).

Métodos

Metaanálisis de los efectos del ODM en THGO para cirugía no cardiaca de adultos, las complicaciones postoperatorias y la mortalidad, acorde a PRISMA. Se practicó búsqueda sistemática en Medline, PubMed, EMBASE y la Cochrane Library (última actualización, marzo de 2015). Criterios de inclusión: ensayos clínicos aleatorizados (ECA) que comparan THGO con otra alternativa de manejo de fluidos. Desenlaces primarios: complicaciones generales. Desenlaces secundarios: mortalidad; número de pacientes con complicaciones; complicaciones específicas. Se realizó análisis cuantificable, análisis predefinido de subgrupos y sensibilidad, y análisis secuencial de estudios.

Resultados

Se identificaron inicialmente 56 ECA, siendo finalmente admitidos para el estudio 15 (1.368 pacientes). Se observó una reducción significativa global, con THGO, de las complicaciones asociadas comparada con fluidoterapia convencional (RR = 0,75; IC 95%: 0,63-0,89; p = 0,0009), en cirugía colorrectal, urológica y de alto riesgo No se encontraron diferencias en los resultados secundarios, ni en otros subgrupos. El impacto en la prevención de complicaciones en pacientes con ODM es alto, con una reducción del riesgo relativo (RRR) del 50% y un número necesario a tratar (NNT) = 6.

Conclusiones

La THGO guiada por ODM disminuye las complicaciones postoperatorias, principalmente en pacientes sometidos a cirugía colorrectal y de alto riesgo. No se encontraron diferencias con respecto a la fluidoterapia restrictiva y en pacientes de riesgo intermedio.