围手术期液体管理与术后结局的关系：20 年系统评价和主要内脏/非心脏手术中目标导向性随机试验的荟萃分析。
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.
机构信息
Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
出版信息
Crit Care. 2021 Feb 1;25(1):43. doi: 10.1186/s13054-021-03464-1.
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); Chi = 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.
背景
适当的围手术期液体管理对于减少术后并发症至关重要，这些并发症会影响患者的早期和长期预后。所谓的围手术期目标导向治疗（GDT）方法旨在根据个体患者的血流动力学反应来定制围手术期液体管理。在 GDT 背景下输注的围手术期总体液体量是否会影响术后手术结局尚不清楚。
方法
我们对比较 GDT 组和对照组研究人群中减少术后并发症和围手术期死亡率的效果的随机对照试验（RCT）进行了系统评价和荟萃分析，使用了 MEDLINE、EMBASE 和 Cochrane 对照临床试验注册中心。根据在重症监护病房（围手术期）输注的术中及入院后 24 小时内的液体量，将纳入的研究分组。
结果
荟萃分析纳入了 21 项 RCT，共纳入了 2729 名患者，围手术期液体输注中位数为 4500ml。在报告总体量低于或高于该阈值的研究中，对照组和 GDT 亚组之间的术后并发症发生率差异无统计学意义[43.4% vs. 34.2%，p 值=0.23 和 54.8% vs. 39.8%；p 值=0.09]。总体而言，与对照组相比，GDT 降低了总体术后并发症发生率[汇总风险差异（95%CI）= -0.10（-0.14，-0.07）；卡方=30.97；p 值<0.0001]，但并未降低围手术期死亡率[汇总风险差异（95%CI）= -0.016（-0.0334；0.0014）；p 值=0.07]。考虑到与器官相关的术后事件发生率，GDT 既没有减少肾脏（p 值=0.52）、心血管（p 值=0.86）或肺部（p 值=0.14）或神经（p 值=0.44）或感染性（p 值=0.12）并发症。
结论
无论围手术期液体的输注量如何，GDT 策略都可降低术后并发症发生率，但不能降低围手术期死亡率。
试验注册
CRD42020168866；注册时间：2020 年 2 月 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866。
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