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非血管性腹部手术的限制性液体疗法与开放性液体疗法及目标导向性液体疗法:一项网状Meta分析和系统评价

Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review.

作者信息

Yang Timothy Xianyi, Tan Adrian Y, Leung Wesley H, Chong David, Chow Yu Fat

机构信息

Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG.

出版信息

Cureus. 2023 Apr 28;15(4):e38238. doi: 10.7759/cureus.38238. eCollection 2023 Apr.

Abstract

Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.

摘要

围手术期的最佳液体管理至关重要,补液过多或过少均会引发并发症。液体治疗有多种策略,包括自由液体治疗(LFT)、限制性液体治疗(RFT)和目标导向液体治疗(GDT),目前对于哪种策略更佳尚无明确共识。我们旨在找出围手术期接受非血管腹部手术的成年外科患者中,哪种液体治疗方案更为有效。本研究是一项系统评价和网状Meta分析(NMA),采用节点拆分分析评估不一致性、敏感性分析和Meta回归。我们对PubMed、Cochrane图书馆、EMBASE、谷歌学术和科学网进行了文献检索。仅纳入比较成年患者在非心脏大手术围手术期进行限制性、自由性和目标导向性液体治疗的研究。儿科患者、产科患者和心脏手术的试验被排除。专注于使用肺动脉导管和静脉血氧饱和度(SvO2)进行目标导向治疗监测的试验,以及那些仅检查纯生化和实验室终点的试验也被排除。总共纳入了102项随机对照试验(RCT)和78项研究(12100例患者)。NMA得出结论,使用FloTrac的目标导向液体治疗是缩短住院时间(LOS)最有效的干预措施(累积排序曲线下面积(SUCRA)=91%,比值比(OR)=-2.4,95%可信区间(CrI)=-3.9至-0.85)和减少伤口并发症(SUCRA=86%,OR=0.41,95%CrI=0.24至0.69)。使用脉压变异的目标导向液体治疗在降低并发症发生率(SUCRA=80%,OR=0.25,95%CrI=0.047至1.2)、肾脏并发症(SUCRA=93%,OR=0.23,95%CrI=0.045至1.0)、呼吸并发症(SUCRA=74%,OR=0.42,95%CrI=0.053至3.6)和心脏并发症(SUCRA=97%,OR=0.067,95%CrI=0.0058至0.57)方面最为有效。自由液体治疗在降低死亡率方面最为有效(SUCRA=81%,OR=0.40,95%CrI=0.12至1.5)。使用食管多普勒的目标导向治疗在减少吻合口漏方面最为有效(SUCRA=79%,OR=0.45,95%CrI=0.12至1.5)。不存在发表偏倚,但在所有网络中均发现了中度至高度的异质性。在预防不同并发症方面,除死亡率外,目标导向液体治疗始终比标准(SFT)、自由或限制性液体治疗排名更高且更有效。除伤口并发症和吻合口漏的结果外,所有结果的证据等级均为低质量至极低质量。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4de7/10226838/efda3a505a48/cureus-0015-00000038238-i01.jpg

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