Jalalzadeh Hasti, Hulskes Rick H, Weenink Robert P, Wolfhagen Niels, van Dusseldorp Ingeborg, Schaad Roald R, Veelo Denise P, Hollmann Markus W, Boermeester Marja A, de Jonge Stijn W
Department of Surgery, Amsterdam UMC, Location the University of Amsterdam, Amsterdam, the Netherlands.
Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands.
EClinicalMedicine. 2024 Nov 22;78:102944. doi: 10.1016/j.eclinm.2024.102944. eCollection 2024 Dec.
Surgical site infection (SSI) is the most common postoperative complication. Goal-directed haemodynamic therapy (GDHT) may help to prevent SSI, but recommendations for its use initially have been set at conditional because of low-certainty evidence at the time. An updated systematic review with SSI as the primary endpoint has not been performed since 2011, and important new evidence has emerged. We assessed the influence of GDHT on SSI and other postoperative outcomes.
We searched Ovid/MEDLINE, Excerpta Medica Database (Embase.com), and Cochrane library from inception up to September 2024 for randomised controlled trials comparing the effect of any GDHT algorithm to conventional fluid therapy on SSI incidence in adult patients undergoing surgery and analysed eligible data using random effects. We conducted several subgroup analyses, including the risk of bias (RoB), and a trial sequential analysis (TSA). We evaluated the certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluations. This study is registered with PROSPERO, CRD42022277535.
We found 75 studies that met the inclusion criteria with an incidence of 1,478 SSI among 13,010 patients (11.4%). The incidence of SSI was reduced from 13.3% in the conventional fluid therapy to 9.4% after GDHT (absolute risk reduction 3.9%); pooled relative risk 0.71 (95% CI 0.62-0.81). Subgroup analysis for the low RoB studies revealed comparable results. Meta-regression indicated no strong evidence for individual subgroup effects. In the TSA, the cumulative z-line crossed the boundary for effect.
High-certainty evidence indicates that GDHT reduces the risk of SSI when compared to conventional fluid therapy in adults undergoing surgery. New studies are unlikely to change this outcome. These findings justify a stronger recommendation for the use of GDHT.
Dutch Association for Quality Funds Medical Specialists.
手术部位感染（SSI）是最常见的术后并发症。目标导向血流动力学治疗（GDHT）可能有助于预防SSI，但由于当时证据的确定性较低，其最初使用的建议被设定为有条件的。自2011年以来，尚未进行以SSI为主要终点的更新系统评价，并且出现了重要的新证据。我们评估了GDHT对SSI和其他术后结局的影响。
我们检索了Ovid/MEDLINE、医学文摘数据库（Embase.com）和Cochrane图书馆，从数据库创建至2024年9月，以查找比较任何GDHT算法与传统液体疗法对接受手术的成年患者SSI发生率影响的随机对照试验，并使用随机效应分析符合条件的数据。我们进行了多项亚组分析，包括偏倚风险（RoB）和试验序贯分析（TSA）。我们使用推荐分级、评估、制定和评价（GRADE）来评估证据的确定性。本研究已在国际前瞻性系统评价注册库（PROSPERO）注册，注册号为CRD42022277535。
我们发现75项符合纳入标准的研究，13010例患者中有1478例发生SSI（发生率为11.4%）。SSI发生率从传统液体疗法组的13.3%降至GDHT组的9.4%（绝对风险降低3.9%）；合并相对风险为0.71（95%置信区间0.62 - 0.81）。低RoB研究的亚组分析显示了类似结果。Meta回归表明没有强有力的证据支持个体亚组效应。在TSA中，累积z线越过了效应边界。
高确定性证据表明，与接受手术的成年患者的传统液体疗法相比，GDHT可降低SSI风险。新的研究不太可能改变这一结果。这些发现证明对使用GDHT提出更强有力的推荐是合理的。
荷兰医学专家质量基金协会。
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