A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients.
BACKGROUND
Complications from major surgery are undesirable, common, and potentially avoidable. The long-term consequences of short-term surgical complications have recently been recognized to have a profound influence on longevity and quality of life in survivors. In the past 30 years, there have been a number of studies conducted attempting to reduce surgical mortality and morbidity by deliberately and preemptively manipulating perioperative hemodynamics. Early studies had a high control-group mortality rate and were criticized for this as being unrepresentative of current practice and raised opposition to its implementation as routine care. We performed this review to update this body of literature and to examine the effect of changes in current practice and quality of care to see whether the conclusions from previous quantitative analyses of this field remain valid.


METHODS
Randomized clinical trials evaluating the use of preemptive hemodynamic intervention to improve surgical outcome were identified using multiple methods. Electronic databases (MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials register) were screened for potential trials, reference lists of identified trials were examined, and additional sources were sought from experts and industry representatives. Identified studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, subgroup analysis, and sensitivity analysis where possible.


RESULTS
There were 29 studies identified, 23 of which reported surgical complications. In total, the 29 trials involved 4805 patients with an overall mortality of 7.6%. The use of preemptive hemodynamic intervention significantly reduced mortality (pooled odds ratio [95% confidence interval] of 0.48 [0.33-0.78]; P = 0.0002) and surgical complications (odds ratio 0.43 [0.34-0.53]; P < 0.0001). Subgroup analysis showed significant reductions in mortality for studies using a pulmonary artery catheter, supranormal resuscitation targets, studies using cardiac index or oxygen delivery as goals, and the use of fluids and inotropes as opposed to fluids alone. By contrast, there was a significant reduction in morbidity for each of the 4 subgroups analyzed.


CONCLUSIONS
The use of a preemptive strategy of hemodynamic monitoring and coupled therapy reduces surgical mortality and morbidity.
Department of Intensive Care Medicine, St. George's Healthcare NHS Trust, London, SW17 0QT, UK. andyr@sgul.ac.uk
Mark A
MA
Hamilton
Maurizio
M
Cecconi
Andrew
A
Rhodes
D000758:Anesthesia / Q000009:adverse effects / Q000379:methods*; D002404:Catheterization; D016208:Databases, Factual; D006439:Hemodynamics; D006801:Humans; D016017:Odds Ratio; D011184:Postoperative Period; D011785:Quality Assurance, Health Care; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D012306:Risk; D012984:Software; D013514:Surgical Procedures, Operative / Q000379:methods*; D016896:Treatment Outcome