Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery

Critical Care

Denise Battaglini¹  Chiara Robba¹  Paolo Pelosi²  Silvia Scarano²  Edoardo Molinari²  Francesca Iannuzzi²  Giacomo De Mattei³  Marta Baggiani⁴  Giovanni Sotgiu⁵  Laura Saderi⁵  Lorenzo Calabrò⁶  Daniel Zambelli⁶  Antonio Messina⁷  Maurizio Cecconi⁷ 

[1] Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy;Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy;Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy;Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Integrata Udine, Udine, Italy;Anesthesia and Intensive Care Medicine, Maggiore Della Carità University Hospital, Novara, Italy;Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy;Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center – IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy;Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center – IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy;Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy;

关键词: Liberal;    Restrictive;    Fluid therapy;    Postoperative complications;    Postoperative mortality;   

DOI  :  10.1186/s13054-021-03629-y

来源: Springer

【 摘 要 】

BackgroundPostoperative complications impact on early and long-term patients’ outcome. Appropriate perioperative fluid management is pivotal in this context; however, the most effective perioperative fluid management is still unclear. The enhanced recovery after surgery pathways recommend a perioperative zero-balance, whereas recent findings suggest a more liberal approach could be beneficial. We conducted this trial to address the impact of restrictive vs. liberal fluid approaches on overall postoperative complications and mortality.MethodsSystematic review and meta-analysis, including randomised controlled trials (RCTs). We performed a systematic literature search using MEDLINE (via Ovid), EMBASE (via Ovid) and the Cochrane Controlled Clinical trials register databases, published from 1 January 2000 to 31 December 2019. We included RCTs enrolling adult patients undergoing elective abdominal surgery and comparing the use of restrictive/liberal approaches enrolling at least 15 patients in each subgroup. Studies involving cardiac, non-elective surgery, paediatric or obstetric surgeries were excluded.ResultsAfter full-text examination, the metanalysis finally included 18 studies and 5567 patients randomised to restrictive (2786 patients; 50.0%) or liberal approaches (2780 patients; 50.0%). We found no difference in the occurrence of severe postoperative complications between restrictive and liberal subgroups [risk difference (95% CI) = 0.009 (− 0.02; 0.04); p value = 0.62; I2 (95% CI) = 38.6% (0–66.9%)]. This result was confirmed also in the subgroup of five studies having a low overall risk of bias. The liberal approach was associated with lower overall renal major events, as compared to the restrictive [risk difference (95% CI) = 0.06 (0.02–0.09); p value  = 0.001]. We found no difference in either early (p value  = 0.33) or late (p value  = 0.22) postoperative mortality between restrictive and liberal subgroupsConclusionsIn major abdominal elective surgery perioperative, the choice between liberal or restrictive approach did not affect overall major postoperative complications or mortality. In a subgroup analysis, a liberal as compared to a restrictive perioperative fluid policy was associated with lower overall complication renal major events, as compared to the restrictive.Trial RegistrationCRD42020218059; Registration: February 2020, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=218059.

【 授权许可】

CC BY