Meta-Analysis of Fluid Management Strategies, Dr. Mjos

Bahar Mjos, DO

Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis

This article reviewed the outcome of goal directed fluid therapy versus liberal fluid therapy intraoperative. Many previous studies focus on perioperative fluid therapy. However, the optimal strategy remains controversial and uncertain. Most current studies center around the type of fluids administered (colloid versus crystalloid), the total volume administered (restrictive versus liberal [LVR]), and whether the administration of fluids should be guided by hemodynamic goals (goal directed [GD] versus not goal directed. In this paper it was hypothesized that liberal use of perioperative fluid therapy without hemodynamic goals is not equivalent to GD fluid therapy, and a meta-analysis was conducted to compare these 2 approaches of managing perioperative fluid therapy and how they many have different end results. 

Studies were grouped into 2 strata, standard therapy with hemodynamic goals versus GD and liberal versus restrictive in this meta-analysis. The primary outcome was postoperative mortality. Secondary outcomes were organ-specific complications, recovery of bowel function (time to first flatus, time to first bowel movement, and return to oral diet), and length of hospital stay.

The findings:

1)    “ GD fluid therapy reduced renal complications, pneumonia, time to first bowel movement, resumption of normal diet and length of stay compared to non-GD therapy”

2)    “Restrictive fluid strategy reduced the incidence of pulmonary edema and pneumonia, time to first bowel movement, and the length of stay compared to liberal fluid therapy without using hemodynamic goals”

3)    “Both patients randomized to have GD fluid strategy and liberal fluid therapy without hemodynamic goals received more perioperative fluid than those managed with non-GD therapy and a restrictive fluid strategy, respectively.”

4)     “Although both GD and liberal fluid therapy both used a large amount of perioperative fluid, their effects on perioperative outcomes were different; patients in the GD groups had a shorter length of stay, time to recovery of gastrointestinal function, and a lower incidence of pneumonia compared to those in the liberal groups;

5)     “No specific fluid management strategy was associated with an improvement in mortality”

6)     “Significant heterogeneity in continuous outcome was observed, but publication bias was not apparent.”

This study showed that both methods of GD fluid therapy and liberal use of fluid w/o hemodynamics goals ended up using a large amount of fluid intraop. But the end outcomes still favored the use of hemodynamic monitoring. With the limited data available, significant uncertainty remains concerning the relative benefits of GD and restrictive fluid strategies, or the superiority of one modality of hemodynamic monitoring over another.