Classification and differential effectiveness of goal-directed hemodynamic therapies in surgical patients: A network meta-analysis of randomized controlled trials.

Abstract

To investigate the most effective goal-directed hemodynamic therapy (GDHT) in surgical patients. GDHTs were classified as methods for intravascular volume, preload, stroke volume, cardiac output, oxygen delivery, systemic oxygenation, or tissue oxygenation optimization, alone or in combination. Their relative effectiveness and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA), respectively. 101 randomized controlled trials investigating GDHT effectiveness in surgical patients were eligible. The most commonly reported outcomes were 30-day mortality, acute kidney injury (AKI), and arrhythmia. Mortality was significantly reduced by GDHTs aimed at intravascular volume and cardiac output optimization (OR 0.40; 95% CrI 0.14-0.997; low quality). AKI was significantly reduced by GDHT aimed at intravascular volume optimization (OR 0.26; 95% CrI 0.08-0.71; moderate quality). No GDHT significantly reduced arrhythmia. GDHT aimed at intravascular volume and stroke volume optimization was likely most effective for mortality reduction (SUCRA=78.8%) while that aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for AKI reduction (SUCRA=85.4%). Different GDHTs likely have different and outcome-dependent effectiveness in surgical patients. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective as per the overall evidence. PROSPERO registration number: CRD42020159978.