Hemodynamic management and surgical site infection: Network meta-analysis of randomized controlled trials

Abstract

Study objectiveTo investigate which hemodynamic management strategy is most effective in reducing surgical site infection (SSI). DesignNetwork meta-analysis of randomized controlled trials. SettingPerioperative setting. PatientsSurgical patients. InterventionsUsual care vs. optimized hemodynamic management, including goal-directed hemodynamic therapy (GDHT) and liberal/restrictive fluid therapy. MeasurementsThe primary outcome was SSI arising within postoperative 30 days. The secondary outcomes included postoperative respiratory and urinary system infectious complications and sepsis/septic shock. The effect and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA) scores, respectively. Main resultsWe systematically searched Ovid MEDLINE, Ovid Embase, and Web of Science for eligible randomized controlled trials from inception to October 11, 2019. Fifty-three eligible studies reported SSI and comprised of 56 GDHT groups (patients, n = 4205) and 51 usual care groups (patients, n = 3895). Comparing with usual care, GDHTs aimed at intravascular volume and stroke volume optimization (odds ratio (OR), 0.28 [95% credible interval (CrI), 0.13 to 0.56]; moderate quality), stroke volume and cardiac output optimization (OR, 0.34 [95% CrI, 0.16 to 0.70]; moderate quality), and intravascular volume and cardiac output optimization (OR, 0.51 [95% CrI, 0.24 to 0.99]; low quality) significantly reduced SSI. GDHT strategy aimed at intravascular volume and stroke volume optimization was likely most effective (SUCRA = 80%). Certain GDHTs significantly reduced respiratory infectious complications; however, no GDHT significantly reduced urinary infectious complications and sepsis/septic shock. GDHT strategy aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for reducing respiratory infectious complications (SUCRA = 88%). ConclusionsDifferent hemodynamic managements exert different effectiveness for SSI reduction. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective based on the overall evidence.