is perioperative goal-directed therapy able to reduce surgical complications in different surgical settings? a meta-analytic study

Introduction: goal directed therapy (gdt) is a method aiming at optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. several meta analyses confirm that gdt can reduce post-operative complications in highrisk patients, and a recent trial suggests its significant effect also in low-moderate risk patients. the aim of the present metaanalysis is to investigate the effect of gdt on post-operative complications, in both high and low-risk patients. moreover, we stratified the effect of gdt in different kind of surgical procedures.methods: randomized controlled trials (rcts) on perioperative gdt in adult surgical patients were included. the primary outcome measure was complications, defined as number of patients with a least one post-operative complication. a subgroup analysis was also performed including rcts with a mortality rate in the control group 10%, and considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery, and so on. meta-analytic techniques (analysis software rev man, version 5.3.5, cochrane collaboration, oxford, england, uk) were used to combine studies using odds ratios (ors) and 95% confidence intervals (cis).results: in 47 rcts, 2329 patients developed at least one complication: 1030 out of 2781 (37%) were randomized to perioperative gdt, and 1299 out of 2772 (47%) were randomized to control. pooled or was 0.58 and 95% ci was 0.470.70. the sensitivity analysis confirmed the main result. the subgroup analysis including only studies in which the mortality rate in the control group was higher than 10% showed significant results (or 0.51, 95% ci 0.350.74, p=0.004, 10 rcts), as well as a statistical significant effect, was observed in those rcts with a mortality rate in control group 10%. the subgroup analysis enrolling major abdominal patients showed a significant result as well as a significant effect was observed in those rcts enrolling exclusively orthopedic (or 0.48, 95% ci 0.300.79,p=0.004, 6 rcts, 501 patients) and neurosurgical procedures (or 0.40, 95% ci 0.210.78, p=0.008, 2 rcts, 208 patients).conclusions: the present metaanalysis suggests that gdt can reduce postoperative complication rates in highrisk as well as in lowrisk patients. moreover, the beneficial effect of gdt on postoperative morbidity is significant on major abdominal, orthopedic, and neurosurgical procedures. however, heterogeneity was found in some subgroups, reducing the strength of the results. several welldesigned rcts are needed to further explore the effect of gdt in lowrisk patients and in different kinds of surgeries.