Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery
- 14 November 2012
- journal article
- research article
- Published by Wiley in Emergencias
- Vol. 2016 (10), CD004082
- https://doi.org/10.1002/14651858.cd004082.pub5
Abstract
Studies have suggested that increasing whole body blood flow and oxygen delivery around the time of surgery reduces mortality, morbidity and the expense of major operations. To describe the effects of increasing perioperative blood flow using fluids with or without inotropes or vasoactive drugs. Outcomes were mortality, morbidity, resource utilization and health status. We searched CENTRAL (The Cochrane Library 2012, Issue 1), MEDLINE (1966 to March 2012) and EMBASE (1982 to March 2012). We manually searched the proceedings of major conferences and personal reference databases up to December 2011. We contacted experts in the field and pharmaceutical companies for published and unpublished data. We included randomized controlled trials with or without blinding. We included studies involving adult patients (aged 16 years or older) undergoing surgery (patients having a procedure in an operating room). The intervention met the following criteria. 'Perioperative' was defined as starting up to 24 hours before surgery and stopping up to six hours after surgery. 'Targeted to increase global blood flow' was defined by explicit measured goals that were greater than in controls, specifically one or more of cardiac index, oxygen delivery, oxygen consumption, stroke volume (and the respective derived indices), mixed venous oxygen saturation (SVO2), oxygen extraction ratio (02ER) or lactate. Two authors independently extracted the data. We contacted study authors for additional data. We used Review Manager software. We included 31 studies of 5292 participants. There was no difference in mortality: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI 0.76 to 1.05, P = 0.18). However, the results were sensitive to analytical methods and the intervention was better than control when inverse variance or Mantel–Haenszel random-effects models were used, RR of 0.72 (95% CI 0.55 to 0.95, P = 0.02). The results were also sensitive to withdrawal of studies with methodological limitations. The rates of three morbidities were reduced by increasing global blood flow: renal failure, RR of 0.71 (95% CI 0.57 to 0.90); respiratory failure, RR of 0.51 (95% CI 0.28 to 0.93); and wound infections, RR of 0.65 (95% CI 0.51 to 0.84). There were no differences in the rates of nine other morbidities: arrhythmia, pneumonia, sepsis, abdominal infection, urinary tract infection, myocardial infarction, congestive cardiac failure or pulmonary oedema, or venous thrombosis. The number of patients with complications was reduced by the intervention, RR of 0.68 (95% CI 0.58 to 0.80). Hospital length of stay was reduced in the treatment group by a mean of 1.16 days (95% CI 0.43 to 1.89, P = 0.002). There was no difference in critical care length of stay. There were insufficient data to comment on quality of life and cost effectiveness. It remains uncertain whether increasing blood flow using fluids, with or without inotropes or vasoactive drugs, reduces mortality in adults undergoing surgery. The primary analysis in this review (mortality at longest follow-up) showed no difference between the intervention and control, but this result was sensitive to the method of analysis, the withdrawal of studies with methodological limitations, and is dominated by a single large RCT. Overall, for every 100 patients in whom blood flow is increased perioperatively to defined goals, one can expect 13 in 100 patients (from 40/100 to 27/100) to avoid a complication, 2/100 to avoid renal impairment (from 8/100 to 6/100), 5/100 to avoid respiratory failure (from 10/100 to 5/100), and 4/100 to avoid postoperative wound infection (from 10/100 to 6/100). On average, patients receiving the intervention stay in hospital one day less. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced. Augmentation périopératoire du débit sanguin global pour atteindre des objectifs et critères d'évaluation définis et explicites après une opération Les études ont suggéré que l'augmentation du débit sanguin et de l'apport en oxygène dans le corps entier au moment de l'opération réduisait la mortalité, la morbidité et le coût des opérations importantes. Décrire les effets de l'augmentation du débit sanguin périopératoire en utilisant des liquides avec ou sans inotropes ou médicaments vasoactifs. Les critères de jugement étaient la mortalité, la morbidité, l'utilisation des ressources et l'état de santé. Nous avons effectué des recherches dans CENTRAL (The Cochrane Library 2012, numéro 1), MEDLINE (de 1966 à mars 2012) et EMBASE (de 1982 à mars 2012). Nous avons effectué des recherches manuelles dans les actes de grandes conférences et dans des bases de données de bibliographies personnelles jusqu'en décembre 2011. Nous avons contacté des experts dans le domaine et des sociétés pharmaceutiques pour obtenir des données publiées et non publiées. Nous avons inclus des essais contrôlés randomisés avec ou sans assignation secrète. Nous avons inclus des études portant sur des patients adultes (âgés de 16 ans ou plus) subissant une chirurgie (patients subissant une procédure dans une salle d'opération). L'intervention remplissait les critères suivants. « Périopératoire » a été utilisé pour définir une intervention commençant jusqu'à 24 heures avant l'opération...Keywords
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