Meta-analysis of hemodynamic goal directed fluid therapy during surgery on the prevention of surgical-site infection

Author(s):
Hasti Jalalzadeh; Rick Hulskes; Markus Hollmann; Marja Boermeester

Background:

Surgical site infection (SSI) is the most common postoperative complication and substantially increases health-care costs. Perioperative fluid management has been proposed to reduce SSI and other postoperative complications. We aim to investigate the influence of intra-operative goal directed fluid therapy (GDFT) on SSI and other postoperative outcomes.

Hypothesis:

We hypothesize that a goal directed fluid therapy during surgery will reduce the number of patients with an SSI.

Methods:

This systematic review and meta-analysis compared any GDFT management with no specific fluid management in the prevention of SSI in adult patients undergoing any type of surgery. We searched for randomized controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 22, 2022. Studies comparing different GDFT regimens, or only pre- or postoperative GDFT were excluded. Summary relative risks with corresponding 95% CIs were calculated using a random effects model. Sensitivity analysis based on risk of bias, and subgroup analysis based on studies with high versus low risk patients (high risk: ≥50% of patients ASA ≥3) were carried out. Trial sequential analysis (TSA) was performed to assess the risk of random error. The Cochrane Risk of Bias-2 tool and GRADE approach were used to evaluate the certainty of evidence. This study is registered with PROSPERO, CRD42022277535.

Results:

The search resulted in 1319 articles, of which 64 studies were included in this systematic review and meta-analysis. The overall incidence of SSI was 11.7% (1261 of 10,745 patients. The pooled relative risk of SSI was 0.69 (95% CI 0.60–0.80) for GDFT versus control fluid therapy. Sensitivity analysis of only studies with low risk of bias did not change the overall effect (RR 0.74, 95%CI 0.60-0.91 in favor of GDFT). In studies including high-risk patients, the effect of GDFT was greater (RR 0.61, 95%CI 0.49-0.77) than for low risk patient studies (RR 0.77, 95%CI 0.63-0.94). In the TSA the cumulative z-line crossed the boundary for effect but did not reach the required sample size, indicating that new RCTs are unlikely to modify the effect estimate.

Conclusions:

Goal directed fluid therapy in adult patients undergoing surgery is effective for the prevention of surgical site infections, and new RCTs are unlikely to change this outcome.