Timing of peri-operative goal-directed hemodynamic optimisation: before, during or after surgery?
Searches
PubMed, cross-referencing from identified RCTs and previous meta-analyses
English language
Types of study to be included
Randomized controlled trials
Reporting mortality or number of patients with post-operative complications (overall complications, NOT organ-specific)
Peer-reviewed
Published, English language articles
Condition or domain being studied
Major surgery can be associated with significant morbidity and mortality. Several RCts have attempted to reduce peri-operative morbidity and mortality and improve patient outcomes by deliberately manipulating peri-operative hemodynamics. The objective of this systematic review is to examine whether timing of peri-operative goal-directed hemodynamic optimisation can affect patient outcomes.
Participants/ population
Adult patients undergoing elective or emergency major surgery
Intervention(s), exposure(s)
Inclusion criteria:
Use of hemodynamic monitoring and therapies (fluids / inotropes)
In the peri-operative period (pre/intra/post or a combination - to be clearly stated)
Therapy to be goal-directed (no fixed-dose regimes)
Goals to be different between control and protocol groups
Comparator(s)/ control
Non-goal directed therapy
Outcome(s)
Primary outcomes
Mortality
Number of patients with complications (overall complication rate)
Secondary outcomes
None
Data extraction, (selection and coding)
The title and abstracts identified from the search will be scanned for potential articles by two reviewers independently. Full-texts of eligible articles will be independently examined by each of 4 reviewers for consideration for inclusion in the review. Data will be extracted by each of 4 reviewers and entered into a standard database. All discrepancies will be resolved by consensus. Authors will not be blinded to study author / journal.
Data to be extracted
• First author
• Year of publication
• Type of surgery
• Number of patients randomised
• Number of patients analysed
• Timing of optimisation:
o Optimisation in the postoperative period only
o Optimisation in the postoperative and intraoperative and/or preoperative period
o Optimisation in the preoperative and / or intraoperative period but not in the postoperative period
• Hemodynamic monitoring technique (device) used
• Hemodynamic goal
• Whether goal is normal CI or DO2 / supra-normal CI or DO2 / Stroke volume maximisation / SvO2 or ScvO2 or lactate levels / dynamic indices of preload responsiveness
• Interventions required to meet target (fluids, inotropes, other)
• Mortality in control group
Risk of bias (quality) assessment
Quality assessment of included studies will be performed using the Cochrane Risk of Bias tool.
Sensitivity analysis will be carried out for good versus poor-quality studies
Strategy for data synthesis
• Studies will be categorised as follows:
o Optimisation in the postoperative period only
o Optimisation in the postoperative and intraoperative and/or preoperative period
o Optimisation in the preoperative and / or intraoperative period but not in the postoperative period
• Data will be analysed using RevMan 5.0 software. Aggregate data will be used for analysis. Individual patient data analysis is not planned. Outcomes will be expressed as Odds ratios. Studies will be examined for heterogeneity and fixed / random effects model will be used accordingly.
Analysis of subgroups or subsets
Sub-group analysis planned
• Quality of study (risk of bias)
• Year of publication (pre-2000 versus post-2000)
• Type of intervention
• Type of goal (normal / supra-normal / dynamic)
• Patient group (<5% mortality, 5-10% mortality, > 10% mortality in control group)
Contact details for further information
Priya Ranganathan
Department of Anaesthesiology, Tata Memorial Hospital, Parel, Mumbai 400012
drpriyaranganathan@gmail.com
Organisational affiliation of the review
None
Review team
Dr Jigeeshu Divatia, Tata Memorial Hospital Dr Priya Ranganathan, Tata Memorial Hospital Dr Atul Kulkarni, Tata Memorial Hospital Dr Sheila Myatra, Tata Memorial Hospital
Anticipated or actual start date
01 September 2012
Anticipated completion date
30 November 2012
Funding sources/sponsors
None
Conflicts of interest
None known
Language
English
Country
India
Subject index terms status
Subject indexing assigned by CRD
Subject index terms
Humans; Perioperative Care; Hemodynamics; Time Factors
Date of registration in PROSPERO
27 September 2012
Date of publication of this revision
28 September 2012
Stage of review at time of this submission
Started
Completed
Preliminary searches
Yes
Piloting of the study selection process
Formal screening of search results against eligibility criteria
Data extraction
Risk of bias (quality) assessment
Data analysis
Prospective meta-analysis
PROSPERO This information has been provided by the named contact for this review. CRD has accepted this information in good faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration record, any associated files or external websites.
