Perioperative hemodynamic goal-directed therapy and mortality: a systematic review and meta-analysis with meta-regression

INTRODUCTION: Recent data found that perioperative goal directed therapy (GDT) was effective only in higher control mortality rates (> 20%) with a relatively high heterogeneity that limited the strength of evidence. The aim of the present meta-analysis was to clearly understand which high risk patients may benefit of GDT. EVIDENCE ACQUISITION: Systematic review of randomized controlled trials with meta-analyses, including a meta-regression technique. MEDLINE, EMBASE, and The Cochrane Library databases were searched (1980-January 2015). Trials enrolling adult surgical patients and comparing the effects of GDT versus standard hemodynamic therapy were considered. The primary outcome measure was mortality. Data synthesis was obtained by using Odds Ratio (OR) with 95% confidence interval (CI) by random-effects model. EVIDENCE SYNTHESIS: Fifty eight studies met the inclusion criteria (8171 participants). Pooled OR for mortality was 0.70 (95% CI 0.56-0.88, P= 0.002, no statistical heterogeneity). GDT significantly reduced mortality when it is > 10% in control group (OR 0.43, 95% CI 0.30-0.61, P< 0.00001). The meta-regression model showed that the cut off of 10% of mortality rate in control group significantly differentiates 43 studies from the other 15, with a regression coefficient b of -0.033 and a P value of 0.0001. The significant effect of GDT was driven by high risk of bias studies (OR 0.48, 95% CI 0.34-0.67, P< 0.0001). CONCLUSIONS: The present meta-analysis, adopting the meta-regression technique, suggests that GDT significantly reduces mortality even when the event control rate is > 10%.