What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Critical illness (peri-operative, trauma, sepsis, organ failure) (n=5733). Intervention: Hemodynamic optimization vs. Standard care. Primary outcome: Overall mortality at 28 to 30 days (RR 0.75, 95% CI 0.62 to 0.90).

November 15, 2005Open Access

Meta-analysis of hemodynamic optimization: relationship to methodological quality

Key Result

Hemodynamic optimization reduced overall mortality (RR 0.75) compared to standard care, an effect primarily driven by peri-operative interventions in high-risk surgical patients.

Study Design

Type

Meta-Analysis (n=5,733)

Structured PICO

Does hemodynamic optimization reduce mortality in adult intensive care and surgical patients?

Population

5,733 adult critically ill patients (peri-operative, trauma, sepsis, or organ failure) from 30 randomized clinical trials evaluating hemodynamic optimization, followed for 28 to 30 days.

Intervention

Hemodynamic optimization using fluid and/or vasoactive therapy (e.g., dobutamine, dopexamine, noradrenaline) to maximize oxygen delivery, cardiac index, oxygen consumption, mixed venous oxygen saturation, and/or stroke volume.

Comparator

Standard care without deliberate hemodynamic optimization to supranormal values.

Outcome

Mortality at up to 28 or 30 days.hard clinical

Hemodynamic optimization using fluids and vasoactive agents significantly reduces mortality in high-risk peri-operative and trauma patients, but offers no survival benefit for patients with sepsis and organ failure.

Main Result

Relative Risk: 0.75 (95% CI 0.62–0.9)

Absolute Risk Reduction: 0.4%

Limitations

Overall methodological quality of the included studies was moderate
Studies with a high trial quality score did not report an improved mortality rate
Some included studies had lower statistical power than expected due to low baseline mortality

Abstract

INTRODUCTION: To review systematically the effect of interventions aimed at hemodynamic optimization and to relate this to the quality of individual published trials. METHODS: A systematic, computerized bibliographic search of published studies and citation reviews of relevant studies was performed. All randomized clinical trials in which adult patients were included in a trial deliberately aiming at an optimized or maximized hemodynamic condition of the patients (with oxygen delivery, cardiac index, oxygen consumption, mixed venous oxygen saturation and/or stroke volume as end-points) were selected. A total of 30 studies were selected for independent review. Two reviewers extracted data on population, intervention, outcome and methodological quality. Agreement between reviewers was high: differences were eventually resolved by third-party decision. The methodological quality of the studies was moderate (mean 9.0, SD 1.7), and the outcomes of the randomized clinical trials were not related to their quality. RESULTS: Efforts to achieve an optimized hemodynamic condition resulted in a decreased mortality rate (relative risk ratio (RR) 0.75 (95% confidence interval (CI) 0.62 to 0.90) in all studies combined. This was due to a significantly decreased mortality in peri-operative intervention studies (RR 0.66 (95% CI 0.54 to 0.81). Overall, patients with sepsis and overt organ failure do not benefit from this method (RR 0.92 (95% CI 0.75 to 1.11)). CONCLUSION: This systematic review showed that interventions aimed at hemodynamic optimization reduced mortality. In particular, trials including peri-operative interventions aimed at the hemodynamic optimization of high-risk surgical patients reduce mortality. Overall, this effect was not related to the trial quality.

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