Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

Alves, Márcia Regina Dias; Saturnino, Saulo Fernandes; Zen, Ana Beatriz; Albuquerque, Dayane Gabriele Silveira de; Diegoli, Henrique

doi:10.62675/2965-2774.20240196-en

Márcia Regina Dias Alves

concept and design

analysis and interpretation of the data

critical revision of the paper for important intellectual content

funding

administrative support and supervision

Edwards Lifesciences - São Paulo (SP), Brazil.

https://orcid.org/0000-0001-9798-6977

Saulo Fernandes Saturnino

concept and design

analysis and interpretation of the data and critical revision of the paper for important intellectual content

Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil.

https://orcid.org/0000-0002-8999-961X

Ana Beatriz Zen

acquisition of data

drafting of the manuscript

analysis and interpretation of the data and critical revision of the paper for important intellectual content

Academia VBHC Educação e Consultoria - São Paulo (SP), Brazil.

https://orcid.org/0009-0002-6312-8346

Dayane Gabriele Silveira de Albuquerque

concept and design

analysis and interpretation of data and critical revision of paper for important intellectual content

Edwards Lifesciences - São Paulo (SP), Brazil.

https://orcid.org/0000-0002-2059-7217

Henrique Diegoli

concept and design

acquisition of data

drafting of the manuscript

analysis and interpretation of data and critical revision of the paper for important intellectual content

Academia VBHC Educação e Consultoria - São Paulo (SP), Brazil.

https://orcid.org/0000-0002-3970-019X

Corresponding author: . Henrique Diegoli. Academia VBHC Educação e Consultoria. Rua Ministro Godoi, 637. Zip code: 050515-000 - São Paulo (SP), Brazil. E-mail: hdiegoli@academiavbhc.org

Conflicts of interest: Henrique Diegoli was a paid consultant to Edwards Lifesciences. Márcia Alves and Dayane Albuquerque are employees of Edwards Lifesciences. The other authors declare that they have no conflict of interest.

Responsible editor: Gilberto Friedman - https://orcid.org/0000-0001-9369-2488

Author	Country	Population
Benes et al.⁽¹⁶⁾	Czech Republic	Patients undergoing high-risk major abdominal surgery, or patients with ischemic heart disease, cardiac dysfunction, moderate to severe chronic obstructive pulmonary disease, age above 70 years, or ASA classified as 3 or more
Hamed et al.⁽²³⁾	Egypt	Patients (between 45 and 65 years old) scheduled for saphenous vein graft surgery (2 or more grafts)
Aaen et al.⁽²⁴⁾	Denmark	Emergency surgery for intestinal obstruction or gastrointestinal perforation in adult patients
Cecconi et al.⁽²⁵⁾	Italy	Patients undergoing hip arthroplasty surgery
Colantonio et al.⁽²⁶⁾	Italy	ASA II-III patients diagnosed with peritoneal carcinomatosis candidates for peritonectomy and HIPEC
Gupta et al.⁽²⁷⁾	India	Patients undergoing resection of head and neck cancer with tissue transfer
Hand et al.⁽²⁸⁾	United States	Adult patients with tissue transfer surgery for primary reconstruction with head and neck oncological surgeons
Kapoor et al.⁽²⁹⁾	India	Patients undergoing saphenous vein graft surgery with EuroSCORE greater than or equal to 3
Kapoor et al.⁽³⁰⁾	India	Patients undergoing saphenous vein graft surgery with EuroSCORE greater than or equal to 3
Kapoor et al.⁽³¹⁾	India	Patients undergoing saphenous vein graft surgery with EuroSCORE greater than or equal to 3
Kumar et al.⁽³²⁾	India	Patients undergoing major abdominal surgeries (aortic aneurysm, intestinal obstruction, mesenteric ischemia, intestine cancer involving resection and anastomosis)
Kumar et al.⁽³³⁾	India	ASA I-II patients undergoing major abdominal surgeries (Whipple procedure, resection, retroperitoneal tumor and gastrectomy)
Liu et al.⁽³⁴⁾	China	ASA II-IV patients over 65 years old undergoing open gastrointestinal surgery (elective)
Martin et al.⁽³⁵⁾	United Kingdom	Patients between 18 and 80 years old diagnosed with liver cirrhosis and undergoing liver transplantation
Mayer et al.⁽³⁶⁾	Germany	ASA III patients with 2 or more risk factors undergoing major open abdominal surgery (intestinal/stomach/liver/esophagus resection, Whipple procedure)
Mishra et al.⁽³⁷⁾	India	ASA I-II patients between 18 and 65 years old with large supratentorial tumors undergoing elective craniotomy and excision
Parke et al.⁽³⁸⁾	New Zealand	Patients aged 16 or older, classified with EuroSCORE II of 0.9 or more, undergoing elective cardiac surgery
Peng et al.⁽³⁹⁾	China	Patients undergoing major orthopedic surgeries, including hip arthroplasty, spinal fusion, femur fracture, and sacral tumor
Ramsingh et al.⁽⁴⁰⁾	United States	Patients undergoing major abdominal surgeries
Scheeren et al.⁽⁴¹⁾	Germany	ASA III-IV adult patients undergoing high-risk surgery
Sujatha et al.⁽⁴²⁾	India	ASA I-II patients between 20 and 70 years old undergoing elective intestinal surgery
Tribuddharat et al.⁽⁴³⁾	Thailand	ASA II-IV adult patients undergoing saphenous vein graft surgery
Tribuddharat et al.⁽⁴⁴⁾	Thailand	ASA II-III patients undergoing saphenous vein graft surgery
Van der Linde et al.⁽⁴⁵⁾	Belgium	ASA II-III patients undergoing coronary artery bypass surgery
de Waal et al.⁽⁴⁶⁾	Netherlands	Patients undergoing high-risk abdominal surgery such as esophagectomy, duodenopancreatectomy, repair of abdominal aneurysm, resection of tissues with malignancy classified above III
Weinberg et al.⁽⁴⁷⁾	Australia	Adult patients undergoing major elective liver resection surgery
Zhang et al.⁽⁴⁸⁾	China	ASA I-II patients between 18 and 60 years old undergoing thoracoscopic lobectomy surgery under mechanical ventilation of one lung
Zhao et al.⁽⁴⁹⁾	China	ASA II-III patients above 60 years old undergoing major abdominal cancer surgery
Zheng et al.⁽⁵⁰⁾	China	Patients between 60 and 80 years old with coronary heart disease and undergoing gastrointestinal surgery

Outcome - number of studies included	RR or MD (95%CI)	Heterogeneity (I²)	Test for subgroup differences (p value)	Test for publication bias (p value)
Mortality - 16 (RR)
Noncardiac surgery	1.01 (0.69 - 1.49)	0	0.77	0.13
Cardiac surgery	0.84 (0.25 - 2.82)	0.71	0.77
Low risk of bias	1.35 (0.86 - 2.10)	0	0.04
Some concerns	0.69 (0.42 - 1.11)	0	0.04
Overall	0.97 (0.68 - 1.37)	0.09
Myocardial infarction - 11 (RR)
Noncardiac surgery	0.64 (0.30 - 1.37)	0	NA	0.51
Cardiac surgery	NA	NA	NA
Low risk of bias	0.55 (0.21 - 1.42)	0	0.77
Some concerns	0.72 (0.42 - 2.14)	0	0.77
Overall	0.64 (0.30 - 1.37)	0
Heart failure or pulmonary edema - 10 (RR)
Noncardiac surgery	0.50 (0.24 - 1.02)	0	0.58	0.07
Cardiac surgery	0.26 (0.03 - 2.29)	0	0.58
Low risk of bias	0.51 (0.23 - 1.11)	0	0.63
Some concerns	0.32 (0.06 - 1.69)	0.17	0.63
Overall	0.46 (0.23 - 0.92)	0
Acute kidney injury - 20 (RR)
Noncardiac surgery	0.87 (0.58 - 1.30)	0	0.96	0.04
Cardiac surgery	0.88 (0.70 - 1.11)	0.09	0.96
Low risk of bias	0.88 (0.71 - 1.10)	0	0.87
Some concerns	0.84 (0.50 - 1.42)	0	0.87
Overall	0.88 (0.72 - 1.07)	0
Hypotension - 8 (RR)
Noncardiac surgery	0.64 (0.28 - 1.45)	0.42	NA	0.65
Cardiac surgery	NA	NA	NA
Low risk of bias	0.46 (0.28 - 0.74)	0	0.25
Some concerns	1.17 (0.26 - 5.21)	0.56	0.25
Overall	0.64 (0.28 - 1.45)	0.42
Hospital stay - 23 (MD, days)
Noncardiac surgery	-1.81 (-2.80 - -0.81)	0.74	0.35	0.07
Cardiac surgery	-1.16 (-1.94 - -0.37)	0.89	0.35
Low risk of bias	-1.19 (-2.04 - -0.34)	0.76	0.39
Some concerns	-1.79 (-2.86 - -0.73)	0.81	0.39
Overall	-1.43 (-2.07 - -0.79)	0.81
ICU stay - 18 (MD, days)
Noncardiac surgery	-0.49 (-0.93 - -0.05)	0.73	0.21	0.22
Cardiac surgery	-1.14 (-1.85 - -0.42)	0.97	0.21
Low risk of bias	-0.60 (-1.17 - -0.03)	0.9	0.46
Some concerns	-0.92 (-1.53 - -0.31)	0.95	0.46
Overall	-0.77 (-1.18 - -0.36)	0.93
Duration of mechanical ventilation - 11 (MD, hours)
Noncardiac surgery	-3.44 (-6.13 - -0.76)	0.44	0.68	<.01
Cardiac surgery	-2.19 (-4.14 - -0.25)	0.70	0.68
Low risk of bias	-2.4 (-5.04 - 0.23)	0.48	0.74
Some concerns	-3.04 (-5.80 - -0.29)	0.77	0.74
Overall	-2.48 (-4.10 - -0.86)	0.63

Outcomes	Illustrative comparison		Relative effect (95%CI)	Number of participants (studies)	Quality of evidence (GRADE)
Outcomes	Usual care	GDT with FloTrac	Relative effect (95%CI)	Number of participants (studies)	Quality of evidence (GRADE)
Mortality	55 per 1000	51 per 1000	RR 0.97 (0.68 - 1.37)	2647 (16)	Moderate*
Myocardial infarction	26 per 1000	15 per 1000	RR 0.64 (0.3 - 1.37)	1339 (11)	Moderate*
Hypotension	132 per 1000	78 per 1000	RR 0,64 (0,28 - 1,45)	514 (9)	Moderate*
Heart failure or pulmonary edema	46 per 1000	16 per 1000	RR 0.46 (0.23 - 0.92)	1148 (10)	Moderate*
Acute kidney injury	119 per 1000	99 per 1000	RR 0.88 (0.72 - 1.07)	2881 (20)	Low*†
Hospital stay	10.63 days (ranging between 6 - 29)	-1.43 days (95%CI -2.07 - -0.79)	MD -1.43 (-2.07 - -0.79)	2616 (23)	Moderate‡
ICU stay	2.24 days (ranging between 1 - 7)	-0.77 days (95%CI -1.18 - -0.36)	MD -0.77 (-1.18 - -0.36)	2711 (18)	Moderate‡
Duration of MV	60 hours (ranging between 5 - 264 hours)	-2.48 hours (95%CI -4.10 - -0.86)	MD -2.48 (-4.10 - -0.86)	1688 (11)	Low†‡

[1] Corresponding author: . Henrique Diegoli. Academia VBHC Educação e Consultoria. Rua Ministro Godoi, 637. Zip code: 050515-000 - São Paulo (SP), Brazil. E-mail: hdiegoli@academiavbhc.org

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Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

ABSTRACT

Objective

Methods

Results

Conclusion