Systematic review and meta-analysis of goal-directed haemodynamic therapy algorithms during surgery for the prevention of surgical site infection

Hasti Jalalzadeh; Rick H Hulskes; Robert P Weenink; Niels Wolfhagen; Ingeborg van Dusseldorp; Roald R Schaad; Denise P Veelo; Markus W Hollmann; Marja A Boermeester; Stijn W de Jonge

doi:10.1016/j.eclinm.2024.102944

Systematic review and meta-analysis of goal-directed haemodynamic therapy algorithms during surgery for the prevention of surgical site infection

EClinicalMedicine. 2024 Nov 22:78:102944. doi: 10.1016/j.eclinm.2024.102944. eCollection 2024 Dec.

Authors

Hasti Jalalzadeh^{1

2

3}, Rick H Hulskes^{1

3

4}, Robert P Weenink⁴, Niels Wolfhagen^{1

2

3}, Ingeborg van Dusseldorp⁵, Roald R Schaad³, Denise P Veelo⁴, Markus W Hollmann⁴, Marja A Boermeester^{1

2

3}, Stijn W de Jonge^{1

2}

Affiliations

¹ Department of Surgery, Amsterdam UMC, Location the University of Amsterdam, Amsterdam, the Netherlands.
² Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands.
³ Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections.
⁴ Department of Anaesthesiology, Amsterdam UMC, Location the University of Amsterdam, Amsterdam, the Netherlands.
⁵ Knowledge Institute for the Federation of Medical Specialists, Utrecht, the Netherlands.

Abstract

Background: Surgical site infection (SSI) is the most common postoperative complication. Goal-directed haemodynamic therapy (GDHT) may help to prevent SSI, but recommendations for its use initially have been set at conditional because of low-certainty evidence at the time. An updated systematic review with SSI as the primary endpoint has not been performed since 2011, and important new evidence has emerged. We assessed the influence of GDHT on SSI and other postoperative outcomes.

Methods: We searched Ovid/MEDLINE, Excerpta Medica Database (Embase.com), and Cochrane library from inception up to September 2024 for randomised controlled trials comparing the effect of any GDHT algorithm to conventional fluid therapy on SSI incidence in adult patients undergoing surgery and analysed eligible data using random effects. We conducted several subgroup analyses, including the risk of bias (RoB), and a trial sequential analysis (TSA). We evaluated the certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluations. This study is registered with PROSPERO, CRD42022277535.

Findings: We found 75 studies that met the inclusion criteria with an incidence of 1,478 SSI among 13,010 patients (11.4%). The incidence of SSI was reduced from 13.3% in the conventional fluid therapy to 9.4% after GDHT (absolute risk reduction 3.9%); pooled relative risk 0.71 (95% CI 0.62-0.81). Subgroup analysis for the low RoB studies revealed comparable results. Meta-regression indicated no strong evidence for individual subgroup effects. In the TSA, the cumulative z-line crossed the boundary for effect.

Interpretation: High-certainty evidence indicates that GDHT reduces the risk of SSI when compared to conventional fluid therapy in adults undergoing surgery. New studies are unlikely to change this outcome. These findings justify a stronger recommendation for the use of GDHT.

Funding: Dutch Association for Quality Funds Medical Specialists.

Keywords: Anaesthesiology; Goal-directed haemodynamic therapy; Meta-analysis; Surgery; Surgical site infection; Systematic review; Wound infection.