Impact Of Volume Status And Types Of Fluid Administration On Outcomes In Elective Non-Cardiac Surgery Patients: A Systematic Review

Objectives To evaluate the efficacy and safety of a)restrictive versus liberal,and b)colloid versus crystalloid fluid managemengt in the patients with elective non-cardiac surgeries.Methods The database including Medline,Embase,Central,CBM,CNKI,Wanfang and VIP and the websites of clinical trial registration were searched.Reference lists of relevant articles were also screened.The late search date was to January 2017.Criteria for considering studies for this meta-analysis included: a)Types of participants: all adults(age>18 year)with elective non-cardiac surgeries;b)Types of studies: randomised and quasi-randomised clinical trials;c)Intervention: liberal versus restrictive fluid management;colloid versus crystalloid fluid management;d)Types of outcome measures: The primary outcome was all-cause mortality.Secondary outcomes included complications rate,length of hospital stay,gastrointestinal function recovery,intraoperative blood loss and postoperative blood transfusion rate and so on.Risk of bias of included studies was assessed on recommendations from the Cochrane Handbook for Systematic Reviews of Interventions,includeing sequence generation,allocation concealment,blinding,incomplete outcome data,selective outcome reporting,and other bias.Treatment effects were measured by risk ratios(RR)with their 95% confidence interval(CI)for dichotomous data and mean difference with 95% CI for continuous data.I2 statistic was used to assess the impact of heterogeneity on the meta-analysis.And fixed or random effect model was selected according to the I2 statistic.Results Part ?(liberal versus restrictive fluid management): A total of 2737 patients from 28 studies were subjected to this meta-analysis.Compared with liberal fluid therapy,restrictive fluid therapy significantly reduced mortality rate(RR=0.42,95% CI 0.23 to 0.78,P<0.01;I2=0%)among patients with elective non-cardiac surgeries.Restrictive fluid therapy could shorten the length of hospital stay(MD =-2.02,95% CI-3.07 to-0.97,P<0.001),reduce postoperative complications rate(RR=0.70,95% CI 0.58 to 0.85,P<0.001),improve gastrointestinal function(MD=-0.96,95%CI-1.41 to-0.51,P<0.001),decrease intraoperative blood loss(MD=-47,95% CI-72.40 to-21.60,P<0.001)and postoperative blood transfusion(RR=0.76,95% CI 0.61 to 0.94,P<0.05).Additionally,there were no difference in postoperative acute renal insufficiency(RR=0.90,95% CI 0.58 to 1.41,P=0.65)and the hemodynamic parameters(MAP)(MD=0.73,95CI%-6.63 to 8.15,P=0.85)between 2 groups.Part ?(colloid versus crystalloid fluid management):A total of 2476 patients from 33 studies were subjected to this meta-analysis.Compared with the crystalloid fluid management,6% hydroxyethyl starch(130/40)increased the postoperative 30 d mortality rate among patients with elective noncardiac surgeries(RR=2.55,95% CI 1.37 to 4.76,P<0.005;I2=0%).However,human serum albumin didn't increase the postoperative 30 d mortality rate(RR=5,95% CI 0.27 to 91.52,P=0.28).The following results were obtained by analyzing the secondary outcomes: 1)compared with the crystalloid fluid,colloid fluid didn't increase the risk of postoperative complications rate(RR=1.11,95% CI 0.89 to 1.35,P=0.37);2)colloid fluid significantly reduced the volume of intraoperative infusion(MD=-513.35,95%CI-645.31 to-381.38,P<0.001)and intraoperative positive balance(MD=-315.53,95% CI-400.24 to-230.82,P<0.001).However,there was no significant difference in postoperative renal function(Cr)(MD =-3.89,95%CI-8.2 to 0.43,P = 0.08)between 2 groups;3)colloid fluid shortened postoperative gastrointestinal function recovery(exhaust)time(MD=-0.36,95% CI-0.56 to-0.16,P<0.001),decreased the perioperative adverse events(RR=0.38,95%CI 0.25 to 0.57,P<0.001),including nausea,vomiting in postoperative period and intraoperativeanesthesia-related hypotension.In addition,colloid fluid shorted the length of hospital stady(MD=-2.47,95% CI-3.46 to-1.49,P<0.001);4)artificial colloid,included 6% hydroxyethyl starch and 4% succinylated gelatin,significantly reduced TEG-MA(MD=-6.43,95%CI-8.27 to-4.56,P<0.001)and the number of PLTs(MD=-22.21,95% CI-35.59 to-8.83,P<0.005),inhibited exogenous coagulation pathways(MD =1.43,95%CI 0.49 to 2.38,P<0.001)or endogenous coagulation pathways(MD =0.6,95%CI 0.23 to 0.98,P<0.001),but didn't significantly increase the intraoperative blood loss(MD=1.68,95%CI-10.18 to 13.54,P=0.79)and the postoperative blood transfusion rate(RR=1.11,95%CI 0.73 to 1.65,P=0.66).Conclusions Part ?: Restrictive fluid therapy can reduce the postoperative mortality and complications rate and improve gastrointestinal function for elective non-cardiac surgeries patients.Part ?:The 6% hydroxyethyl starch may increase postoperative mortality in elective non-cardiac surgery patients,but thus is no found in other type of collid fulid.There is no significant difference in the postoperative complications and renal functions colloid versus crystalloid fluid management.In addition,collid administration can reduce the volume of infusion and fluid balance in introperative period,improve gastrointestinal function,and shorten hospital stay.