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Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis

Journal of Anesthesia, Analgesia and Critical Care volume 1, Article number: 26 (2021) Cite this article

Abstract

Background

Goal-directed therapy (GDT) aims to assure tissue perfusion, by optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications. However, all recent evidences focused on high-risk patients and on major abdominal surgery.

Objectives

The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications (defined as number of patients with a least one postoperative complication) in different kind of surgical procedures.

Data sources

Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. A subgroup-analysis was performed considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery. and so on.

Study appraisal and synthesis methods

Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs).

Results

In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49–0.72. The sensitivity analysis confirmed the main result.

The analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59–0.87, p = 0.0007, 31 RCTs, 4203 patients), both in high- and low-risk patients. A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35–0.80, p = 0.002, 7 RCTs, 650 patients. Also neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21–0.78, p = 0.008, 2 RCTs, 208 patients). In both major abdominal and orthopedic surgery, a strategy adopting fluids and inotropes yielded significant results. The total volume of fluid was not significantly different between the GDT and the control group.

Conclusions and implications of key findings

The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, suggests that GDT can reduce postoperative complication rate. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. Several well-designed RCTs are needed to further explore the effect of GDT in different kind of surgeries.

Background

Goal-directed therapy (GDT) is a strategy that aims to optimize dose and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters, in order to assure an adequate tissue perfusion and oxygen delivery. In the last 30 years, many authors have reported that GDT adoption can reduce the incidence of morbidity, and in some studies, mortality [1,2,3]. Several meta-analyses [1, 4] support its use in high-risk patients, and a recent trial reports a significant effect also in low–moderate-risk patients [5]. However, all recent meta-analyses focused mainly on major abdominal surgery and on high-risk patients [6,7,8], while the evidence is less clear in other surgical procedures.

The aim of the present updated meta-analysis is to investigate the effect of GDT on postoperative complications in different kind of surgical procedures. Moreover, we analyzed the amount of crystalloids and colloids administered during the intraoperative period in order to verify if a GDT approach is useful to control the total amount of administered fluids.

Methods

Eligibility criteria

RCTs were selected according to the following inclusion criteria [9]:

  • Types of participants. Adult patients (ages 18 years and older) undergoing major non cardiac surgery were considered. Studies involving mixed populations of critically ill, nonsurgical patients, or postoperative patients with sepsis or organ failure were excluded.

  • Types of interventions. GDT was defined as monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluid infusion alone or in combination with inotropic therapy in the perioperative period within 8 h after surgery. Studies including late hemodynamic optimization treatment were excluded.

  • Types of comparisons. Trials comparing the beneficial and harmful effects of GDT versus standard hemodynamic therapy were considered. RCTs with no description or no difference in optimization strategies between groups, as well as RCTs in which therapy was titrated to the same goal in both groups or was not titrated to predefined end-points were excluded.

  • Types of outcome measures. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. Postoperative complications include minor and major cardiac, renal, gastrointestinal, infective and respiratory ones. Mortality was not included. Sensitivity analysis was planned including only low risk of bias trials (see below). Studies were splitted considering the kind of surgery (i.e., major abdominal, orthopedic, vascular, and so on). Moreover, studies were divided on the basis of the strategy adopted (i.e., only fluids or fluids and inotropes). In those studies that used fluids alone, the volume of crystalloids and of colloids, as well as the total volume of fluids received during the GDT period were also analyzed.

  • Types of studies. RCTs on perioperative GDT in surgical patients were included. No language, publication date, or publication status restrictions were imposed.

Information sources

Different search strategies (last update July 2021) were performed to retrieve relevant randomized controlled trials (RCTs) by using MEDLINE, The Cochrane Library and EMBASE databases. No date restriction was applied for MEDLINE and The Cochrane Library databases, while the search was limited to 2008–2021 for EMBASE database [10]. Additional RCTs were searched in The Cochrane Library and the Database of Abstracts of Reviews of Effects (DARE) databases and in the reference lists of previously published reviews and retrieved articles. Other data sources were hand-searched in the annual proceedings (2008–2020) of the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, the Society of Cardiovascular Anesthesiologists, the Royal College of Anaesthetists, the American Society of Anesthesiologists. In order to reduce publication bias, abstracts were searched [11]. Publication language was not a search criterion.

Search terms

Trials selection was performed by using the following search terms: randomized controlled trial, controlled clinical trial, surgery, goal-directed, goal oriented, goal target, cardiac output, cardiac index, DO2, oxygen consumption, cardiac volume, stroke volume, fluid therapy, fluid loading, fluid administration, optimisation, optimization, supranormal. The search strategies used for the MEDLINE, The Cochrane Library, and EMBASE databases are reported in Supplementary material 1.

Study selection

Two investigators (FP, LT) examined at first each title and abstract to exclude clearly irrelevant studies and to identify potentially relevant articles. Other two investigators (MG, NB) independently determined eligibility of full-text articles retrieved. The names of the author, institution, journal of publication and results were unknown to the two investigators at this time.

Data abstraction and study characteristics

Data were independently collected by two investigators (GB, SR), with any discrepancy resolved by re-inspection of the original article. To avoid transcription errors, the data were input into statistical software and rechecked by different investigators (AC, NB).

RCT data gathered

Data abstraction included surgical risk (defined by the authors on the basis of POSSUM score [12], ASA physical status classification, age > 60 years, pre-operative morbidity, and type of surgery), type of surgery (i.e., elective or emergent, abdominal, thoracic, vascular), anesthesiological management, and hemodynamic goal-directed therapy (end-points, therapeutic intervention, and monitoring tools). The volume of crystalloids and of colloids, as well as the total volume of fluid received during the GDT period was also analyzed.

Risk of bias in individual studies

A domain-based evaluation, as proposed by the Cochrane Collaboration, was used to evaluate the methodological quality of RCTs [13]. This is a two-part tool, addressing seven specific domains that are strongly associated with bias reduction [14, 15]. Each domain in the tool includes one or more specific entries in a ‘risk of bias’ table. Within each entry, the first part of the tool describes what was reported to have happened in the study, in sufficient detail to support a judgement about the risk of bias. The second part of the tool assigns a judgement relating to the risk of bias for that entry. This is achieved by assigning a judgement of ‘low risk’, ‘high risk’, or ‘unclear risk’ of bias. After each domain was completed, a ‘risk of bias summary’ figure presenting all of the judgements in a cross-tabulation of study by entry is generated. The green plus indicates low risk of bias, the red minus indicates high risk of bias, the white color indicates unclear risk of bias. For each study, the number of green plus obtained for every domain was calculated: RCTs with 5 or 6 green plus were considered as having an overall low risk of bias.

Summary measures and planned method of analysis

Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous variables, and weighted mean difference (WMD) and 95% CI for continuous variables. A statistical difference between groups was considered to occur if the pooled 95% CI did not include 1 for the OR. An OR less than 1 favored GDT when compared with control group. Two-sided p values were calculated. A random-effects model was chosen for all analyses. Statistical heterogeneity and inconsistency were assessed by using the Q and I2 tests, respectively [16, 17]. When the p value of the Q test was < 0.10 and/or the I2 was > 40%, heterogeneity and inconsistency were considered significant [18].

Results

Study selection

The search strategies identified 3561 (MEDLINE), 10306 (Cochrane Library), and 3110 (EMBASE) articles. Thirteen articles were identified through other sources (congress abstracts, reference lists). After initial screening and subsequent selection, a pool of 148 potentially relevant RCTs was identified. The subsequent eligibility process (Fig. 1) excluded 96 articles and, therefore, 52 articles (5, 18–68) with a total sample of 6315 patients, were considered for the analysis.

Fig. 1
figure 1

Flow chart summarizing the studies selection procedure for the meta-analysis. RCT, andomized controlled trial

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Study characteristics

All inclueded articles evaluated the effects of hemodynamic optimization on morbidity as primary or secondary outcome and had a population sample of adult surgical patients, undergoing both elective and emergent procedures (Table 1). The studies were performed in Australia, the USA, Europe, Canada, Brazil, China, India, and Japan from 1991 to 2021 (Table 1) and were all published in English.

Table 1 Characteristics of included studies
Full size table

Data concerning population and type of surgery are presented in Table 1. The risk of bias assessment for each trial is showed in Table 2.

Table 2 The risk of bias assessment for each trial, according to the Cochrane domain-based evaluation
Full size table

Quantitative data synthesis

In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49–0.72 (Fig. 2). The sensitivity analysis showed that the significant effect of GDT on postoperative complications was confirmed by low risk of bias RCTs, with high statistical heterogeneity and inconsistency (OR 0.64, 95% CI 0.52–0.79, p < 0.00001, Q statistic p = 0.0001; I2 = 56 %, 34 RCTs, 4841 patients) (Fig. 2).

Fig. 2
figure 2

Rates of postoperative complications in subgroups defined according to risk of bias (see text for details) with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI

Full size image

The subgroup analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59–0.87, p = 0.0007, Q statistic p = 0.01, I2 = 40%, 31 RCTs, 4203 patients) (Fig. 3). A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35–0.80, p = 0.002, Q statistic p = 0.30; I2 = 17%, 7 RCTs, 650 patients) (Fig. 4). Also, neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21–0.78, p = 0.008, Q statistic p = 0.56; I2 = 0%, 2 RCTs, 208 patients, Fig. 5). Only 2 RCTs considered exclusively vascular surgery, and the pooled OR showed a non-significant effect of GDT on postoperative complications (OR 1.18, 95% CI 0.56–2.46, p = 0.67, Q statistic p = 0.79; I2 = 0%, 2 RCTs, 168 patients) as well as for thoracic surgery (OR 1.04, 95% CI 0.28–3.88, p = 0.95, Q statistic p = 0.01; I2 = 77%, 3 RCTs, 371 patients) (Supplementary material). For other surgeries, no other subgroup analyses were performed due to the very low number of RCTs included.

Fig. 3
figure 3

Rates of postoperative complications in patients undergoing abdominal surgery, with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI

Full size image
Fig. 4
figure 4

Rates of postoperative complications in patients undergoing orthopedic surgery, with odds ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI

Full size image
Fig. 5
figure 5

Rates of postoperative complications in patients undergoing neurosurgery, with Odds Ratios (ORs) and 95% confidence intervals (CI). The pooled OR and 95% CI are shown as the total. The size of the box at the point estimate of the OR gives a visual representation of the “weighting” of the study. The diamonds represent the point estimate of the pooled ORs and the length of the diamonds is proportional to the CI

Full size image

A strategy adopting only fluids yielded significant results (OR 0.67, 95% CI 0.47–0.97, p = 0.04, 17 RCTs, 1937 patients), as well as one using fluids and inotropes (OR 0.563, 95% CI 0.45–0.70, p < 0.00001, 35 RCTs, 4378 patients); both analyses had high statistical heterogeneity (Table 3). In both analyses, abdominal procedures were the most frequent ones. Considering only major abdominal surgery, using fluids alone yielded not significant results (OR 0.87, 95% CI 0.64–1.19 p = 0.39, Q statistic p =0.07; I2 = 40%, 13 RCTs, 1627 patients), while adopting a combined strategy with fluids and inotropes showed significant results (OR 0.63, 95% CI 0.49–0.79 p = 0.0001, Q statistic p = 0.09; I2 = 32%, 18 RCTs, 2476 patients). Also, in orthopedic surgery, a GDT strategy adopting only fluids yielded not significant result (OR 0.43, 95% CI 0.15–1.22 p = 0.11, Q statistic p = 0.009; I2 = 59%, 3 RCTs, 242 patients), while a strategy adopting fluids and inotropes showed significant results (OR 0.59, 95% CI 0.37–0.94 p = 0.03, Q statistic p = 0.56; I2 = 0%, 4 RCTs, 406 patients). No further analyses were possible in other kind of surgeries.

Table 3 The results of the subgroup analyses. RCTs were divided considering the kind of surgery (i.e., major abdominal, orthopedic, vascular, and so on) and on the basis of the strategy adopted (i.e., only fluids or fluids and inotropes)
Full size table

In those RCTs adopting only fluids as optimization strategy, patients in the GDT group received more colloids (Table 4) and less crystalloids (Table 4) than patients in the control group. The total volume of fluid was not significantly different between the GDT and the control group.

Table 4 Total amount of fluids, colloids, and crystalloids used in all RCTS included
Full size table

Discussion

The epresent meta-analysis suggests that GDT can significantly reduce postoperative complications. This effect is confirmed when only low risk of bias RCTs were included in the analysis. The surgical procedures that seem to benefit most are abdominal, orthopedic, and neurosurgical ones.

GDTe was initially proposed for the maintenance of an optimal cardiac output, in order to allow prompt restoration of perfusion and avoid cellular hypoxia and tissue injury [55]. Nowadays, GDT does not aim to a maximized cardiac output but rather pursues personalized hemodynamic management assessing blood flow and fluid responsiveness, in order to prevent not only tissue hypoperfusion and hypovolemia, but also perioperative fluid overload, since both are associated with adverse postoperative outcomes [70, 71].

Several RCTs and meta-analyses show that GDT reduces postoperative complications in high-risk surgical patients, regardless the monitoring or the target [49, 72]. Therefore, the use of GDT has been suggested from expert groups [73, 74], at least in high-risk patients and in major abdominal surgery, when high intravascular volume replacement is needed. However, the great heterogeneity of the studies exploring GDT effects, in terms of types of surgery, timing, type of monitoring device, the hemodynamic variables assessed and targeted and the types and amounts of fluids, vasopressors, and/or inotropes used can not be ignored [75], and make a definite conclusion on GDT application much less clear. Focusing on specific type of procedures or strategies could add more clarity to the available evidences.

The incidence of postoperative complications is well documented in abdominal surgery (from 12% after hepatectomy to 44% after esophagectomy) [69], and similar data are reported in other type of surgical procedures: for example, in fracture surgery the incidence of postoperative complications ranges from 7 to 42% [76]. Also, vascular surgery shows similar trends, with a range varying from 21 to 33% [69]. The incidence of systemic complications in neurosurgical procedures is estimated approximately at around 14% [77].

Our results confirm the significant reduction of postoperative complications in major abdominal surgery. Differently from others [77, 78], however, the present meta-analysis yielded significant results also in other kind of surgeries, suggesting that GDT application could be extended to other surgical settings, since also orthopedic and neurosurgical procedures can benefit from a GDT approach, while no effects were seen in thoracic or vascular surgery. Moreover, considering all types of surgeries, a GDT approach that uses only fluids or fluids and inotropes has shown significant results, while in major abdominal and orthopaedic surgery, only a strategy adopting inotropes in addiction to fluids yielded significant results. It is possible to argue that GDT, guiding to an individualized and timely fluid administration, allows to use fluids judiciously when they are needed, but also to avoid unnecessary fluid loading when hemodynamic targets are already met [6, 76]. This strategy can allow to avoid fluid overload from one side and maintain tissue perfusion on the other, thus reducing postoperative complications. When fluids are not sufficient, a combination of vasoconstrictors to maintain an adequate mean arterial pressure and of inotropes to increase stroke volume, guided by advanced hemodynamic monitoring could help to assure adequate perfusion [73, 74]. The present results suggest that in those surgical settings expected to be managed with large amounts of fluids or enrolling old, high-risk patients, such as abdominal or orthopedic ones, a GDT approach including fluids and inotropes is effective in reducing postoperative complications. We cannot state if the effects of fluids and inotropes are synergistic or the beneficial effect of one intervention counteracts the adverse effect of the other, but it can be supposed that a more extensive hemodynamic monitoring and targeting can help to guide perioperative management and to reduce postoperative complications in these specific surgical scenarios. In this way, for example, patients with a reduced physiologic reserve may benefit of additional and early administration of inotropic drugs to increase oxygen delivery and counteract hypoperfusion. The low number of patients involved, the mixed nature of surgical procedures and the lack of individual data are all possible explanations to the inconclusive findings in the other surgical procedures (thoracic or vascular surgery).

Another finding of our meta-analysis is that the total volume of fluids did not increase with the use of GDT. Patients received more colloids, but less crystalloids, so that the total volume of fluids was not significantly different between the control and the GDT group. This finding goes against the perception or the fear that using hemodynamic optimization protocols may be associated with excessive fluid administration, but, on the contrary, supports the idea that GDT helps clinicians to give the right amount of fluid to the right patients at the right time.

A major limitation of our analysis is the presence of heterogeneity in defining postoperative complications, and keeping this in mind a random effects model was used even when the estimated amount of heterogeneity was low. A high heterogeneity was found in almost all subgroups, reducing the strength of the results. Moreover, even if we tried to control clinical heterogeneity with subgroup analyses splitting studies on the basis of surgery type and targets, statistical heterogeneity remained high, and therefore, the results should be interpreted with caution. Third, the consistency of data reporting postoperative fluid administration is lacking, as well as data on oral fluid intake and perioperative management is missing in many studies, so direct comparison is difficult. Finally, the definition of postoperative complications is another crucial point of all these studies. We choose to consider the rate of patients who had at least one complication, like other authors proposed [6] since the evaluation of specific organ-related events has numerous bias linked to the definition of postoperative event, the overlapping of postoperative complications and the risk to over-estimate the total number of complications.

Conclusion

The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, gives new suggestions on the beneficial effect of GDT in reducing postoperative morbidity rate in other type of surgeries, different from the major abdominal. These results call for other RCTs with the aim to explore the real impact of hemodynamic goal-directed strategy and its specific issues (i.e., monitoring tools and targets, means adopted, patients to enroll) in different surgical settings.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

GDT:

Goal-directed therapy

ReCTs:

Randomized controlled trials

POSSUM score:

Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity

ASA:

American Society of Anestesiology

ORs:

Odds ratios

CIs:

95% confidence intervals

WMD:

Weighted mean difference

References

  1. Giglio M, Dalfino L, Puntillo F, Brienza N. (2019) Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis. Crit Care. Jun 26;23(1):2322.

  2. Giglio M , Manca F, Dalfino L, Brienza N. (2016)Perioperative haemodynamic goal-directed therapy and mortality: systematic review and meta-analysis with meta-regression.Minerva Anestesiol. Nov;82(11):1199-1213

  3. Giglio MT, Marucci M, Testini M, Brienza N (2009) Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. Nov 103(5):637–646. https://doi.org/10.1093/bja/aep279

    Article  CAS  Google Scholar 

  4. Gurgel ST, do Nascimento P Jr. (2011) Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg. Jun;112(6):1384-91.

  5. Calvo-Vecino JM, Ripollés-Melchor J, Mythen MG, Casans-Francés R, Balik A, Artacho JP, Martínez-Hurtado E, Serrano Romero A, Fernández Pérez C, Asuero de Lis S; FEDORA Trial Investigators Group (2018) Effect of goal-directed haemodynamic therapy on postoperative complications in lowemoderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial). British Journal of Anaesthesia 120(4):734–744. https://doi.org/10.1016/j.bja.2017.12.018

    Article  Google Scholar 

  6. Messina A, Robba C, Calabrò L, et al. (2021) Association between perioperative fuid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery. Crit Care 25:43. 7. Som A, Maitra S, Bhattacharjee S, Baidya DK. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials. J Anesth. 2017 Feb;31(1):66-81.

  7. Rollins KE, Lobo DN. (2016) Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg. Mar;263(3):465-76.

  8. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535

    Article  Google Scholar 

  9. Lefebvre C, Manheimer E, Glanville J: Searching for studies. In Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1. Volume Chapter 6. Edited by: Higgins JPT, Green S. The Cochrane Collaboration (updated September 2008); [http://www.cochrane-handbook.org/].

  10. McAuley L, Pham B, Tugwell P, Moher D (2000) Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Lancet 356(9237):1228–1223. https://doi.org/10.1016/S0140-6736(00)02786-0

    Article  CAS  PubMed  Google Scholar 

  11. Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78(3):355–360. https://doi.org/10.1002/bjs.1800780327

    Article  CAS  PubMed  Google Scholar 

  12. Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

  13. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of randomized clinical trials: is blinding necessary? Control Clin Trials 17(1):1–12. https://doi.org/10.1016/0197-2456(95)00134-4

    Article  CAS  PubMed  Google Scholar 

  14. Juni P, Witschi A, Bloch R, Egger M (1999) The hazards of scoring he quality of clinical trials for meta-analysis. JAMA 282(11):1054–1060. https://doi.org/10.1001/jama.282.11.1054

    Article  CAS  PubMed  Google Scholar 

  15. Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  16. Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558. https://doi.org/10.1002/sim.1186

    Article  PubMed  Google Scholar 

  17. Deeks JJ, Higgins JPT, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.

  18. Ackland GL, Iqbal S, Gallego Paredes L et al (2015) Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial. Lancet Respir Med 3(1):33–34. https://doi.org/10.1016/S2213-2600(14)70205-X

    Article  CAS  PubMed  Google Scholar 

  19. Arslan-Carlon V, Tan KS, Dalbagni G, Pedoto AC, Herr HW, Bochner BH, Cha EK, Donahue TF, Fischer M, Donat SM (2020) Goal-directed versus standard fluid therapy to decrease ileus after open radical cystectomy: a prospective randomized controlled trial. Anesthesiology. 133(2):293–303. https://doi.org/10.1097/ALN.0000000000003367

    Article  PubMed  Google Scholar 

  20. Bahlmann H, Halldestam I, Nilsson L (2019) Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial. Eur J Anaesthesiol. 36(2):153–161. https://doi.org/10.1097/EJA.0000000000000908

    Article  PubMed  Google Scholar 

  21. Bartha E, Davidson T, Berg HE, Kalman S.A (2019) 1-year perspective on goal-directed therapy in elderly with hip fracture: secondary outcomes. Acta Anaesthesiol Scand. 63(5):610–14. https://doi.org/10.1111/aas.13320.

  22. Bender JS, Smith-Meek MA, Jones CE (1997) Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial. Ann Surg 226(3):229–236. https://doi.org/10.1097/00000658-199709000-00002

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M (2010) Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 14(3):R118. https://doi.org/10.1186/cc9070

    Article  PubMed  PubMed Central  Google Scholar 

  24. Bisgaard J, Gilsaa T, Rønholm E, Toft P. (2013) Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial.Acta Anaesthesiol Scand. 57(2):178-88. Epub 2012 Aug 17.

  25. Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SÅ, Hansen B, Møller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L. (2012) Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth. 191-9. Epub 2012 Jun 17.

  26. Broch O, Cartens A, Grunewald M, et al. (2016) Non-invasive hemodynamic optimization in major abdominal surgery: a feasibility study. Minerva Anestesiologica82(11):1158-69.

  27. Cecconi M, Fasano N, Langiano N, Divella M, Costa MG, Rhodes A, Della RG (2011) Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care. 15(3):R132. https://doi.org/10.1186/cc10246 Epub 2011 May 30

    Article  PubMed  PubMed Central  Google Scholar 

  28. Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G (2012) Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 108(1):53–62. https://doi.org/10.1093/bja/aer273. Epub 2011 Aug 26

  29. Colantonio L, Claroni C, Fabrizi L, Marcelli ME, Sofra M, Giannarelli D, Garofalo A, Forastiere E (2015) A Randomized Trial of Goal Directed vs Standard Fluid Therapy in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. J Gastrointest Surg 19(4):722–729. https://doi.org/10.1007/s11605-015-2743-1

    Article  PubMed  Google Scholar 

  30. Correa-Gallego C, See Tan K, Arslan-Carlon V et al (2015) Goal-directed fluid therapy using stroke volume variation for resuscitation after low central pressure-assisted liver resection: a randomized clinical trial. J Am Coll Surg 221(2):591–601. https://doi.org/10.1016/j.jamcollsurg.2015.03.050

    Article  PubMed  PubMed Central  Google Scholar 

  31. Elgendy MA, Esmat IM, Kassim DY. (2017)Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: a prospective randomized trial.Egypt J Anaesth 33:263-69.

  32. Forget P, Lois F, de Kock M (2010) Goal-directed fluid management based on the pulse oximeterderived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg 111(4):910–914. https://doi.org/10.1213/ANE.0b013e3181eb624f

    Article  PubMed  Google Scholar 

  33. Gómez-Izquierdo JC, Trainito A, Mirzakandov D, Stein BL, Liberman S, Charlebois P, Pecorelli N, Feldman LS, Carli F, Baldini G (2017) Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial. Anesthesiology. 127(1):36–49. https://doi.org/10.1097/ALN.0000000000001663

    Article  PubMed  Google Scholar 

  34. Jammer I, Ulvik A, Erichsen C, Lødemel O, Ostgaard G (2010) Does central venous oxygen saturation-directed fluid therapy affect postoperative morbidity after colorectal surgery? A randomized assessor-blinded controlled trial. Anesthesiology. 113(5):1072–1080. https://doi.org/10.1097/ALN.0b013e3181f79337

    Article  PubMed  Google Scholar 

  35. Jhanii S, Vivian-Smith A, Lucena-Amaro S, Watson D, Hinds CJ, Pearse RM. (2010) Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Crit Care. 14(4):R151. d

  36. Joosten A, Raj Lawrence S, Colesnicenco A, Coeckelenbergh S, Vincent JL, Van der Linden P, Cannesson M, Rinehart J (2019) Personalized versus protocolized fluid management using noninvasive hemodynamic monitoring (Clearsight System) in Patients undergoing moderate-risk abdominal surgery. Anesth Analg. 129(1):e8–e12. https://doi.org/10.1213/ANE.0000000000003553

    Article  PubMed  Google Scholar 

  37. Kaufmann KB, Stein L, Bogatyreva L, Ulbrich F, Kaifi JT, Hauschke D, Loop T, Goebel U (2017) Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery - a single centre randomized parallel-arm trial. Br J Anaesth. 118(6):852–861. https://doi.org/10.1093/bja/aew447

    Article  CAS  PubMed  Google Scholar 

  38. Kumar L, Rajan S, Baalachandran R (2016) Outcomes associated with stroke volume variation versus central venous pressure guided fluid replacements during major abdominal surgery. J Anaesthesiol Clin Pharmacol. 32(2):182–186. https://doi.org/10.4103/0970-9185.182103

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Lobo SM, Salgado PF, Castillo VG et al (2020) Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med 28(10):3396–3404

    Article  Google Scholar 

  40. Lopes MR, Oliveira MA, Pereira V, Lemos I, Auler J, Michard F (2007) Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care 11(5):R100. https://doi.org/10.1186/cc6117

    Article  PubMed  PubMed Central  Google Scholar 

  41. Luo J, Xue J, Liu J, et al. (2017) Goal-directed fluid restriction during brain surgery: a prospective randomized controlled trial.Ann Intensive Care. 7(1):16.

  42. Mayer J, Boldt J, Mengistu A et al (2010) Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care 14(10):R18. https://doi.org/10.1186/cc8875

    Article  PubMed  PubMed Central  Google Scholar 

  43. Mikor A, Trásy D, Németh MF, et al. (2015) Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiol. 4;15:82.

  44. Moppett IK, Rowlands M, Mannings A, et al. (2014) LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. Br J Anaesth.444-59.

  45. Mukai A, Suehiro K, Watanabe R, Juri T, Hayashi Y, Tanaka K, Fujii T, Ohira N, Oda Y, Okutani R, Nishikawa K (2020) Impact of intraoperative goal-directed fluid therapy on major morbidity and mortality after transthoracic oesophagectomy: a multicentre, randomised controlled trial. BJA 125(6):953–961. https://doi.org/10.1016/j.bja.2020.08.060

    Article  PubMed  Google Scholar 

  46. Noblett SE, Snowden CP, Shenton BK, Horgan AF (2006) Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 93(9):1069–1076. https://doi.org/10.1002/bjs.5454

    Article  CAS  PubMed  Google Scholar 

  47. Pearse R, Dawson D, Fawcett J, et al. (2005) Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care9:687-693.

  48. Pearse R, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, Grocott MP, Ahern A, Griggs K, Scott R, Hinds C, Rowan K, OPTIMISE Study Group (2014) Effect of a perioperative, cardiac output-guided haemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 311(21):2181–2190. https://doi.org/10.1001/jama.2014.5305

    Article  CAS  PubMed  Google Scholar 

  49. Pestana D, Espinoza E, Eden A et al (2014) Perioperative goal-directed haemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth Analg 119(3):579–587. https://doi.org/10.1213/ANE.0000000000000295

    Article  PubMed  Google Scholar 

  50. Pillai P, McEleavy I, Gaughan M, Snowden C, Nesbitt I, Durkan G, Johnson M, Cosgrove J, Thorpe A (2011) A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol. 186(6):2201–2206. https://doi.org/10.1016/j.juro.2011.07.093

    Article  PubMed  Google Scholar 

  51. Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG, Reuter DA (2013) Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care 17(5):R191. https://doi.org/10.1186/cc12885

    Article  PubMed  PubMed Central  Google Scholar 

  52. Scheeren TWL, Wiesenack C, Gerlach H, Marx G (2013) Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. J Clin Monit Comput 27(3):225–233. https://doi.org/10.1007/s10877-013-9461-6

    Article  PubMed  Google Scholar 

  53. Schmid S, Blobner M, Haas B, Lucke M, Neumaier M, Anetsberger A, Jungwirth B (2019) Perioperative multi-system optimization protocol in elderly hip fracture patients: a randomized-controlled trial. Perioperative multi-system optimization protocol in elderly hip fracture patients: a randomized-controlled trial. Can J Anesth 66(12):17–1482. https://doi.org/10.1007/s12630-019-01475-9

    Article  Google Scholar 

  54. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94(6):1176–1186. https://doi.org/10.1378/chest.94.6.1176

    Article  CAS  PubMed  Google Scholar 

  55. Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 315(7113):909–912. https://doi.org/10.1136/bmj.315.7113.909

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Srinivasa S, Taylor MH, Singh PP, Yu TC, Soop M, Hill AG (2013) Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg. 100(1):66–74. https://doi.org/10.1002/bjs.8940

    Article  CAS  PubMed  Google Scholar 

  57. Stens J, Hering P, van der Hoeven CWP et al (2017) The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial. Anaesthesia. 72(9):1078–1087. https://doi.org/10.1111/anae.13834

    Article  CAS  PubMed  Google Scholar 

  58. Szturz P, Folwarczny P, Kula R, Neiser J, Ševčík P, Benes J (2019) Multi-parametric functional hemodynamic optimization improves postsurgical outcome after intermediate risk open gastrointestinal surgery: a randomized controlled trial. Minerva Anestesiol. 85(3):244–254. https://doi.org/10.23736/S0375-9393.18.12467-9

    Article  PubMed  Google Scholar 

  59. Ueno S, Tanabe G, Yamada H, Kusano C, Yoshidome S, Nuruki K, Yamamoto S, Aikou T (1998) Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Surgery 123(3):278–286. https://doi.org/10.1016/S0039-6060(98)70180-1

    Article  CAS  PubMed  Google Scholar 

  60. van Beest PA, Vos JJ, Poterman M, et al. (2014) Tissue oxygenation as a target for goal-directed therapy in high-risk surgery: a pilot study.BMC Anesthesiol. 16;14:122.

  61. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P (2002) Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 88(1):65–71. https://doi.org/10.1093/bja/88.1.65

    Article  CAS  PubMed  Google Scholar 

  62. Wakeling HG, McFall MR, Jenkins CS et al (2005) Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 95(5):634–642. https://doi.org/10.1093/bja/aei223

    Article  CAS  PubMed  Google Scholar 

  63. Weineberg L, Ianno D, Churilov L, et al. (2017) Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial.PLoS One. 7;12(9):e0183313.

  64. Weinberg L, Ianno D, Churilov L, et al. (2019) Goal directed fluid therapy for major liver resection: a multicentre randomized controlled trial. Ann Med Surg (Lond). 10;45:45-53

  65. Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E (1999) Reducing the risk of major elective surgery: Randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 318(7191):1099–1103. https://doi.org/10.1136/bmj.318.7191.1099

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Wu J, Ma Y, Wang T et al (2017) Goal-directed fluid management based on the auto-calibrated arterial pressure-derived stroke volume variation in patients undergoing supratentorial neoplasms surgery.Int. J Clin Exp Med 10(2):3106–3114

    CAS  Google Scholar 

  67. Zhang J, Chen CQ, Lei XZ, Feng ZY, Zhu SM (2013) Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study. Clinics 68(7):1065–1070. https://doi.org/10.6061/clinics/2013(07)27

    Article  PubMed  PubMed Central  Google Scholar 

  68. Zheng H, Guo H, Ye JR, Chen L, Ma HP (2013) Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. World J Surg 37(12):2820–2829. https://doi.org/10.1007/s00268-013-2203-6

    Article  PubMed  Google Scholar 

  69. Sander M, Emmanuel Schneck E, Habicher M. Management of perioperative volume therapy – monitoring and pitfalls. (2020) Korean J Anesthesiol 73(2):103-113. https://doi.org/10.4097/kja.20022.

  70. Thacker JK, Mountford WK, Ernst FR, Krukas MR, Mythen MM (2016) Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample us surgical populations. Ann Surg 263(3):502–510. https://doi.org/10.1097/SLA.0000000000001402

    Article  PubMed  Google Scholar 

  71. Brienza N, Giglio MT, Marucci M, Fiore T (2009) Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med. 37(6):2079–2090. https://doi.org/10.1097/CCM.0b013e3181a00a43

    Article  PubMed  Google Scholar 

  72. Brienza N, Biancofiore G, Cavaliere F, Corcione A, de Gasperi A, de Rosa RC, Fumagalli R, Giglio MT, Locatelli A, Lorini FL, Romagnoli S, Scolletta S, Tritapepe L (2019) Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients.Minerva. Anestesiol. 85(12):1315–1333. https://doi.org/10.23736/S0375-9393.19.13584-5

    Article  Google Scholar 

  73. Fellahi JL, Futier E, Camille Vaisse C et al (2021) Perioperative hemodynamic optimization: from guidelines to implementation—an experts’ opinion paper. Ann. Intensive Care 11(1):58. https://doi.org/10.1186/s13613-021-00845-1

    Article  PubMed  PubMed Central  Google Scholar 

  74. Kaufmann T, Saugel B, Scheeren TWL. (2019) Perioperative goal-directed therapy - What is the evidence? Best Pract Res Clin Anaesthesiol. 179-187.

  75. Makaryus R, Miller TE, Gan TJ (2018) Current concepts of fluid management in enhanced recovery pathways. Br J Anaesth. 120(2):376–383. https://doi.org/10.1016/j.bja.2017.10.011

    Article  CAS  PubMed  Google Scholar 

  76. Fugate JE.(2015) Complications of neurosurgery. Continuum (Minneap Minn). 21(5 Neurocritical Care):1425-44.

  77. Rollins KE, Lobo DN (2016) Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials. Ann Surg. 263(3):465–476. https://doi.org/10.1097/SLA.0000000000001366

    Article  PubMed  Google Scholar 

  78. Sun Y, Chai F, Pan C, Romeiser J, Gan T (2017) Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. Critical Care 21(1):141. https://doi.org/10.1186/s13054-017-1728-8

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Anesthesia and Intensive Care Unit, Policlinico di Bari, Piazza G. Cesare, 11, 70124, Bari, Italy

    Mariateresa Giglio

  2. UO Anestesia e Rianimazione Trapianti, Università degli Studi, Pisa, Italy

    Giandomenico Biancofiore

  3. Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy

    Alberto Corriero

  4. Anesthesia, Intensive Care Unit and Pain Unit, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy

    Stefano Romagnoli

  5. Dipartimento di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy

    Luigi Tritapepe

  6. Direttore UOC Anestesia e Rianimazione, AO San Camillo Forlanini-Roma, Rome, Italy

    Nicola Brienza & Filomena Puntillo

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Contributions

NB and GB are substantial contributors to the conception of the study. MG and SR retrieved all articles. FP and LT examined at first each title and abstract to exclude clearly irrelevant studies and to identify potentially relevant articles. AC and NB determined eligibility of full-text articles retrieved. GB and SR collected the data while the data were input into statistical software and rechecked by different investigators (MG, NB). MG, FP, and GB were major contributors in writing the manuscript. All authors read and approved the final manuscript.

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Additional file 1: Supplementary file 1.

The search strategies used for the MEDLINE, The Cochrane Library and EMBASE databases.

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Giglio, M., Biancofiore, G., Corriero, A. et al. Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis. J Anesth Analg Crit Care 1, 26 (2021). https://doi.org/10.1186/s44158-021-00026-3

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Keywords

  • Postoperative complications
  • Fluid therapy
  • Cardiac output
  • Meta-analysis

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