Journal of Critical Care 29 (2014) 204–209
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A systematic review of goal directed fluid therapy: Rating of evidence for goals and monitoring methods☆ Heath Wilms, BCom, MBus, Anubhav Mittal, BHB, MBChB, PhD, FRACS, Matthew D. Haydock, Marc van den Heever, BCA, BSc, Marcello Devaud, MBChB, John A. Windsor, BSc, MBChB, MD, FRACS, FACS ⁎ The University Of Auckland, Auckland, New Zealand
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Keywords: Goals Fluid therapy Endpoint Treatment outcome Physiologic monitoring
a b s t r a c t Purpose: To review the literature on goal directed fluid therapy and evaluate the quality of evidence for each combination of goal and monitoring method. Materials and Methods: A search of major digital databases and hand search of references was conducted. All studies assessing the clinical utility of a specific fluid therapy goal or set of goals using any monitoring method were included. Data was extracted using a pre-determined pro forma and papers were evaluated using GRADE principles to assess evidence quality. Results: Eighty-one papers met the inclusion criteria, investigating 31 goals and 22 methods for monitoring fluid therapy in 13052 patients. In total there were 118 different goal/method combinations. Goals with high evidence quality were central venous lactate and stroke volume index. Goals with moderate quality evidence were sublingual microcirculation flow, the oxygen extraction ratio, cardiac index, cardiac output, and SVC collapsibility index. Conclusions: This review has highlighted the plethora of goals and methods for monitoring fluid therapy. Strikingly, there is scant high quality evidence, in particular for non-invasive G/M combinations in non-operative and nonintensive care settings. There is an urgent need to address this research gap, which will be helped by methodologies to compare utility of G/M combinations. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Almost 40 years ago, Shoemaker and colleagues published a landmark study introducing the use of physiological goals to guide fluid therapy [1]. They demonstrated that mortality could be reduced by titrating fluid therapy to pre-determined cardiorespiratory variables. This was the birth of ‘goal directed fluid therapy’ (GDFT). Since then many goals have been promoted to direct fluid therapy, both invasive and non-invasive [2]. Despite evidence demonstrating the potential benefit of GDFT in a number of disease states [3], there remains no consensus about the most effective goals for fluid therapy or the most appropriate monitoring methods. As such, GDFT remains a well-accepted concept that has not yet translated to an established standard of care. Formal evaluation of the different goal/method (G/M) combinations for GDFT has been hampered by the many different goals, the number of methods to monitor fluid therapy, the variation in study design, and the lack of comparable controls. A new approach to evaluating G/M ☆ Conflicts of Interest and Sources of Funding: the authors have had no financial support in the preparation of this manuscript. The authors have no conflicts of interest to declare. ⁎ Corresponding author. Pancreas Research Group, Surgical Research Network, Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1023 (New Zealand). Tel.: +64 9 373 7599. E-mail address: [email protected] (J.A. Windsor). 0883-9441/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcrc.2013.10.019
combinations is required so that the leading options can be formally studied to establish an evidence based standard of care for GDFT. The aim of this study was to conduct a systematic review of the literature and evaluate the quality of evidence for each G/M combination using the established GRADE methodology [4–9]. 2. Materials and methods 2.1. Literature search A systematic and comprehensive search of major reference databases (PubMed, MEDLINE, Embase, and the Cochrane Library) was undertaken with no constraint on publication date (all available entries to Feb 2013 were searched) or language using the search string: “(fluid and (goal-directed or endpoint)).mp. [mp = protocol supplementary concept, rare disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier]”. The reference lists of articles selected for inclusion as well as all relevant review articles were hand searched to ensure inclusion of all relevant studies. 2.2. Inclusion and exclusion criteria Articles were assessed for inclusion by 2 reviewers (HW and MH). All laboratory studies, observational studies and clinical trials that directly
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assessed the efficacy of a specific fluid therapy goal or set of goals in combination were identified. Randomized controlled trials (RCTs), cohort studies, case control studies, case series and historical control studies were all included. Review papers were excluded (although their reference lists were hand searched) as well as any papers that did not investigate the benefits of at least one goal for fluid therapy. The concurrent use of inotropes and vasopressors was permitted. 2.3. Data extraction Four authors (HW, MH, MV and MD) were involved in data extraction and checking the data for accuracy, which was done using a pre-defined pro forma. The data fields in the template included title, authors, date of publication, study type, setting, participant numbers, participant description, goal(s) assessed, outcomes assessed, exposure and comparison interventions, outcomes and precision of outcomes. 2.4. Data definitions The term fluid therapy included any form of intravenous fluid encompassing resuscitation, maintenance, replacement and nutrition fluid therapy. The publications were identified as human or animal studies. As each goal could be measured by several different methods, and thus there could be several G/M combinations. The methodology used to measure each goal was further categorized as invasive or noninvasive. Invasive was defined as requiring a monitoring method that involved puncture of the skin (excluding peripheral venous blood sampling), use of an indwelling catheter or an endoscope. Invasive methods were further subdivided into those that required the patient to be ventilated or those that could be used in non-ventilated patients. Non-invasive techniques were defined as those that were monitored by an entirely external methodology.
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Table 1 Rating of evidence quality and usefulness Factor
Descriptors
Study design
+1 Paper is an RCT −1 Paper is an observational study 0 Negligible limitations likely to cause biases in the body of evidence Study bias −1 Serious limitations likely to cause biases in the body of evidence −2 Very serious limitations likely to cause biases in the body of evidence +1 Paper finds benefit by targeting goal Inconsistency 0 Paper finds no benefit by targeting goal −1 Paper finds harm done by targeting goal 0 Negligible doubts about directness of measures used in body of evidence Indirectness −1 Serious doubts about directness of measures used in body of evidence −2 Very serious doubts about directness of measures used in body of evidence 0 No significant result, or significant results have clinically significant CI margins Imprecision −1 Some key significant results with questionably clinically significant CI margins −2 Significant results with no clinically significant CI margins 0 No evidence of publication bias for body of evidence (peer reviewed journal) Publication bias −1 High probability of publication bias (non peer reviewed journal) −2 Very high probability of bias (known previous non publication of results) Large effect +2 Relative risk ratio N5 or b0.20 +1 Relative Risk Ratio 2-5 or 0.5-0.2 0 = Relative Risk Ratio 0.5-2 or not presented in paper/not calculable Bias causing conservatism +1 All possible biases are likely to cause conservative estimation of effects 0 All possible biases are not likely to have this effect.
2.5. Rating the quality of evidence The body of evidence from clinical studies supporting each G/M combination was assessed using the GRADE methodology [4–9]. The GRADE method identifies several qualities that either decrease or increase the quality of a body of evidence. The factors decreasing evidence quality are poor study design (for example observational studies rather than RCTs), study bias (for example, an RCT with inadequate blinding), inconsistency of results between studies (if more than 33% of studies investigating a particular G/M combination are found to have opposing findings), indirectness of measures (if a secondary measure is used to proxy for a main study outcome), imprecision in outcome measurement and publication bias. Factors increasing evidence quality include; a large intervention effect, the presence of a dose response gradient and when confounding variables are present that would likely cause a conservative estimate of the true effect. Each clinical paper was evaluated in the same fashion as done by the GRADEPro software [10] and all factors were included excepting the presence of a dose response gradient as this was deemed not applicable to the outcomes assessed in our sample of papers. The reason for this being that the outcomes investigated are not consistently reported as continuous variables and therefore it is not possible to demonstrate a dose–response gradient. The rating rubric used is shown in Table 1. In line with the GRADE method, an evidence score of ≥1 equates to high quality evidence, 0 equates to moderate quality, -1 equates to low quality and ≤ −2 equates to very low quality.
studies is summarized in Fig. 1. A total of 81 studies were included. These included six laboratory studies (Supplementary Table 1) and 75 clinical studies comprising 13,052 patients. Of the 81 studies, 42 were obtained by hand searching reference lists. The entire sample of studies investigated 31 unique goals, and 22 methods of monitoring to give a total of 118 G/M combinations. Of these combinations, 96 were invasive and 22 non-invasive. Table 2 shows the 108 different combinations of goals and methods for monitoring fluid therapy evaluated by the 75 clinical studies. Three G/M combinations were only investigated by laboratory studies and as a result are not included in Table 2. The 6 laboratory studies investigated 10 G/M combinations between them (see Supplementary Table 1). The most frequently investigated goal for monitoring fluid therapy was stroke volume as determined by oesophageal Doppler (n = 14). 3.2. Clinical endpoints The studies covered a large number of different clinical endpoints making quantitative analysis (i.e. a meta analysis) impossible. Studies generally investigated either clinical endpoints or the accuracy of measurement of a specific G/M combination.
3.3. Rating the evidence around goals and methods of monitoring fluid therapy
3. Results 3.1. Data overview A total of 1118 articles published between 1984 and 2013 were identified by the initial literature search. The inclusion and exclusion of
Fig. 2 shows a breakdown of the evidence quality behind the 108 G/M combinations from the clinical studies. The most striking finding is that very little high quality evidence exists in any category. Table 2 further subdivides clinical studies into individual G/M combinations within the non-invasive, invasive non-ventilated and
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3.5. Invasive non-ventilated G/M combinations Only 2 goals in this category had an evidence base of high or moderate quality (central venous lactate and the oxygen extraction ratio respectively). 3.6. Invasive ventilated G/M combinations Goals in this category were investigated more often than any other, and four goals achieved high (stroke volume index) or moderate evidence quality (cardiac index, cardiac output and SVC collapsibility index). In this group, oesophageal Doppler was the most frequently investigated method but the quality of the evidence was low to very low. 4. Discussion
Fig. 1. PRISMA flow diagram.
invasive ventilated categories and states the quality of evidence for each combination as a whole.
3.4. Non-invasive G/M combinations Generally the quality of evidence investigating non-invasive G/M combinations is poor. No goal had a high quality evidence base and only a single goal (sublingual microcirculation flow) was found to have moderate quality.
Goal directed fluid therapy has a rapidly expanding literature base and is a well-accepted concept. This is the first comprehensive systematic review of the many non-invasive and invasive G/M combinations used to guide fluid therapy. It demonstrates that despite the plethora of studies there is no consensus on which approach is best, or worthy of further investigation. Direct comparison between studies is hampered by the large range of goals and methods for monitoring, inconsistent study design and the lack of a common control group. This review found that most studies have investigated invasive techniques to monitor the effects of fluid therapy (96 invasive G/M combinations compared with 22 noninvasive), even though the vast majority of patients receiving intravenous fluid therapy are neither anaesthetized nor ventilated. This is a surprising result given the widespread availability of simple and inexpensive monitoring methods, and the low level of training required for non-invasive GDFT. There is a clear need for further research to evaluate non-invasive G/M combinations to direct fluid therapy in non-operative and non-intensive care settings. The lack of a common control group around GDFT prevented a formal comparison of different G/M combinations for clinical utility. This means that it is not possible to provide clear guidance to clinicians about which goals or monitoring methods are more clinically useful or to researchers as to which should be prioritized for further study. Future research efforts may focus on developing an index of utility to allow comparison between diverse goals, settings, disease states and outcomes.
Fig. 2. Publications by category and evidence quality.
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Table 2 Clinical studies and evidence quality by goal/method combination
Non invasive
Invasive Non-ventilated
Goal
Monitoring method
Evidence quality Number of papers References
Sublingual microcirculation flow Mean arterial pressure Urine output Stroke volume Maintenance of normal fluid balance Lactate clearance Pulse oximeter-derived pleth variability index Skeletal muscle O2 saturation Lactate Cerebral O2 saturation Central venous pressure Central venous lactate Oxygen extraction ratio Oxygen delivery index Cardiac index Mixed venous O2 saturation Central venous O2 saturation
Sidestream Darkfield Imaging BP Cuff Urinary catheter Finometer finger pressure cuff Fluid balance monitoring Peripheral blood sample Pulse oximeter with PVI capability NIRS optode Peripheral blood sample NIRS optode Ultrasound Central line sampling Central line + arterial line sampling Invasive CO measurement + arterial sampling Transpulmonary dilution Pulmonary artery catheter Central line
Moderate Very low Very low Very low Very low Very low Very low Very low Very low Very low Very low High Moderate Low Low Low Very low
2 2 2 1 4 1 3 1 2 1 1 1 1 4 3 1 10
Pulmonary artery catheter + VoLEF + PiCCO Central line + pressure transducer Central line + arterial line sampling Transpulmonary dilution Transpulmonary dilution Pulmonary artery catheter Self calibrating pulse contour analysis Self calibrating pulse contour analysis Oesophageal doppler Oesophageal doppler Self calibrating pulse contour analysis Calibrated pulse contour analysis (PiCCO/LiDCO) Oesophageal doppler Calibrated pulse contour analysis (PiCCO/LiDCO) Oesophageal doppler Arterial line + monitoring equipment Oesophageal doppler Calibrated pulse contour analysis (PiCCO/LiDCO) Self calibrating pulse contour analysis Oesophageal doppler Oesophageal doppler
Very low Very low Very low Very low Very low Very low High Moderate Moderate Low Low Low Low Low Very low Very low Very low Very low Very low Very low Very low
1 7 5 4 2 3 1 3 1 13 7 2 2 2 1 4 4 2 2 1 1
Left ventricle end diastolic volume index Central venous pressure Arterio-venous CO2 pressure difference Intrathoracic blood volume Global end diastolic volume index Pulmonary wedge pressure Invasive ventilated Stroke volume index Cardiac index SVC collapsibility index Stroke volume Stroke volume variation Cardiac output Stroke volume index Stroke volume IVC diameter change Pulse pressure variation Corrected aortic flow time Cardiac index Stroke volume Cardiac output Aortic blood flow variation
In conclusion, this systematic review of the literature relating to goal directed fluid therapy has highlighted the weak evidential base for this well-accepted concept. The published research in this area is slanted towards more invasive and technology dependent methods in ventilated patients. However, the majority of patients receiving fluid therapy are ward patients who are not appropriate for invasive methods. Therefore, the research priority must be to evaluate goals and monitoring methods that are appropriate to the awake nonventilated ward patient. The development of a pragmatic utility rating index may in the future permit comparison of different G/M combinations. Most important is the need for undertaking better designed and powered studies to provide evidence in support of different goals and methods of monitoring fluid therapy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jcrc.2013.10.019. Acknowledgments The authors have had no financial assistance in preparing this review and have no conflicts of interest to declare. References [1] Shoemaker WC, Appel P, Bland R. Use of physiologic monitoring to predict outcome and to assist in clinical decisions in critically ill postoperative patients. Am J Surg 1983;146:43–50. [2] Strunden MS, Heckel K, Goetz AE, Reuter DA. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care 2011;1: 2–9.
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A systematic review of goal directed fluid therapy: Rating of evidence for goals and monitoring methods☆ Heath Wilms, BCom, MBus, Anubhav Mittal, BHB, MBChB, PhD, FRACS, Matthew D. Haydock, Marc van den Heever, BCA, BSc, Marcello Devaud, MBChB, John A. Windsor, BSc, MBChB, MD, FRACS, FACS ⁎ The University Of Auckland, Auckland, New Zealand
a r t i c l e
i n f o
Keywords: Goals Fluid therapy Endpoint Treatment outcome Physiologic monitoring
a b s t r a c t Purpose: To review the literature on goal directed fluid therapy and evaluate the quality of evidence for each combination of goal and monitoring method. Materials and Methods: A search of major digital databases and hand search of references was conducted. All studies assessing the clinical utility of a specific fluid therapy goal or set of goals using any monitoring method were included. Data was extracted using a pre-determined pro forma and papers were evaluated using GRADE principles to assess evidence quality. Results: Eighty-one papers met the inclusion criteria, investigating 31 goals and 22 methods for monitoring fluid therapy in 13052 patients. In total there were 118 different goal/method combinations. Goals with high evidence quality were central venous lactate and stroke volume index. Goals with moderate quality evidence were sublingual microcirculation flow, the oxygen extraction ratio, cardiac index, cardiac output, and SVC collapsibility index. Conclusions: This review has highlighted the plethora of goals and methods for monitoring fluid therapy. Strikingly, there is scant high quality evidence, in particular for non-invasive G/M combinations in non-operative and nonintensive care settings. There is an urgent need to address this research gap, which will be helped by methodologies to compare utility of G/M combinations. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Almost 40 years ago, Shoemaker and colleagues published a landmark study introducing the use of physiological goals to guide fluid therapy [1]. They demonstrated that mortality could be reduced by titrating fluid therapy to pre-determined cardiorespiratory variables. This was the birth of ‘goal directed fluid therapy’ (GDFT). Since then many goals have been promoted to direct fluid therapy, both invasive and non-invasive [2]. Despite evidence demonstrating the potential benefit of GDFT in a number of disease states [3], there remains no consensus about the most effective goals for fluid therapy or the most appropriate monitoring methods. As such, GDFT remains a well-accepted concept that has not yet translated to an established standard of care. Formal evaluation of the different goal/method (G/M) combinations for GDFT has been hampered by the many different goals, the number of methods to monitor fluid therapy, the variation in study design, and the lack of comparable controls. A new approach to evaluating G/M ☆ Conflicts of Interest and Sources of Funding: the authors have had no financial support in the preparation of this manuscript. The authors have no conflicts of interest to declare. ⁎ Corresponding author. Pancreas Research Group, Surgical Research Network, Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1023 (New Zealand). Tel.: +64 9 373 7599. E-mail address: [email protected] (J.A. Windsor). 0883-9441/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcrc.2013.10.019
combinations is required so that the leading options can be formally studied to establish an evidence based standard of care for GDFT. The aim of this study was to conduct a systematic review of the literature and evaluate the quality of evidence for each G/M combination using the established GRADE methodology [4–9]. 2. Materials and methods 2.1. Literature search A systematic and comprehensive search of major reference databases (PubMed, MEDLINE, Embase, and the Cochrane Library) was undertaken with no constraint on publication date (all available entries to Feb 2013 were searched) or language using the search string: “(fluid and (goal-directed or endpoint)).mp. [mp = protocol supplementary concept, rare disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier]”. The reference lists of articles selected for inclusion as well as all relevant review articles were hand searched to ensure inclusion of all relevant studies. 2.2. Inclusion and exclusion criteria Articles were assessed for inclusion by 2 reviewers (HW and MH). All laboratory studies, observational studies and clinical trials that directly
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assessed the efficacy of a specific fluid therapy goal or set of goals in combination were identified. Randomized controlled trials (RCTs), cohort studies, case control studies, case series and historical control studies were all included. Review papers were excluded (although their reference lists were hand searched) as well as any papers that did not investigate the benefits of at least one goal for fluid therapy. The concurrent use of inotropes and vasopressors was permitted. 2.3. Data extraction Four authors (HW, MH, MV and MD) were involved in data extraction and checking the data for accuracy, which was done using a pre-defined pro forma. The data fields in the template included title, authors, date of publication, study type, setting, participant numbers, participant description, goal(s) assessed, outcomes assessed, exposure and comparison interventions, outcomes and precision of outcomes. 2.4. Data definitions The term fluid therapy included any form of intravenous fluid encompassing resuscitation, maintenance, replacement and nutrition fluid therapy. The publications were identified as human or animal studies. As each goal could be measured by several different methods, and thus there could be several G/M combinations. The methodology used to measure each goal was further categorized as invasive or noninvasive. Invasive was defined as requiring a monitoring method that involved puncture of the skin (excluding peripheral venous blood sampling), use of an indwelling catheter or an endoscope. Invasive methods were further subdivided into those that required the patient to be ventilated or those that could be used in non-ventilated patients. Non-invasive techniques were defined as those that were monitored by an entirely external methodology.
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Table 1 Rating of evidence quality and usefulness Factor
Descriptors
Study design
+1 Paper is an RCT −1 Paper is an observational study 0 Negligible limitations likely to cause biases in the body of evidence Study bias −1 Serious limitations likely to cause biases in the body of evidence −2 Very serious limitations likely to cause biases in the body of evidence +1 Paper finds benefit by targeting goal Inconsistency 0 Paper finds no benefit by targeting goal −1 Paper finds harm done by targeting goal 0 Negligible doubts about directness of measures used in body of evidence Indirectness −1 Serious doubts about directness of measures used in body of evidence −2 Very serious doubts about directness of measures used in body of evidence 0 No significant result, or significant results have clinically significant CI margins Imprecision −1 Some key significant results with questionably clinically significant CI margins −2 Significant results with no clinically significant CI margins 0 No evidence of publication bias for body of evidence (peer reviewed journal) Publication bias −1 High probability of publication bias (non peer reviewed journal) −2 Very high probability of bias (known previous non publication of results) Large effect +2 Relative risk ratio N5 or b0.20 +1 Relative Risk Ratio 2-5 or 0.5-0.2 0 = Relative Risk Ratio 0.5-2 or not presented in paper/not calculable Bias causing conservatism +1 All possible biases are likely to cause conservative estimation of effects 0 All possible biases are not likely to have this effect.
2.5. Rating the quality of evidence The body of evidence from clinical studies supporting each G/M combination was assessed using the GRADE methodology [4–9]. The GRADE method identifies several qualities that either decrease or increase the quality of a body of evidence. The factors decreasing evidence quality are poor study design (for example observational studies rather than RCTs), study bias (for example, an RCT with inadequate blinding), inconsistency of results between studies (if more than 33% of studies investigating a particular G/M combination are found to have opposing findings), indirectness of measures (if a secondary measure is used to proxy for a main study outcome), imprecision in outcome measurement and publication bias. Factors increasing evidence quality include; a large intervention effect, the presence of a dose response gradient and when confounding variables are present that would likely cause a conservative estimate of the true effect. Each clinical paper was evaluated in the same fashion as done by the GRADEPro software [10] and all factors were included excepting the presence of a dose response gradient as this was deemed not applicable to the outcomes assessed in our sample of papers. The reason for this being that the outcomes investigated are not consistently reported as continuous variables and therefore it is not possible to demonstrate a dose–response gradient. The rating rubric used is shown in Table 1. In line with the GRADE method, an evidence score of ≥1 equates to high quality evidence, 0 equates to moderate quality, -1 equates to low quality and ≤ −2 equates to very low quality.
studies is summarized in Fig. 1. A total of 81 studies were included. These included six laboratory studies (Supplementary Table 1) and 75 clinical studies comprising 13,052 patients. Of the 81 studies, 42 were obtained by hand searching reference lists. The entire sample of studies investigated 31 unique goals, and 22 methods of monitoring to give a total of 118 G/M combinations. Of these combinations, 96 were invasive and 22 non-invasive. Table 2 shows the 108 different combinations of goals and methods for monitoring fluid therapy evaluated by the 75 clinical studies. Three G/M combinations were only investigated by laboratory studies and as a result are not included in Table 2. The 6 laboratory studies investigated 10 G/M combinations between them (see Supplementary Table 1). The most frequently investigated goal for monitoring fluid therapy was stroke volume as determined by oesophageal Doppler (n = 14). 3.2. Clinical endpoints The studies covered a large number of different clinical endpoints making quantitative analysis (i.e. a meta analysis) impossible. Studies generally investigated either clinical endpoints or the accuracy of measurement of a specific G/M combination.
3.3. Rating the evidence around goals and methods of monitoring fluid therapy
3. Results 3.1. Data overview A total of 1118 articles published between 1984 and 2013 were identified by the initial literature search. The inclusion and exclusion of
Fig. 2 shows a breakdown of the evidence quality behind the 108 G/M combinations from the clinical studies. The most striking finding is that very little high quality evidence exists in any category. Table 2 further subdivides clinical studies into individual G/M combinations within the non-invasive, invasive non-ventilated and
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3.5. Invasive non-ventilated G/M combinations Only 2 goals in this category had an evidence base of high or moderate quality (central venous lactate and the oxygen extraction ratio respectively). 3.6. Invasive ventilated G/M combinations Goals in this category were investigated more often than any other, and four goals achieved high (stroke volume index) or moderate evidence quality (cardiac index, cardiac output and SVC collapsibility index). In this group, oesophageal Doppler was the most frequently investigated method but the quality of the evidence was low to very low. 4. Discussion
Fig. 1. PRISMA flow diagram.
invasive ventilated categories and states the quality of evidence for each combination as a whole.
3.4. Non-invasive G/M combinations Generally the quality of evidence investigating non-invasive G/M combinations is poor. No goal had a high quality evidence base and only a single goal (sublingual microcirculation flow) was found to have moderate quality.
Goal directed fluid therapy has a rapidly expanding literature base and is a well-accepted concept. This is the first comprehensive systematic review of the many non-invasive and invasive G/M combinations used to guide fluid therapy. It demonstrates that despite the plethora of studies there is no consensus on which approach is best, or worthy of further investigation. Direct comparison between studies is hampered by the large range of goals and methods for monitoring, inconsistent study design and the lack of a common control group. This review found that most studies have investigated invasive techniques to monitor the effects of fluid therapy (96 invasive G/M combinations compared with 22 noninvasive), even though the vast majority of patients receiving intravenous fluid therapy are neither anaesthetized nor ventilated. This is a surprising result given the widespread availability of simple and inexpensive monitoring methods, and the low level of training required for non-invasive GDFT. There is a clear need for further research to evaluate non-invasive G/M combinations to direct fluid therapy in non-operative and non-intensive care settings. The lack of a common control group around GDFT prevented a formal comparison of different G/M combinations for clinical utility. This means that it is not possible to provide clear guidance to clinicians about which goals or monitoring methods are more clinically useful or to researchers as to which should be prioritized for further study. Future research efforts may focus on developing an index of utility to allow comparison between diverse goals, settings, disease states and outcomes.
Fig. 2. Publications by category and evidence quality.
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Table 2 Clinical studies and evidence quality by goal/method combination
Non invasive
Invasive Non-ventilated
Goal
Monitoring method
Evidence quality Number of papers References
Sublingual microcirculation flow Mean arterial pressure Urine output Stroke volume Maintenance of normal fluid balance Lactate clearance Pulse oximeter-derived pleth variability index Skeletal muscle O2 saturation Lactate Cerebral O2 saturation Central venous pressure Central venous lactate Oxygen extraction ratio Oxygen delivery index Cardiac index Mixed venous O2 saturation Central venous O2 saturation
Sidestream Darkfield Imaging BP Cuff Urinary catheter Finometer finger pressure cuff Fluid balance monitoring Peripheral blood sample Pulse oximeter with PVI capability NIRS optode Peripheral blood sample NIRS optode Ultrasound Central line sampling Central line + arterial line sampling Invasive CO measurement + arterial sampling Transpulmonary dilution Pulmonary artery catheter Central line
Moderate Very low Very low Very low Very low Very low Very low Very low Very low Very low Very low High Moderate Low Low Low Very low
2 2 2 1 4 1 3 1 2 1 1 1 1 4 3 1 10
Pulmonary artery catheter + VoLEF + PiCCO Central line + pressure transducer Central line + arterial line sampling Transpulmonary dilution Transpulmonary dilution Pulmonary artery catheter Self calibrating pulse contour analysis Self calibrating pulse contour analysis Oesophageal doppler Oesophageal doppler Self calibrating pulse contour analysis Calibrated pulse contour analysis (PiCCO/LiDCO) Oesophageal doppler Calibrated pulse contour analysis (PiCCO/LiDCO) Oesophageal doppler Arterial line + monitoring equipment Oesophageal doppler Calibrated pulse contour analysis (PiCCO/LiDCO) Self calibrating pulse contour analysis Oesophageal doppler Oesophageal doppler
Very low Very low Very low Very low Very low Very low High Moderate Moderate Low Low Low Low Low Very low Very low Very low Very low Very low Very low Very low
1 7 5 4 2 3 1 3 1 13 7 2 2 2 1 4 4 2 2 1 1
Left ventricle end diastolic volume index Central venous pressure Arterio-venous CO2 pressure difference Intrathoracic blood volume Global end diastolic volume index Pulmonary wedge pressure Invasive ventilated Stroke volume index Cardiac index SVC collapsibility index Stroke volume Stroke volume variation Cardiac output Stroke volume index Stroke volume IVC diameter change Pulse pressure variation Corrected aortic flow time Cardiac index Stroke volume Cardiac output Aortic blood flow variation
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