Fluidoterapia guiada por metas versus fluidoterapia convencional em adultos submetidos a procedimentos neurocirúrgicos: revisão sistemática e metanálise
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2024-02-22
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Universidade Estadual Paulista (Unesp)
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Justificativa e Objetivos: existe uma associação entre a sobrecarga hídrica e de eletrólitos e desfechos clínicos desfavoráveis em indivíduos submetidos a procedimentos cirúrgicos. O objetivo do presente estudo foi comparar a eficácia e segurança entre diferentes modalidades de fluidoterapia durante a anestesia em pacientes adultos submetidos a procedimentos neurocirúrgicos. Métodos: foi conduzida revisão sistemática de acordo com as recomendações da Colaboração Cochrane e declaração PRISMA 2020. A estratégia de busca foi realizada nas principais bases de dados eletrônicas (PubMed, EMBASE, Cochrane CENTRAL, Lilacs, Scielo, Scopus e Web of Science) e a última pesquisa foi realizada em 27 de dezembro de 2023. Não houve restrições quanto a idioma, data, revista ou publicação. Foram incluídos somente estudos que avaliaram desfechos perioperatórios em paciente neurocirúrgicos submetidos a diferentes metodologias de reposição volêmica: fluidoterapia convencional e fluidoterapia guiada por metas. Dados de cada ensaio clínico randomizado (ECR) foram combinados utilizando o modelo de efeito randômico para cálculo do risco relativo (RR). Resultados: dos 3180 estudos identificados, 15 eram ECRs e foram incluídos na análise final. Não houve diferença estatisticamente significante entre os diferentes tipos de fluidoterapia com relação a falência renal, complicações de ferida operatória e a necessidade de reabordagem cirúrgica, assim como a quantidade de fluidos utilizados no intraoperatório, a perda sanguínea e a taxa de mortalidade. A fluidoretapia guiada por metas resultou em significante redução da incidência de complicações pulmonares (RR 0,49, IC 95%, 0,29 - 0,82, p=0,006) e complicações cardíacas (RR 0,20, IC 95%, 0,05 – 0,79, p=0,02). Notou-se, também, um menor tempo de internação hospitalar (RR -0,97, IC 95%, -1,44 – -0,49, p<0,0001) e de permanência na unidade de terapia intensiva (RR -3,88, IC 95%, -6,43 – -1,33, p=0,003) nos pacientes submetidos a fluidoterapia guiada por metas (RR 0,57, IC 95% 0,33-1,00, p=0,05). Conclusões: Esta revisão sistemática revelou que uma avaliação minuciosa de parâmetros hemodinâmicos e da resposta do paciente, aliado à sua aplicação da fluidoterapia guiada por metas, é imperativo em pacientes neurocirúrgicos. Essa abordagem tem sido associada à redução da incidência de complicações pulmonares e cardíacas, bem como a uma diminuição notável na duração da estadia hospitalar e da permanência na UTI. No entanto, há uma necessidade discernível de ensaios clínicos randomizados adicionais no futuro, focando especialmente em desfechos onde os dados não demonstraram significância estatística.
Background: there is an association between water and electrolyte overload with unfavorable clinical outcomes in individuals undergoing surgical procedures. The aim of the present study was to compare the efficacy and safety among different fluid management during anesthesia in adult patients undergoing neurosurgical procedures. Methods: a systematic review according to the Cochrane Handbook and PRISMA 2020 guidelines was conducted. The search was performed in the main electronic databases (PubMed, EMBASE, Cochrane CENTRAL, Lilacs, Scielo, Scopus and Web of Science) and the last one was carried out in December 27th, 2023. There were no language, year of publication, or publication status restriction. Only randomized clinical trials (RCTs) evaluating which evaluated the use of goal-directed fluid therapy (GDFT) in adult patients undergoing neurosurgical procedures were included. Data from each trial was combined using the random effects models to calculate the pooled relative risk (RR) and 95% confidence intervals. Results: from 3180 studies identified, 15 randomized clinical trials were included in the final analysis. There was no statistically significant difference among the different types of fluid therapy regarding renal failure, surgical wound complications, the need for re-exploration surgery, as well as the amount of fluids used intraoperatively, blood loss, and mortality rate. Goal-directed fluid therapy resulted in a significant reduction in the incidence of pulmonary complications (RR 0.49, 95% CI 0.29 - 0.82, p=0.006) and cardiac complications (RR 0.20, 95% CI 0.05 – 0.79, p=0.02). Additionally, a shorter length of hospital stay (RR -0.97, 95% CI -1.44 – -0.49, p<0.0001) and shorter duration of stay in the intensive care unit (RR -3.88, 95% CI -6.43 – -1.33, p=0.003) were noted in patients undergoing goal-directed fluid therapy (RR 0.57, 95% CI 0.33-1.00, p=0.05). Conclusions: this systematic review has revealed that a thorough examination of hemodynamic parameters and patient responsiveness, combined with the application of goal-directed fluid therapy, is imperative in neurosurgical patients. This approach has been associated with a reduced incidence of pulmonary and cardiac complications, as well as a notable decrease in hospital length of stay and ICU duration. However, there is a discernible need for additional randomized clinical trials in the future, especially focusing on outcomes where the data did not demonstrate statistical significance.
Background: there is an association between water and electrolyte overload with unfavorable clinical outcomes in individuals undergoing surgical procedures. The aim of the present study was to compare the efficacy and safety among different fluid management during anesthesia in adult patients undergoing neurosurgical procedures. Methods: a systematic review according to the Cochrane Handbook and PRISMA 2020 guidelines was conducted. The search was performed in the main electronic databases (PubMed, EMBASE, Cochrane CENTRAL, Lilacs, Scielo, Scopus and Web of Science) and the last one was carried out in December 27th, 2023. There were no language, year of publication, or publication status restriction. Only randomized clinical trials (RCTs) evaluating which evaluated the use of goal-directed fluid therapy (GDFT) in adult patients undergoing neurosurgical procedures were included. Data from each trial was combined using the random effects models to calculate the pooled relative risk (RR) and 95% confidence intervals. Results: from 3180 studies identified, 15 randomized clinical trials were included in the final analysis. There was no statistically significant difference among the different types of fluid therapy regarding renal failure, surgical wound complications, the need for re-exploration surgery, as well as the amount of fluids used intraoperatively, blood loss, and mortality rate. Goal-directed fluid therapy resulted in a significant reduction in the incidence of pulmonary complications (RR 0.49, 95% CI 0.29 - 0.82, p=0.006) and cardiac complications (RR 0.20, 95% CI 0.05 – 0.79, p=0.02). Additionally, a shorter length of hospital stay (RR -0.97, 95% CI -1.44 – -0.49, p<0.0001) and shorter duration of stay in the intensive care unit (RR -3.88, 95% CI -6.43 – -1.33, p=0.003) were noted in patients undergoing goal-directed fluid therapy (RR 0.57, 95% CI 0.33-1.00, p=0.05). Conclusions: this systematic review has revealed that a thorough examination of hemodynamic parameters and patient responsiveness, combined with the application of goal-directed fluid therapy, is imperative in neurosurgical patients. This approach has been associated with a reduced incidence of pulmonary and cardiac complications, as well as a notable decrease in hospital length of stay and ICU duration. However, there is a discernible need for additional randomized clinical trials in the future, especially focusing on outcomes where the data did not demonstrate statistical significance.
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Palavras-chave
Fluidoterapia, Adulto, Neurocirurgia, Coluna, Complicações peroperatórias, Fluid management, Goal-directed fluid therapy, Conventional fluid therapy, Adult, Neurosurgery, Spine, Perioperative complications