Introduction:
In high risk surgical patients, goal-directed haemodynamic therapy (GDHT) protocols have shown to attenuate perioperative organ injury and enhance postoperative recovery(1). 
We aimed to test the hypothesis that GDHT algorithms reduce perioperative complication rates and specifically analyzed whether the treatment effect depended on the applied hemodynamic strategy in GDHT.

Methods:
We conducted a systematic review and meta-analysis of the literature on perioperative GDHT. We used specific keywords to search the CENTRAL, MEDLINE and EMBASE databases for randomized controlled trials (RCT) dated between 01/04/2012 until 31/12/2016. Using these limitations, our search updated the dataset compiled by Grocott et al[1]. We divided the retrieved data into 3 groups based on the particular hemodynamic strategy: algorithms using dynamic preload variables (DPV) or those using fluid challenges (FC).
The results were statistically analysed in a random effects model using the Biggerstaff-Tweedie method. We report treatment effect as relative risk (RR) visualised in a Forest plot using the RevMan v5.3 software. For trial sequential analysis (TSA), we used Trial Sequential Analysis Viewer v 0.9.5.5 Beta.  

Results:
The literature search resulted in the addition of 23 RCTs (2906 patients) expanding the available dataset to 8198 participants. Reported data on the number of patients with complications were available for 4275 participants (52.1%).

We confirm the earlier reported significant reduction of number of patients with complications (RR 0.7; 95%CI 0.69-0.71; p < 0.001). A cumulative Z-statistic in the significance range confirms this result. 
GDHT algorithms using DPV showed a significant risk reduction (RR 0.66; 95%CI 0.46–0.96; p=0.0009). Risk reduction with FC GDHT algorithms was less marked (RR 0.84; 95% CI 0.69 to 1.02; p = 0.01). TSA confirms these treatment effects with a Z-statistic in respectively significant range and futile range for DPV- and FC-mediated GDHT algorithms.

Conclusions:
In our systematic review with trial sequential analysis, we show a significant beneficial treatment effect for GDHT algorithms to reduce the number of patients with complications which is most evident in DPV GDHT algorithms.



References:
1. 	Grocott M, Dushianthan A, Ma H, Mg M, Harrison D, Rowan K. Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery ( Review ). Cochrane Database Syst Rev. 2012;(Nov 14).

Perioperative complication rates vary with the applied hemodynamic strategy in goal-directed hemodynamic therapy (GDHT). A systematic review and trial sequential analysis