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BMC Anesthesiology

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Open Access 01-12-2017 | Research article

Targeting urine output and 30-day mortality in goal-directed therapy: a systematic review with meta-analysis and meta-regression

Authors: Esther N. van der Zee, Mohamud Egal, Diederik Gommers, A. B. Johan Groeneveld

Published in: BMC Anesthesiology | Issue 1/2017

Abstract

Background

Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal outcome have been investigated frequently, whether urine output is a modifiable risk factor for mortality or simply an epiphenomenon remains unclear. We investigated whether targeting urine output, defined as achieving and maintaining urine output above a predefined threshold, in hemodynamic management protocols affects 30-day mortality in perioperative and critical care.

Methods

We performed a systematic review with a random-effects meta-analyses and meta-regression based on search strategy through MEDLINE, EMBASE and references in relevant articles. We included studies comparing conventional fluid management with goal-directed therapy and reporting whether urine output was used as target or not, and reporting 30-day mortality data in perioperative and critical care.

Results

We found 36 studies in which goal-directed therapy reduced 30-day mortality (OR 0.825; 95% CI 0.684-0.995; P = 0.045). Targeting urine output within goal-directed therapy increased 30-day mortality (OR 2.66; 95% CI 1.06-6.67; P = 0.037), but not in conventional fluid management (OR 1.77; 95% CI 0.59-5.34; P = 0.305). After adjusting for operative setting, hemodynamic monitoring device, underlying etiology, use of vasoactive medication and year of publication, we found insufficient evidence to associate targeting urine output with a change in 30-day mortality (goal-directed therapy: OR 1.17; 95% CI 0.54-2.56; P = 0.685; conventional fluid management: OR 0.74; 95% CI 0.39-1.38; P = 0.334).

Conclusions

The principal finding of this meta-analysis is that after adjusting for confounders, there is insufficient evidence to associate targeting urine output with an effect on 30-day mortality. The paucity of direct data illustrates the need for further research on whether permissive oliguria should be a key component of fluid management protocols.

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Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: Lange Medical Books/McGraw Hill, Medical Pub. Division; 2006.

Marino PL, Sutin KM. The ICU book. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2007.

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165–228.CrossRefPubMed

Kheterpal S, Tremper KK, Englesbe MJ, O'Reilly M, Shanks AM, Fetterman DM, Rosenberg AL, Swartz RD. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology. 2007;107(6):892–902.CrossRefPubMed

Hubner M, Lovely JK, Huebner M, Slettedahl SW, Jacob AK, Larson DW. Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications. J Am Coll Surg. 2013;216(6):1124–34.CrossRefPubMed

Matot I, Dery E, Bulgov Y, Cohen B, Paz J, Nesher N. Fluid management during video-assisted thoracoscopic surgery for lung resection: a randomized, controlled trial of effects on urinary output and postoperative renal function. J Thorac Cardiovasc Surg. 2013;146(2):461–6.CrossRefPubMed

Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015;62(2):158–68.CrossRefPubMed

Goren O, Matot I. Perioperative acute kidney injury. Br J Anaesth. 2015;115 Suppl 2:ii3–14.CrossRefPubMed

Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia. 2016;71 Suppl 1:40–5.CrossRefPubMed

10.

Egal M, de Geus HR, van Bommel J, Groeneveld AB. Targeting oliguria reversal in perioperative restrictive fluid management does not influence the occurrence of renal dysfunction: A systematic review and meta-analysis. Eur J Anaesthesiol. 2016;33(6):425–35.CrossRefPubMed

11.

Egal M, Erler NS, de Geus HR, van Bommel J, Groeneveld AB. Targeting oliguria reversal in goal-directed hemodynamic management does not reduce renal dysfunction in perioperative and critically ill patients: a systematic review and meta-Analysis. Anesth Analg. 2016;122(1):173–85.CrossRefPubMed

12.

Macedo E, Malhotra R, Bouchard J, Wynn SK, Mehta RL. Oliguria is an early predictor of higher mortality in critically ill patients. Kidney Int. 2011;80(7):760–7.CrossRefPubMed

13.

Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, Forfori F, Pelaia P, Rocco M, Ronco C, et al. Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care. 2013;17(1):R14.CrossRefPubMedPubMedCentral

14.

Zhang Z, Xu X, Ni H, Deng H. Urine output on ICU entry is associated with hospital mortality in unselected critically ill patients. J Nephrol. 2014;27(1):65–71.CrossRefPubMed

15.

Mizota T, Minamisawa S, Imanaka Y, Fukuda K. Oliguria without serum creatinine increase after living donor liver transplantation is associated with adverse post-operative outcomes. Acta Anaesthesiologica Scandinavica. 2016;60(7):874–81.CrossRefPubMed

16.

Chapter 8: Assessing risk of bias in included studies [http://handbook.cochrane.org/]. Accessed 22 June 2016.

17.

Viechtbauer W. Conducting meta-analysis in R with the metafor package. J Stat Soft. 2010;36(3):1–48.CrossRef

18.

R Core Team: R: A Language and Environment for Statistical Computing, 2015. In. Vienna, Austria: R Foundation for Statistical Computing; 2015.

19.

Knapp G, Hartung J. Improved tests for a random effects meta-regression with a single covariate. Stat Med. 2003;22(17):2693–710.CrossRefPubMed

20.

Sidik K, Jonkman JN. A comparison of heterogeneity variance estimators in combining results of studies. Stat Med. 2007;26(9):1964–81.CrossRefPubMed

21.

9.5.2 Identifying and measuring heterogeneity [http://handbook.cochrane.org/]. Accessed 22 June 2016.

22.

Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94.CrossRefPubMed

23.

van Houwelingen HC, Arends LR, Stijnen T. Advanced methods in meta-analysis: multivariate approach and meta-regression. Stat Med. 2002;21(4):589–624.CrossRefPubMed

24.

Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315(7113):909–12.CrossRefPubMedPubMedCentral

25.

Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90(5):1052–9.CrossRefPubMed

26.

Rhodes A, Cusack RJ, Newman PJ, Grounds RM, Bennett ED. A randomised, controlled trial of the pulmonary artery catheter in critically ill patients. Intensive Care Med. 2002;28(3):256–64.CrossRefPubMed

27.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care. 2005;9(6):R687–693.CrossRefPubMedPubMedCentral

28.

Szakmany T, Toth I, Kovacs Z, Leiner T, Mikor A, Koszegi T, Molnar Z. Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial. Intensive Care Med. 2005;31(5):656–63.CrossRefPubMed

29.

Wakeling H, McFall M, Jenkins C, Woods W, Miles W, Barclay G, Fleming S. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–42.CrossRefPubMed

30.

Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg. 2010;111:910–4.PubMed

31.

WenKui Y, Ning L, JianFeng G, WeiQin L, ShaoQiu T, Zhihui T, Tao G, JuanJuan Z, FengChan X, Hui S, et al. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Surgery. 2010;147(4):542–52.CrossRefPubMed

32.

Cecconi M, Fasano N, Langiano N, Divella M, Costa M, Rhodes A, Della Rocca G. Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care. 2011;15:R132.CrossRefPubMedPubMedCentral

33.

Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G. Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 2012;108(1):53–62.CrossRefPubMed

34.

Bartha E, Arfwedson C, Imnell A, Fernlund ME, Andersson LE, Kalman S. Randomized controlled trial of goal-directed haemodynamic treatment in patients with proximal femoral fracture. Br J Anaesth. 2013;110(4):545–53.CrossRefPubMed

35.

Bisgaard J, Gilsaa T, Ronholm E, Toft P. Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica. 2013;57(2):178–88.CrossRefPubMed

36.

Lai CW, Starkie T, Creanor S, Struthers RA, Portch D, Erasmus PD, Mellor N, Hosie KB, Sneyd JR, Minto G. Randomized controlled trial of stroke volume optimization during elective major abdominal surgery in patients stratified by aerobic fitness. Br J Anaesth. 2015;115(4):578–89.CrossRefPubMed

37.

Bishop M, Shoemaker W, Appel P, Meade P, Ordog G, Wasserberger J, Wo C, Rimle D, Kram H, Umali R. Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma. J Trauma. 1995;38:780–7.CrossRefPubMed

38.

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258.CrossRefPubMedPubMedCentral

39.

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

40.

Mayer J, Boldt J, Mengistu AM, Rohm KD, Suttner S. 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. 2010;14(1):R18.CrossRefPubMedPubMedCentral

41.

McKenny M, Conroy P, Wong A, Farren M, Gleeson N, Walsh C, O'Malley C, Dowd N. A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery. Anaesthesia. 2013;68(12):1224–31.CrossRefPubMed

42.

Zakhaleva J, Tam J, Denoya PI, Bishawi M, Bergamaschi R. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis. 2013;15(7):892–9.CrossRefPubMed

43.

Osawa EA, Rhodes A, Landoni G, Galas FR, Fukushima JT, Park CH, Almeida JP, Nakamura RE, Strabelli TM, Pileggi B, et al. Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac surgery: a randomized clinical trial and systematic review. Crit Care Med. 2016;44(4):724–33.PubMed

44.

Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176–86.CrossRefPubMed

45.

Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA. 1993;270(22):2699–707.CrossRefPubMed

46.

Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med. 1995;333(16):1025–32.CrossRefPubMed

47.

Lobo SM, Salgado PF, Castillo VG, Borim AA, Polachini CA, Palchetti JC, Brienzi SL, de Oliveira GG. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med. 2000;28(10):3396–404.CrossRefPubMed

48.

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative G. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.CrossRefPubMed

49.

Chytra I, Pradl R, Bosman R, Pelnar P, Kasal E, Zidkova A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care. 2007;11(1):R24.CrossRefPubMedPubMedCentral

50.

Donati A, Loggi S, Preiser J, Orsetti G, Munch C, Gabbanelli V, Pelaia P, Pietropaoli P. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–24.CrossRefPubMed

51.

Kapoor P, Kakani M, Chowdhury U, Choudhury M, Kiran U. Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth. 2008;11:27–34.CrossRefPubMed

52.

Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum. 2009;52(12):1935–40.CrossRefPubMed

53.

Jammer I, Ulvik A, Erichsen C, Lodemel O, Ostgaard G. Does central venous oxygen saturation-directed fluid therapy affect postoperative morbidity after colorectal surgery?: A randomized assessor-blinded controlled trial. Anesthesiology. 2010;113(5):1072–80.CrossRefPubMed

54.

Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J, group Ls. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182(6):752–61.CrossRefPubMed

55.

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

56.

Bisgaard J, Gilsaa T, Ronholm E, Toft P. Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Acta Anaesthesiologica Scandinavica. 2013;57(2):189–98.CrossRefPubMed

57.

Zheng H, Guo H, Ye JR, Chen L, Ma HP. Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. World J Surg. 2013;37(12):2820–9.CrossRefPubMed

58.

Peng K, Li J, Cheng H, Ji FH. Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Med Princ Pract. 2014;23(5):413–20.CrossRefPubMed

59.

Correa-Gallego C, Tan KS, Arslan-Carlon V, Gonen M, Denis SC, Langdon-Embry L, Grant F, Kingham TP, DeMatteo RP, Allen PJ, et al. Goal-directed fluid therapy using stroke volume variation for resuscitation after low central venous pressure-assisted liver resection: a randomized clinical trial. J Am Coll Surg. 2015;221(2):591–601.CrossRefPubMedPubMedCentral

60.

Hussien M, Refaat E, Fayed N, Yassen K, Khalil M, Mourad W. Use of transesophageal Doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: An observational study. Saudi J Anaesth. 2011;5(3):264–9.CrossRefPubMedPubMedCentral

61.

Sivayoham N, Rhodes A, Jaiganesh T, van Zyl Smit N, Elkhodhair S, Krishnanandan S. Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock: a 4-year observational cohort study. Eur J Emerg Med. 2012;19(4):235–40.CrossRefPubMed

62.

Reydellet L, Blasco V, Mercier MF, Antonini F, Nafati C, Harti-Souab K, Leone M, Albanese J. Impact of a goal-directed therapy protocol on postoperative fluid balance in patients undergoing liver transplantation: a retrospective study. Ann Fr Anesth Reanim. 2014;33(4):e47–54.CrossRefPubMed

63.

Thomson R, Meeran H, Valencia O, Al-Subaie N. Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury. J Crit Care. 2014;29(6):997–1000.CrossRefPubMed

64.

Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care. 2015;19:261.CrossRefPubMedPubMedCentral

65.

See KC, Mukhopadhyay A, Lau SC, Tan SM, Lim TK, Phua J. Shock in the first 24 h of intensive care unit stay: observational study of protocol-based fluid management. Shock. 2015;43(5):456–62.CrossRefPubMed

66.

Brienza N, Giglio MT, Marucci M, Fiore T. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med. 2009;37(6):2079–90.CrossRefPubMed

67.

Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114(3):640–51.CrossRefPubMed

68.

Zhang L, Zhu G, Han L, Fu P. Early goal-directed therapy in the management of severe sepsis or septic shock in adults: a meta-analysis of randomized controlled trials. BMC Med. 2015;13:71.CrossRefPubMedPubMedCentral

69.

Burton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. Contin Educ Anaest Crit Care Pain. 2004;4(5):144–7.CrossRef

70.

Naughton CA. Drug-induced nephrotoxicity. Am Fam Physician. 2008;78(6):743–50.PubMed

71.

Thompson SG, Higgins JP. How should meta-regression analyses be undertaken and interpreted? Statistics in medicine. 2002;21(11):1559–73.CrossRefPubMed

72.

ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1689–93.CrossRef

73.

ARISE Investigators, Anzics Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, Higgins AM, Holdgate A, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.CrossRef

74.

Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Harvey SE, Bell D, Bion JF, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–11.CrossRefPubMed

75.

McIsaac DI, Bryson GL, van Walraven C. Elective, major noncardiac surgery on the weekend: a population-based cohort study of 30-day mortality. Med Care. 2014;52(6):557–64.CrossRefPubMed

76.

Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ. 2013;346:f2424.CrossRefPubMedPubMedCentral

77.

Rydenfelt K, Engerstrom L, Walther S, Sjoberg F, Stromberg U, Samuelsson C. In-hospital vs. 30-day mortality in the critically ill - a 2-year Swedish intensive care cohort analysis. Acta Anaesthesiologica Scandinavica. 2015;59(7):846–58.CrossRefPubMed

Title: Targeting urine output and 30-day mortality in goal-directed therapy: a systematic review with meta-analysis and meta-regression
Authors: Esther N. van der Zee
Mohamud Egal
Diederik Gommers
A. B. Johan Groeneveld
Publication date: 01-12-2017
Publisher: BioMed Central
Published in: BMC Anesthesiology / Issue 1/2017
Electronic ISSN: 1471-2253
DOI: https://doi.org/10.1186/s12871-017-0316-4

At a glance: The STEP trials

Springer Medicine

Targeting urine output and 30-day mortality in goal-directed therapy: a systematic review with meta-analysis and meta-regression

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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