Both "liberal" and "goal-directed" (GD)
therapy use a large amount of perioperative fluid, but they appear to have very different effects on perioperative outcomes. We sought to determine whether one fluid management strategy was superior to the others.
METHODS: We selected randomized controlled trials (RCTs) on the use of GD or restrictive versus liberal
fluid therapy (LVR) in major adult surgery from MEDLINE, EMBASE, PubMed (1951 to April 2011), and Cochrane controlled trials register without language restrictions. Indirect comparison between the GD and LVR strata was performed.
RESULTS: A total of 3861 patients from 23 GD RCTs (median sample size = 90, interquartile range [IQR] 57 to 109) and 1160 patients from 12 LVR RCTs (median sample size = 80, IQR36 to 151) were considered. Both liberal and GD
therapy used more fluid compared to their respective comparative arm, but their effects on outcomes were very different. Patients in the liberal group of the LVR stratum had a higher risk of
pneumonia (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.5),
pulmonary edema (RR 3.8, 95% CI 1.1 to 13), and a longer
hospital stay than those in the restrictive group (mean difference [MD] 2 days, 95% CI 0.5 to 3.4). Using GD
therapy also resulted in a lower risk of
pneumonia (RR 0.7, 95% CI 0.6 to 0.9) and renal complications (0.7, 95% CI 0.5 to 0.9), and a shorter length of
hospital stay (MD 2 days, 95% CI 1 to 3) compared to not using GD
therapy. Liberal
fluid therapy was associated with an increased length of
hospital stay (4 days, 95% CI 3.4 to 4.4), time to first bowel movement (2 days, 95% CI 1.3 to 2.3), and risk of
pneumonia (RR ratio 3, 95% CI 1.8 to 4.8) compared to GD
therapy.
CONCLUSION: Perioperative outcomes favored a GD
therapy rather than liberal
fluid therapy without hemodynamic goals. Whether GD
therapy is superior to a restrictive fluid strategy remains uncertain.