Invasive hemodynamic monitoring-guided resuscitation improves survival in shock: A systematic review and meta-analysis

Background Mortality in shock may reach 60%; hence, immediate, adequate resuscitation has a crucial role in improving outcomes. Detailed hemodynamic monitoring is desirable, but evidence on its outcome benefits is limited. Therefore, this study aimed to compare advanced hemodynamic monitoring (AHDM)-guided clinical decision-making and treatment with conventional ones in terms of outcomes in shock. Methods A systematic search was performed in three databases (PubMed, EMBASE, and Cochrane Library) until 9 November 2024. Randomised controlled trials, non-randomised and observational studies involving adult shock patients were eligible for inclusion. Main outcomes were in-hospital and 30-day mortality, and secondary outcomes included length of stay, need for and duration of organ support, and amount of fluid administered. Meta-analyses were performed using a random-effects model, with heterogeneity and risk of bias assessed. The review protocol was registered in PROSPERO (ID: CRD42024607758). Results A total of 34 studies, including seven RCTs and 636,441 shock patients, were analysed to compare AHDM with conventional monitoring. The use of any type of AHDM was associated with a significantly lower in-hospital mortality for any type of shock (OR: 0.66; 95% CI: [0.48; 0.91], p = 0.014), especially in cardiogenic shock patients, managed with pulmonary artery catheter-guided therapy (OR: 0.68, 95% CI: [0.60; 0.78], p < 0.001). This contrasts with the significantly higher odds of requiring organ support treatment, including inotropes (OR: 2.32, CI: [1.29; 4.19], p = 0.012), vasopressors (OR: 1.46, CI: [1.05; 2.04], p = 0.030), mechanical circulatory support (OR: 2.85, CI: [1.62; 5.02], p = 0.002), renal replacement therapy or mechanical ventilation, although the duration of mechanical ventilation was shorter. Heterogeneity was predictably high due to the variety of shock types and monitoring methods. Risk of bias was predominantly low in RCTs and serious in observational studies. Conclusion AHDM use is associated with a significant reduction in mortality in shock patients, with the greatest benefit observed in cardiogenic shock. The observed outcomes suggest that AHDM may facilitate qualitative changes in decision-making, consistent with precision-guided resuscitation.