Abstract

Goal-directed fluid therapy (GDFT) has been proposed to optimize fluid management and reduce perioperative complications in the elderly. This meta-analysis evaluates the effects of intraoperative GDFT compared to conventional fluid therapy (CFT) on postoperative outcomes in elderly surgical patients. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, randomized controlled trials (RCTs) were identified from six databases. Outcomes assessed included overall postoperative complications, 30-day mortality, hospital length of stay (LOS), and total fluid administered. Ten RCTs met the inclusion criteria, of which nine (n = 1,001) were included in the quantitative synthesis after excluding studies employing outdated protocols. GDFT significantly reduced overall complication rates (risk ratios [RR] = 0.80 [95% confidence interval (CI): 0.69–0.92]; P = 0.002), LOS (mean difference [MD] = –1.31 days [95% CI: –2.55 to –0.07]; P = 0.04), and intraoperative fluid volume (MD = –258.74 mL [95% CI: –450.86 to –66.68]; P = 0.008) compared to CFT. GDFT was also associated with lower 30-day mortality (RR = 0.42 [95% CI: 0.17–1.04]), though not statistically significant ( P = 0.06). Substantial heterogeneity was noted for LOS and fluid volume. Subgroup analysis had no impact on LOS but decreased heterogeneity in intraoperative volume, with significant fluid-sparing effects only in the gastrointestinal surgery subgroup. Sensitivity analyses further revealed that the exclusion of specific studies influenced the results for mortality and LOS. In conclusion, when compared with CFT, intraoperative GDFT offers benefits in reducing postoperative complications, hospital stay, and fluid use in elderly patients. Further research is necessary to optimize protocols and address the observed heterogeneity.

Keywords

complications, elderly, goal-directed fluid therapy, intraoperative, meta-analysis

---

Introduction

Perioperative fluid management is a crucial aspect of surgical care, especially in elderly patients. Age-related physiological changes, including reduced renal function, hormonal changes, and alterations in body composition, make elderly patients more susceptible to the risks of fluid overload and hypovolemia during surgery. ¹ Proper intraoperative fluid management is critical to improve overall surgical outcomes in this vulnerable population. One approach that has gained increasing attention in recent years is goal-directed fluid therapy (GDFT), a strategy that tailors fluid administration to individual patient needs based on real-time hemodynamic monitoring. ²

Although there is no consensus regarding the ideal “goals” for GDFT, various parameters and techniques have been evaluated. ² Nevertheless, regardless of modality, previous individual studies that compared GDFT to conventional fluid therapy (CFT) have suggested that the former reduces complication rates, mortality, and hospital length of stay (LOS). ² A couple of meta-analyses in the adult population undergoing gastrointestinal (GI) surgery confirm that morbidity was decreased in those receiving GDFT. ^3,4 However, this finding was not repeated in another meta-analysis focusing on patients undergoing thoracic surgery. ⁵ Furthermore, only one meta-analysis reports LOS reduction, ³ emphasizing the variability of available evidence. GDFT has also been evaluated in pediatric patients. The meta-analysis by Kumba et al. ⁶ found a decrease in mortality, morbidity, and LOS in children receiving GDFT.

The elderly, given their higher risk for perioperative complications, may be particularly well-suited for GDFT. However, evidence regarding its effectiveness in this population is limited. A few randomized controlled trials (RCTs) have been conducted specifically in the elderly population, but there remains uncertainty regarding its efficacy as some studies show significant benefits while others report no major differences in morbidity. ^7-10 Moreover, unlike the adult and pediatric populations, no meta-analysis has been performed in this population.

To address these knowledge gaps, this systematic review and meta-analysis aim to assess the effects of intraoperative GDFT in elderly patients undergoing surgery. By analyzing RCTs, this review will evaluate the impact of GDFT on key postoperative outcomes, including complication rates, length of hospital stay, and total intraoperative fluid volume administered. This analysis will provide a comprehensive overview of the current evidence and help inform clinical decision-making in perioperative fluid management for elderly patients.

Methods

Eligibility Criteria

Studies eligible for inclusion in the systematic review were selected based on the patient, intervention, comparison, outcome, and study design strategy framework. ¹¹ Included patients were the elderly (aged ≥ 60 years old) ^12,13 undergoing any surgical procedures. The intervention under review was GDFT with CFT as the comparator. The primary outcome measured was the occurrence of postoperative complications, defined as any adverse event identified during the post-surgical hospital stay, whereas the secondary outcomes measured included hospital LOS, 30-day mortality, and total intraoperative fluid volume administered. Lastly, only RCTs were included in this review. Studies in languages other than English or Indonesian; those without a clear description of the intraoperative fluid management protocol; those not reporting the primary outcome of interest; and those designed as observational studies, case reports, and non-randomized trials were excluded from the review.

For the meta-analysis, studies were excluded if they utilized monitoring parameters that are no longer recommended in modern GDFT protocols. Examples of such methods include, but are not limited to, fluid therapies guided by central venous pressure (CVP) and pulmonary capillary wedge pressure. ^14-16 To ensure methodological consistency and relevance to practice, these studies were included in the qualitative synthesis but excluded from the quantitative meta-analysis.

Search Strategy

The search for relevant studies was conducted in October 2024 through six electronic databases (PubMed, Proquest, Scopus, Ovid Embase, Ovid MEDLINE, and Web of Science). MeSH terms and keywords derived from the terms “elderly”, “surgery”, “goal-directed fluid therapy”, “complications”, and “randomised controlled trials” were used. Boolean operators and truncation were incorporated to optimise the scope of search results. The detailed search strategy is presented in Table A1 in the Appendix. Additional studies were identified through manual hand-searching and reference tracing from relevant articles.

Study Screening and Selection

This systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. ¹⁷ Collected articles were imported into the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and duplicates were subsequently removed. ¹⁸ Two independent authors screened the identified studies against the inclusion criteria. Initially, the studies were screened according to their title and abstracts. Those who passed the initial screening process had their full text reviewed for inclusion in the final analysis. Discrepancies in decisions were settled by consensus. The screening process is summarized in Figure 1.

Data Extraction

Two authors extracted the following data from the included studies: identifiers of each study (title, authors, year, and country), baseline population information (sample size, sex, age, type of surgery, and type of anesthesia), the specific GDFT parameters used, and relevant outcomes as previously mentioned. One author (JEFL) was tasked with data collection, and another (APM) checked the accuracy of the data extraction form afterwards.

Risk-of-Bias Assessment

Two investigators independently assessed the risk of bias of included RCTs using the revised Cochrane tool for assessing the risk of bias in randomised trials (RoB). ¹⁹ Bias risk of the following aspects were categorised as either “low”, “some concerns”, or “high”: bias due to the randomization process, deviations from intended interventions, missing outcome data, measurement of outcome, and selection of reported results. Only studies with all aspects appraised as “low” are considered to have an overall low risk of bias. Those with one or more aspects marked “high” are considered to be a high risk of bias, whereas the rest are considered to be some concerns for bias risks. ¹⁹ Any disagreements were resolved through consensus. Plots summarizing the bias risks of each study were then generated using the Risk-of-bias VISualization (robvis) tool. ²⁰

Statistical Analysis

Extracted data were exported to the Review Manager software 5.4 (Cochrane Collaboration, Oxford, United Kingdom) for quantitative analysis. Continuous outcomes were analysed using the inverse variance method to obtain the effect estimate, i.e., the mean difference (MD), and their respective 95% confidence interval (CI). For dichotomous variables, risk ratios (RRs) and 95% CIs were obtained through the Mantel–Haenszel method. For studies reporting continuous variables as medians, ranges, and/or interquartile ranges, the available data is converted into means and standard deviations using the method developed by Wan et al. ²¹

The Cochran’s Q test and Higgins’ I ² statistic were used to evaluate the included studies’ heterogeneity. ^11,22 If the P -value from the Q test was less than 0.10, heterogeneity was considered significant. The I ² statistic was used to assess the extent of heterogeneity, with values interpreted as follows: low (< 25%), moderate (25%–50%), and high (> 50%). If heterogeneity was significant ( P < 0.10 on the Q test and I² > 50%), a random-effects model was applied. Otherwise, a fixed-effects model was used. ²³ Sensitivity analyses were performed by sequentially excluding one study at a time to evaluate the consistency of the remaining results. To explore potential sources of heterogeneity, subgroup analyses were conducted based on the type of surgery. Statistical significance was defined as a two-sided P -value < 0.05, except for Cochran’s Q test.

Protocol Registration

A detailed protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) prior to the review (registration ID: CRD42024595378).

Results

Search Results

A total of 1,420 studies were obtained from the database search. After the removal of duplicates, 1,165 unique studies’ titles and abstracts were screened, and 1,050 articles were subsequently removed. All 115 remaining studies were retrieved for full text screening, and a further 105 were excluded due to reasons mentioned in Figure 1. In the end, 10 RCTs were included for quantitative synthesis. ^7-10,24-29 The selection process is illustrated in the PRISMA flow diagram (Figure 1).

Characteristics of Included Studies

The 10 RCTs comprise a total of 1,061 patients, with 528 and 533 patients in the GDFT and CFT groups, respectively. Table 1 ^7-10,24-29 provides the baseline characteristics and summary of relevant findings from the included studies. The studies encompassed various types of surgery, including proximal femoral fracture repair (4 studies), GI surgery (5 studies), and esophagectomy (1 study). A variety of hemodynamic targets were used to guide GDFT. The most commonly used parameters were stroke volume variation (SVV) and cardiac index (CI). Other parameters included pulse pressure variation (PPV), stroke volume (SV), and CVP—the latter used in only one study. Pulse contour analysis was the most frequently employed device for GDFT, used in 7 out of 10 studies. Other devices included pleth variability index sensors and central venous catheter pressure transducers. Furthermore, the clinical benefits of GDFT varied across studies, some with contradicting results. The overall risk of bias is shown in Figure 2. Five of the included studies have a low risk of bias, ^7,8,24,26,29 four studies have some concerns for bias risks, ^9,10,25,28 , and one study was considered to be a high risk of bias. ²⁷ A more detailed risk of bias assessment of individual studies is provided in Figure A1 in the Appendix.

Meta-Analysis of Outcomes

Of the 10 studies included in the systematic review, one study by Venn et al. ¹⁰ was excluded from the meta-analysis as it utilized a GDFT method based on CVP monitoring, which is no longer recommended in modern clinical practice.

Overall Complication Rates

Nine RCTs reported overall complication rates (n = 1,001). ^7-9,24-29 The pooled RR was 0.80 (95% CI: 0.69–0.92; P = 0.002), favouring GDFT as shown in Figure 3. A moderate heterogeneity among studies was noted, but it was not statistically significant (I² = 37%; P = 0.12). A sensitivity analysis was conducted by sequentially excluding each study to assess its impact on the overall effect. The pooled effect size remained consistent across all iterations, indicating the robustness of the findings.

Mortality Within 30 Days

Five RCTs reported 30-day mortality rates (n = 654). ^7,8,24,26,28 Although the pooled analysis (Figure 4) showed no statistically significant difference between GDFT and CFT (RR = 0.42 [95% CI: 0.17, 1.04]; P = 0.06), it suggests a potential benefit in those receiving GDFT. Heterogeneity among the included studies was low (I ² = 0%, P = 0.46), indicating consistency in the findings across studies. Sensitivity analysis was conducted by sequentially removing individual studies to assess their impact on the overall findings. Notably, the exclusion of the study by Göçmen et al. ²⁸ resulted in a statistically significant effect ( P < 0.05), suggesting that this study may have influenced the overall outcome.

Hospital LOS

All nine RCTs reported hospital LOS (n = 1,001). ^7-9,24-29 The pooled MD was –1.31 days (95% CI: –2.55 to –0.07; P = 0.04), favoring GDFT over CFT (Figure 5). A high degree of heterogeneity was observed (I ² = 84%; P < 0.001).

Subgroup analysis based on surgical type did not yield statistically significant differences, and no significant differences were detected between subgroups. Additionally, the level of heterogeneity remained unchanged despite subgroup stratification. Sensitivity analysis, performed by sequentially removing individual studies, did not identify a single study as the primary source of heterogeneity. However, further analysis showed that the pooled results lost statistical significance when specific studies were excluded.
^{7,9,25,26,28,29} This suggests that while the overall trend favours GDFT, the robustness of the findings is influenced by specific trials within the meta-analysis.

Total Intraoperative Fluid Volume

All nine RCTs reported total intraoperative fluid administered (n = 1,001). ^7-9,24-29 The pooled MD was –258.74 mL (95% CI: –450.86 to –66.68; P = 0.008), favouring GDFT over CFT (Figure 6). However, the analysis indicated a high degree of heterogeneity (I ² = 89%; P < 0.00001).

Subgroup analysis based on the type of surgery revealed distinct patterns. In GI surgery, GDFT was associated with significantly less intraoperative fluids (MD: –435.78, 95% CI: –564.12 to –307.44; P < 0.00001). Although lower than the overall analysis, the heterogeneity within this subgroup is still high (I² = 60%, P = 0.04). In contrast, studies on proximal femoral fracture repair showed no significant difference between groups (MD: 39.56, 95% CI: –59.64 to 138.77; P = 0.43) and exhibited no heterogeneity (I² = 0%, P = 0.98). Similarly, the single study on esophagectomy did not demonstrate a significant effect (MD: –9.00, 95% CI: –207.09 to 189.09; P = 0.93). The test for subgroup differences was significant ( P < 0.00001), suggesting that the effect of GDFT on intraoperative fluid volume varied by surgery type.

Sensitivity analysis revealed that the exclusion of Wu et al. ²⁹ from the GI surgery subgroup reduced its heterogeneity to I ² = 0%, indicating that this study contributed to the observed variability. Further, the pooled results remained statistically significant throughout the sensitivity analysis. Thus, the findings were deemed robust.

Discussion

The present systematic review examined the effects of intraoperative GDFT compared to CFT across 10 RCTs involving a total of 1,061 elderly patients. Of these, nine studies, comprising 1,001 patients, were included in the meta-analysis. The pooled results indicate that GDFT is associated with a reduction in overall postoperative complication rates, hospital LOS, and total fluid administered. However, no statistically significant difference was observed in mortality
outcomes.

The included studies varied in their choice of hemodynamic targets and monitoring devices, ranging from dynamic parameters such as SVV, CI, and PPV, to the relatively outdated CVP, which has limited predictive value for fluid responsiveness. ^2,14,15 The majority of studies employed pulse contour analysis systems, reflecting their increasing role in modern GDFT protocols due to their ability to continuously track hemodynamic parameters and related variables in a minimally invasive manner. ²

Furthermore, recent studies increasingly emphasize the use of pulse contour analysis to monitor dynamic parameters such as SVV and CI. These dynamic targets have been more consistently associated with improved clinical outcomes in elderly surgical patients when compared to traditional static measures like CVP. Static parameters have repeatedly been shown to be unreliable predictors of fluid responsiveness. ^2,30 This is because fluid responsiveness depends on the patient’s position on the Frank–Starling curve, which cannot be determined from a single pressure or volume reading. ³⁰ Their accuracy is further compromised by external factors such as intrathoracic pressure, intraabdominal pressure, ventilator settings, venous tone, and cardiac function. ^14,31 In contrast, dynamic parameters assess real-time changes during the respiratory cycle, which better predict the patient’s responsiveness to volume expansion and, thus, offer a more clinically relevant approach to guide fluid management. ³⁰

Benefits of Intraoperative GDFT in the Elderly

A key finding of this meta-analysis is the significant reduction in postoperative complications with the use of GDFT. This result aligns with previous studies conducted in both adult and pediatric populations, ^3,4,6 supporting the concept that GDFT improves patient outcomes by tailoring fluid administration based on advanced hemodynamic monitoring rather than relying on standard static parameters. The elderly population, in particular, stands to benefit greatly from GDFT due to their reduced physiological reserve and increased susceptibility to fluid imbalances, whether in the form of overload (which can precipitate pulmonary edema and heart failure) or under-resuscitation (which can lead to organ hypoperfusion). ^1,32 By utilizing dynamic indices, GDFT enables clinicians to administer fluids only when the patient is likely to be “fluid responsive”, thus minimizing the risk of fluid-related complications.

Despite the observed benefit, a moderate degree of heterogeneity (I² = 37%; P = 0.12) was noted among the included studies. However, this heterogeneity was not statistically significant, suggesting that the variability in study designs, patient populations, and protocols did not substantially affect the overall findings. Moreover, sensitivity analysis demonstrated the robustness of the pooled effect, as sequential exclusion of individual studies did not alter the direction or significance of the result.

In addition to reducing complications, GDFT was associated with a lower volume of total fluids administered, highlighting its efficiency in avoiding unnecessary fluids. This finding is consistent with a meta-analysis by Han et al. ⁵ in the adult population. Further, the decrease in fluids aligns with the principle of “fluid optimization”, suggesting that less fluid can be utilised without compromising hemodynamic stability. Avoiding excessive fluid in the elderly is paramount, as they are less capable of compensating for volume overload due to decreased renal and cardiovascular function. ^1,33

However, a high degree of heterogeneity was noted in the overall analysis (I² = 89%), suggesting variability across studies. Subgroup analysis revealed that the effect of GDFT on intraoperative fluid volume varied by surgery type. In GI surgery, GDFT was associated with significantly lower intraoperative fluid administration, though heterogeneity within this subgroup remained moderate (I² = 60%). Notably, sensitivity analysis within this subgroup indicated that excluding the study by Wu et al. ²⁹ reduced heterogeneity to I² = 0%, suggesting that their study contributed to the observed variability. Several factors may explain this. First, Wu et al. ²⁹ did not specify the tool used to measure their GDFT parameters, introducing potential inconsistencies in measurement and interpretation. Second, their study relied solely on PPV-guided fluid therapy, whereas the other included studies predominantly used SVV. Given that SVV has been shown to have superior diagnostic accuracy in predicting fluid responsiveness compared to PPV, ^34,35 this methodological difference may have contributed to the heterogeneity observed in the primary analysis.

In contrast to GI surgeries, studies focusing on proximal femoral fracture repair and esophagectomy did not show significant differences in fluid administration and exhibited low heterogeneity (I ² = 0%). Multiple reasons may explain these intergroup differences. GI surgeries typically have longer operative durations, providing a greater window for real-time hemodynamic monitoring and fluid titration, which may enhance the effectiveness of GDFT. Additionally, unlike many orthopedic procedures, such as proximal femoral fracture repair, which are often performed under spinal anesthesia, GI surgeries are usually conducted under general anesthesia. This suggests that GDFT may be more useful in titrating fluid volume in patients undergoing the latter. Importantly, sensitivity analyses showed that the overall results remained statistically significant even after sequential exclusion of individual studies, supporting the robustness of the observed effect.

Another important benefit observed was the reduction in hospital LOS by more than one day in patients receiving GDFT. This can be explained by the reduction of postoperative complications mentioned previously. Multiple studies have found that complication rates increase hospital LOS, including in the geriatric population. ^36-38 Interestingly, previous meta-analyses in adults have reported variable results regarding the effects of GDFT on LOS. ^3-5 The discrepancy may indicate that the elderly are a unique group who are at risk of prolonged postoperative LOS ³⁹ and, thus, GDFT is more effective in reducing it in this population.

Nonetheless, the high degree of heterogeneity observed (I² = 84%) suggests variability across studies. Subgroup analysis by surgical type did not resolve this issue, and sensitivity analyses failed to pinpoint a single outlier study driving the variability. This indicates that multiple factors may contribute to the observed variability, such as differences in differences in patient demographics, surgical complexity, and perioperative management strategies. Additionally, the pooled results lost statistical significance when specific studies were excluded, ^{7,9,25,26,28,29} highlighting that the robustness of our findings is influenced by individual trials within the meta-analysis.

The benefits of preventing postoperative complications expand beyond shorter hospital stays. Research has shown that elderly patients who experience postsurgical complications take longer to recover to their baseline preoperative functional status, ⁴⁰ are more dissatisfied with their care, ⁴¹ and are more prone to readmissions. ^42,43 Moreover, the cost of hospital care increases when patients experience postoperative complications. ^36,44 Overall, these evidence magnifies the benefits of GDFT through prevention of surgical complications in the elderly.

Lack of Significant Effect on Mortality

Our analysis did not detect a statistically significant difference in 30-day mortality between the GDFT and CFT groups, which is consistent with findings from previous meta-analyses in adult populations. ^3,4 Several reasons may account for this finding. First, postoperative mortality, especially in the elderly, is a complex and multifactorial outcome that may not be directly influenced by fluid management alone. Patient comorbidities, the type and urgency of surgery, baseline organ function, and the postoperative care environment can all significantly affect survival rates. ^45-47 Second, the effect of GDFT on mortality might be limited due to the relatively short follow-up periods of most studies included in the meta-analysis and, thus, may not capture longer-term survival benefits.

Interestingly, although the overall pooled estimate did not reach statistical significance, sensitivity analysis revealed that excluding the study by Göçmen et al. ²⁸ resulted in a significant difference in mortality favoring GDFT ( P < 0.05). This suggests that the findings are sensitive to individual studies and that certain trial-specific factors may have influenced the outcome. Notably, Göçmen et al. ²⁸ had a relatively small sample size (30 patients per group) compared to other studies, which may have limited its statistical power. Furthermore, it was the only study within the proximal femur fracture subgroup that employed general anesthesia rather than spinal anesthesia, potentially introducing additional variability in outcomes related to anesthesia type. These unique characteristics highlight the importance of considering study-level heterogeneity when interpreting pooled mortality outcomes.

Strengths of the Meta-Analysis

One of the key strengths of this meta-analysis is that, to the best of the authors’ knowledge, it is the first to focus specifically on the impact of intraoperative GDFT in the elderly population. Given that older adults are increasingly undergoing surgical procedures and are at heightened risk for perioperative complications, this focus fills a critical gap in the existing literature. Second, the analysis was based on a thorough and systematic search of multiple databases as recommended by the literature, ⁴⁸ which reduces the risks of publication bias. Third, the study adhered to PRISMA guidelines and used a registered protocol, adding to the transparency and reproducibility of the methodology and findings. Fourth, by exclusively including RCTs, this analysis ensures high methodological rigor. In addition, subgroup and sensitivity analyses were conducted to explore potential sources of heterogeneity and to assess the robustness of the findings. This provides a more comprehensive interpretation of the results and strengthens confidence in the observed associations. Finally, this meta-analysis excluded studies incorporating outdated methods such as CVP-guided fluid therapy, ^14,15 ensuring that the findings remain applicable to current clinical practice and contemporary hemodynamic monitoring strategies.

Limitations

The current meta-analysis has several limitations that must be acknowledged. First, only English-language studies were included, which may introduce language bias and potentially exclude relevant data published in other languages. However, a previous study has suggested that language-based restrictions have little effect on effect estimates. ⁴⁹

Second, notable heterogeneity was observed in the analyses of hospital LOS and total intraoperative fluid volume administered. Although sensitivity analyses were conducted, residual heterogeneity remained, indicating that variability across studies could not be fully explained by individual outliers. Subgroup analysis by type of surgery reduced heterogeneity in intraoperative fluid volume, but did not resolve heterogeneity in LOS, suggesting that additional unmeasured factors, such as differences in GDFT protocols, postoperative care practices, and/or discharge criteria, may contribute.

Third, the risk of bias remains a concern. While most studies had a low risk of bias, four trials were judged to have some concerns, and one was rated as high risk, which may affect the reliability of their findings.

Finally, the surgical procedures included in this meta-analysis are limited to orthopaedic surgeries, GI surgeries, and one esophagectomy, restricting the generalizability of our conclusions to broader surgical populations. Hence, extrapolating these findings to other perioperative settings should be approached with caution.

Future Directions

While the present meta-analysis highlights the potential benefits of intraoperative GDFT in reducing postoperative complications, hospital LOS, and fluid administration in the elderly population, several areas warrant further investigation. First, given the significant heterogeneity observed in our analysis, future studies should focus on optimizing the consistency of GDFT protocols. Standardized guidelines for hemodynamic targets and monitoring technologies may help reduce variability across studies and enhance comparability.

Additionally, future research should consider including studies published in other languages and address different surgical contexts to provide a more comprehensive understanding of GDFT’s impacts. Further, given the notable risk of bias in a few included studies, high-quality, large-scale RCTs are needed to strengthen the evidence base. Lastly, there is a need for research on long-term outcomes, such as postoperative functional recovery, quality of life, and readmission rates, to determine whether the short-term benefits of GDFT extend beyond the immediate postoperative period.

Conclusion

This meta-analysis demonstrates that intraoperative GDFT significantly reduces postoperative complication rates and hospital LOS in elderly patients, underscoring its potential to optimize perioperative care in this high-risk population. A reduction in total intraoperative fluid volume was also observed; however, this effect appeared to be driven primarily by studies involving GI surgery. The substantial heterogeneity in certain outcomes and the presence of bias in some included studies warrant cautious interpretation. Future high-quality trials are needed to standardize GDFT protocols and evaluate their efficacy across a broader range of surgical procedures to better inform clinical practice.

---

References

Appendix