JOURNAL ARTICLE
REVIEW

Fluid resuscitation in sepsis: a systematic review and network meta-analysis

Bram Rochwerg, Waleed Alhazzani, Anees Sindi, Diane Heels-Ansdell, Lehana Thabane, Alison Fox-Robichaud, Lawrence Mbuagbaw, Wojciech Szczeklik, Fayez Alshamsi, Sultan Altayyar, Wang-Chun Ip, Guowei Li, Michael Wang, Anna Wludarczyk, Qi Zhou, Gordon H Guyatt, Deborah J Cook, Roman Jaeschke, Djillali Annane
Annals of Internal Medicine 2014 September 2, 161 (5): 347-55
25047428

BACKGROUND: Fluid resuscitation is the cornerstone of sepsis treatment. However, whether balanced or unbalanced crystalloids or natural or synthetic colloids confer a survival advantage is unclear.

PURPOSE: To examine the effect of different resuscitative fluids on mortality in patients with sepsis.

DATA SOURCES: MEDLINE, EMBASE, ACP Journal Club, CINAHL, HealthSTAR, the Allied and Complementary Medicine Database, and the Cochrane Central Register of Controlled Trials through March 2014.

STUDY SELECTION: Randomized trials that evaluated different resuscitative fluids in adult patients with sepsis or septic shock and death. No language restrictions were applied.

DATA EXTRACTION: Two reviewers extracted data on study characteristics, methods, and outcomes. Risk of bias for individual studies and quality of evidence were assessed.

DATA SYNTHESIS: 14 studies (18916 patients) were included with 15 direct comparisons. Network meta-analysis at the 4-node level showed higher mortality with starches than with crystalloids (high confidence) and lower mortality with albumin than with crystalloids (moderate confidence) or starches (moderate confidence). Network meta-analysis at the 6-node level showed lower mortality with albumin than with saline (moderate confidence) and low-molecular-weight starch (low confidence) and with balanced crystalloids than with saline (low confidence) and low- and high-molecular-weight starches (moderate confidence).

LIMITATIONS: These trials were heterogeneous in case mix, fluids evaluated, duration of fluid exposure, and risk of bias. Imprecise estimates for several comparisons in this network meta-analysis contribute to low confidence in most estimates of effect.

CONCLUSION: Among patients with sepsis, resuscitation with balanced crystalloids or albumin compared with other fluids seems to be associated with reduced mortality.

PRIMARY FUNDING SOURCE: The Hamilton Chapter of the Canadian Intensive Care Foundation and the Critical Care Medicine Residency Program and Critical Care Division Alternate Funding Plan at McMaster University.

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