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

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.

Fluid resuscitation in severe sepsis and septic shock: systematic description of fluids used in randomized trials.

INTRODUCTION:  Fluid therapy is one of the cornerstones of initial management of sepsis, but the choice of fluids used for resuscitation is controversial.  OBJECTIVES:  While trying to determine the effects of alternative fluids used in sepsis resuscitation randomized controlled trials (RCTs), we found that the precise description of those fluids was frequently not available. This report presents the result of our efforts to provide the characteristics of those fluids to both researchers and clinicians. METHODS:  We searched the following electronic databases: CENTRAL, MEDLINE, EMBASE, CINAHL, and ACPJC, and examined the reference lists of recently published meta­analyses of fluid therapies in critically ill patients. These databases were searched from inception until August 2013. The data abstraction stage included determination of fluid composition, pH, chloride concentration, and presence or absence of buffers. We relied on the original articles as well as on manufacturers' websites, contact with authors, and contact with experts in the field.  RESULTS:  Our original search yielded 7002 articles. In consecutive stages, we reduced it to 20. The types of fluids varied widely, including chloride content (110-154 mmol/l) and presence or absence of buffering substances in colloid solutions. Those characteristics were frequently not presented and rarely emphasized in the original articles.  CONCLUSIONS:  The basic characteristics of fluids used in fluid therapy trials are often not easily available, yet of increasingly recognized clinical importance. We provide the information concerning composition of fluids used in RCTs, which will be useful not only to future investigators and systematic reviewers but also to clinicians using those fluids in regular clinical practice.