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 (18 916 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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Author, Article, and Disclosure Information
From McMaster University, Hamilton, Ontario, Canada; Prince Sultan Military Medical City, Riyadh, Saudi Arabia; King Abdulaziz University, Jeddah, Saudi Arabia; Jagiellonian University Medical College, Krakow, Poland; and University of Versailles Saint-Quentin-en-Yvelines, Garches, France.
Note: Dr. Cook coauthored a fluid trial cited in this review, and Dr. Annane was principal investigator of a fluid trial cited in this review.
Acknowledgment: The authors thank Drs. J.L. Vincent (38, 42), L. Jie (40), S. Finfer (2), K. Reinhart (1), A. Chopra and J.L. Falk (38, 42), F. Schortgen (43), B. Wills and N. Haase (5, 6), L.L. McIntyre (41), and K. Maitland and J. Myburgh (3) for providing information contributing to this article. They also thank librarians Lois Cottrell and Jean Maragno for their invaluable help with structuring and performing their search.
Financial Support: By the Hamilton Chapter of the Canadian Intensive Care Foundation and the Critical Care Medicine Residency Program and Critical Care Division Alternate Funding Plan, both at McMaster University. Dr. Cook is supported by the Canadian Institutes of Health Research.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0178.
Corresponding Author: Deborah J. Cook, MD, Academic Chair, Critical Care Medicine, Room D176, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 3A5, Canada; e-mail, [email protected]
Current Author Addresses: Dr. Rochwerg: Critical Care Program Office, 2V3, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
Dr. Alhazzani: St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
Dr. Sindi: Department of Anesthesia and Critical Care, King Abdulaziz University Hospital, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia.
Ms. Heels-Ansdell: Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, HSC-2C13, Hamilton, Ontario L8S 4K1, Canada.
Dr. Thabane: St. Joseph's Healthcare Hamilton, 3rd Floor, Martha Wing, Room H-325, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
Dr. Fox-Robichaud: McMaster University, DBRI C5-106, 237 Barton Street East, Hamilton, Ontario L2L 2X2, Canada.
Mr. Mbuagbaw: Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSC 2C7, Hamilton, Ontario L8S 4K1, Canada.
Drs. Szczeklik and Włudarczyk: Jagiellonian University Medical College, Skawińska 8, 31-066, Krakow, Poland.
Dr. Alshamsi: 1461 Upper Gage Avenue, Unit 7, Hamilton, Ontario L8W 1E6, Canada.
Dr. Altayyar: 67 Caroline Street South, Apartment 4A, Hamilton, Ontario L8P 3K6, Canada.
Dr. Ip: 602-10 John Street, Dundas, Ontario L9H 6J3, Canada.
Mr. Li: 49 Emerson Street, Hamilton, Ontario L8S 2X5, Canada.
Dr. Wang: Department of Internal Medicine, Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario L8L 3Z5, Canada.
Dr. Guyatt: McMaster University Health Sciences Centre, 1280 Main Street West, Room HSC-2C12, Hamilton, Ontario L8S 4K1, Canada.
Dr. Cook: Academic Chair, Critical Care Medicine, Room D176, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 3A5, Canada.
Dr. Jaeschke: 301 James Street South, Room F506, Hamilton, Ontario L8P 3B6, Canada.
Dr. Annane: General Intensive Care Unit, Raymond Poincaré Hospital (Assistance Publique-Hôpitaux de Paris), University of Versailles Saint-Quentin-en-Yvelines, 104 Boulevard Raymond Poincaré, 92380 Garches, France.
Author Contributions: Conception and design: B. Rochwerg, W. Alhazzani, A. Sindi, L. Thabane, L. Mbuagbaw, W. Szczeklik, G.H. Guyatt, R. Jaeschke, D. Annane.
Analysis and interpretation of the data: B. Rochwerg, W. Alhazzani, A. Sindi, D. Heels-Ansdell, L. Thabane, L. Mbuagbaw, W. Szczeklik, G.H. Guyatt, D.J. Cook, R. Jaeschke, D. Annane.
Drafting of the article: B. Rochwerg, W. Alhazzani, A. Sindi, W. Szczeklik, R. Jaeschke, D. Annane.
Critical revision of the article for important intellectual content: B. Rochwerg, W. Alhazzani, A. Sindi, L. Thabane, A. Fox-Robichaud, L. Mbuagbaw, W. Szczeklik, G.H. Guyatt, D.J. Cook, R. Jaeschke, D. Annane.
Final approval of the article: B. Rochwerg, W. Alhazzani, A. Sindi, D. Heels-Ansdell, L. Thabane, A. Fox-Robichaud, L. Mbuagbaw, W. Szczeklik, G. Li, G.H. Guyatt, D.J. Cook, R. Jaeschke, D. Annane.
Provision of study materials or patients: D. Annane.
Statistical expertise: B. Rochwerg, D. Heels-Ansdell, L. Thabane, L. Mbuagbaw, Q. Zhou.
Obtaining of funding: R. Jaeschke.
Administrative, technical, or logistic support: B. Rochwerg, W. Alhazzani, A. Sindi.
Collection and assembly of data: B. Rochwerg, W. Alhazzani, A. Sindi, L. Mbuagbaw, W. Szczeklik, F. Alshamsi, W.C. Ip, G. Li, A. Włudarczyk, R. Jaeschke, D. Annane.
This article was published online first at www.annals.org on 22 July 2014.
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