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Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis.
Rochwerg, Bram MD; Alhazzani, Waleed MD; Sindi, Anees MD; Heels-Ansdell, Diane MSc; Thabane, Lehana PhD; Fox-Robichaud, Alison MD; Mbuagbaw, Lawrence MSc; Szczeklik, Wojciech MD; Alshamsi, Fayez MD; Altayyar, Sultan MD; Ip, Wang-Chun MD; Li, Guowei MSc; Wang, Michael MD; Wludarczyk, Anna MD; Zhou, Qi PhD; Guyatt, Gordon H. MD; Cook, Deborah J. MD; Jaeschke, Roman MD; Annane, Djillali MD, PhD; for the Fluids in Sepsis and Septic Shock Group
[Review] Annals of Internal Medicine. 161(5):347-355, September 2, 2014.

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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.