Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses

Abstract

Background Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients’ conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients. Methods Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence. Results Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74–0.95) and L-HES (OR 0.81; 95% CI 0.69–0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65–0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35–0.87). Conclusions Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients. Trial registration PROSPERO website, registration number: CRD42018115641).

Impact of Comorbidities on Beneficial Effect of Lactated Ringers vs. Saline in Sepsis Patients

“…Recently, a large, pragmatic randomized trial found that critically ill adult patients receiving balanced crystalloids had lower rates of the composite outcome of death and renal adverse events than those receiving saline ( 2 ). Our latest network meta-analysis also found a lower risk of mortality in sepsis patients treated with balanced crystalloids than in those treated with saline ( 3 ). In contrast, balanced crystalloids increased mortality in traumatic brain injury patients ( 3 ).…”

“…Our latest network meta-analysis also found a lower risk of mortality in sepsis patients treated with balanced crystalloids than in those treated with saline ( 3 ). In contrast, balanced crystalloids increased mortality in traumatic brain injury patients ( 3 ). Therefore, both the fluid types and patient condition need to be considered when choosing an optimal fluid treatment.…”

Comparison of hydroxyethylstarch (HES 130/0.4) and 5% human albumin for volume substitution in pediatric neurosurgery: A retrospective, single center study

“…hypoxic neurons, may have a beneficial effect for survival due to the ability of HES to inhibit formation of reactive oxygen species [ 8 ], whereas albumin can be deleterious for astrocyte or neuronal functions by modulating potassium ion and glutamate concentrations, which is driving epileptogenesis [ 13 – 15 ]. HA was associated with higher mortality rates in traumatic brain injury, in contrary HES showed better survival rates (sequential network meta-analyses of 26,351 patients [ 16 ]). In this context, the usage of HA for neurosurgery might also be discussed.…”

Efficacy of Xuebijing Combined with Ulinastatin in the Treatment of Traumatic Sepsis and Effects on Inflammatory Factors and Immune Function in Patients

“…The infection range can affect the whole body, and it is often the common complication after severe trauma, critical illness, infection and major surgery. It usually causes functional damage to important tissues and organs (liver, kidney, lung), and further deterioration will lead to tissue hypoperfusion and continuous hypotension, which in turn develops into severe sepsis and septic shock ( 1 – 4 ). Sepsis has a very important connection with trauma.…”