Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis
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It is unknown whether a conservative approach to fluid administration or deresuscitation (active removal of fluid using diuretics or renal replacement therapy) is beneficial following haemodynamic stabilisation of critically ill patients.
To evaluate the efficacy and safety of conservative or deresuscitative fluid strategies in adults and children with acute respiratory distress syndrome (ARDS), sepsis or systemic inflammatory response syndrome (SIRS) in the post-resuscitation phase of critical illness.
We searched Medline, EMBASE and the Cochrane central register of controlled trials from 1980 to June 2016, and manually reviewed relevant conference proceedings from 2009 to the present. Two reviewers independently assessed search results for inclusion and undertook data extraction and quality appraisal. We included randomised trials comparing fluid regimens with differing fluid balances between groups, and observational studies investigating the relationship between fluid balance and clinical outcomes.
Forty-nine studies met the inclusion criteria. Marked clinical heterogeneity was evident. In a meta-analysis of 11 randomised trials (2051 patients) using a random-effects model, we found no significant difference in mortality with conservative or deresuscitative strategies compared with a liberal strategy or usual care [pooled risk ratio (RR) 0.92, 95 % confidence interval (CI) 0.82–1.02, I 2 = 0 %]. A conservative or deresuscitative strategy resulted in increased ventilator-free days (mean difference 1.82 days, 95 % CI 0.53–3.10, I 2 = 9 %) and reduced length of ICU stay (mean difference −1.88 days, 95 % CI −0.12 to −3.64, I 2 = 75 %) compared with a liberal strategy or standard care.
In adults and children with ARDS, sepsis or SIRS, a conservative or deresuscitative fluid strategy results in an increased number of ventilator-free days and a decreased length of ICU stay compared with a liberal strategy or standard care. The effect on mortality remains uncertain. Large randomised trials are needed to determine optimal fluid strategies in critical illness.
KeywordsFluid therapy Diuretics Water–electrolyte balance Critical Illness Sepsis Respiratory distress syndrome, adult Systemic inflammatory response syndrome
The authors wish to acknowledge the invaluable assistance of information specialists Ms. Viola Machel, Ms. Melanie Anderson, and Ms. Marina Englesakis (University Health Network) and Richard Fallis (Queen’s University of Belfast) in the development and implementation of the search strategies; Ms. Adrienne Ruddock for assistance with image preparation, and Dr. Hong Guo Parke, Dr. Edmund Skibowski, Ms. Ya-Chi Del Sorbo and Ms. Chuer Zhang for translation of non-English manuscripts. This work was supported by a doctoral fellowship award to JS by the Northern Ireland Health and Social Care research and development division.
Compliance with the ethical standards
Conflicts of interest
On behalf of all authors, the corresponding author states that there are no conflicts of interest.
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