Intensive Care Medicine

, Volume 43, Issue 2, pp 155–170 | Cite as

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

  • Jonathan A. Silversides
  • Emmet Major
  • Andrew J. Ferguson
  • Emma E. Mann
  • Daniel F. McAuley
  • John C. Marshall
  • Bronagh Blackwood
  • Eddy Fan
Systematic Review

Abstract

Background

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.

Purpose

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.

Methods

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.

Results

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, I2 = 0 %]. A conservative or deresuscitative strategy resulted in increased ventilator-free days (mean difference 1.82 days, 95 % CI 0.53–3.10, I2 = 9 %) and reduced length of ICU stay (mean difference −1.88 days, 95 % CI −0.12 to −3.64, I2 = 75 %) compared with a liberal strategy or standard care.

Conclusions

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.

Keywords

Fluid therapy Diuretics Water–electrolyte balance Critical Illness Sepsis Respiratory distress syndrome, adult Systemic inflammatory response syndrome 

Supplementary material

134_2016_4573_MOESM1_ESM.doc (136 kb)
Appendix 1––Characteristics and key findings of included observational studies (DOC 135 kb)
134_2016_4573_MOESM2_ESM.doc (55 kb)
Appendix 2––Assessment of study quality (modified Newcastle–Ottawa scale) for observational studies (DOC 55 kb)
134_2016_4573_MOESM3_ESM.doc (452 kb)
Appendix 3––Additional analyses: (3.1) Pre-planned sensitivity analysis excluding studies at high or moderate risk of bias with mortality as outcome. (3.2) Pre-planned subgroup analysis including only adult studies with mortality as outcome. (3.3) Post-hoc sensitivity analysis excluding studies lacking a clinically important separation in fluid balance between groups. (3.4) Univariate meta-regression analysis with RR for mortality as dependent variable and between-group difference in mean daily fluid balance as exposure. R2 = 0.11, P = 0.30. (3.5) Forest plot for renal replacement therapy use, conservative or deresuscitative fluid strategy versus standard care or liberal fluid strategy. (DOC 452 kb)
134_2016_4573_MOESM4_ESM.docx (174 kb)
Appendix 4––List of excluded studies (DOCX 174 kb)

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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Jonathan A. Silversides
    • 1
    • 2
  • Emmet Major
    • 2
  • Andrew J. Ferguson
    • 3
  • Emma E. Mann
    • 2
  • Daniel F. McAuley
    • 1
    • 4
  • John C. Marshall
    • 5
    • 6
  • Bronagh Blackwood
    • 1
  • Eddy Fan
    • 5
  1. 1.Centre for Experimental Medicine, Wellcome-Wolfson InstituteQueen’s University of BelfastBelfastUK
  2. 2.Department of Critical Care Services, Belfast Health and Social Care TrustBelfast City HospitalBelfastUK
  3. 3.Department of Intensive Care, Southern Health and Social Care TrustCraigavon Area HospitalPortadownUK
  4. 4.Regional Intensive Care Unit, Department of Critical Care Services, Belfast Health and Social Care TrustRoyal Victoria HospitalBelfastUK
  5. 5.Interdepartmental Division of Critical CareUniversity of TorontoTorontoCanada
  6. 6.Department of Critical Care MedicineSt Michael’s HospitalTorontoCanada

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