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

Focus on fluid therapy

“…These data add to those of two recent meta-analyses of randomised trials, the results of which indicate no benefits of more vs. less fluid [8,9]. The meta-analysis of the early goal directed therapy trials showed no effect of the protocol resulting in more fluids given vs. usual care in patients with septic shock [8].…”

“…The meta-analysis of the early goal directed therapy trials showed no effect of the protocol resulting in more fluids given vs. usual care in patients with septic shock [8]. The meta-analysis on conservative vs. more liberal fluid strategies after the initial management of patients with sepsis or acute respiratory distress syndrome (ARDS) showed no significant effect on mortality, but reduced time on mechanical ventilation with conservative fluid strategies [9]. While the Surviving Sepsis Campaign guideline still promotes continued fluid therapy after initial resuscitation based on improvements in the circulatory makers [1], we may question if more fluid leads to any sustained improvement in these markers and, more importantly, in patient outcomes.…”

Definition and epidemiology of acute respiratory distress syndrome

“…Among the modifiable risk factors for ARDS, alcohol abuse emerges (48,49) and impaired immune response involving alveolar macrophages is reported (50,51). Since the observation that positive cumulative fluid balance is independently associated to higher mortality rate in patients with lung injury (52), a number of study raised in order to assess the impact of conservative fluid management or active fluid removal on mortality in ARDS patients, but results are yet not conclusive (53,54).…”

Fluid management in acute kidney injury

“…A systematic review and meta-analysis of RCTs on fluid management in sepsis and ARDS following the resuscitation phase found no statistically significant difference in use of RRT for conservative vs. liberal strategies (risk ratio 0.88; 95% CI 0.64-1.22), but the analysis was characterized by imprecision as only three trials were included [59]. The CLASSIC trial where patients with septic shock who had received the initial fluid resuscitation were randomised to either a protocol with restrictive fluid resuscitation or a protocol aiming at standard care reported fewer patients with worsening of AKI in the fluid restriction group [58].…”

“…Fluid removal strategies need to be carefully titrated and monitored for haemodynamic tolerance and continuous methods may be better tolerated. Strategies to limit or resolve fluid overload in critically ill adults or children with lung injury or sepsis have been shown to increase the number of ventilator-free days and decrease ICU length of stay; however, the effect on mortality and other long-term outcomes remains uncertain [59]. Large randomised trials considering both short-and long-term clinical outcomes are needed to determine optimal fluid strategies in critically ill patients including those with AKI.…”