Fluid resuscitation is the standard therapy for patients with sepsis, yet exactly which IV fluid types deliver the best mortality outcomes and why aren't well defined.

To analyze the existing research, researchers conducted an extensive systematic review and network meta-analysis of randomized controlled trials published through August 2013. Studies eligible for inclusion involved adult patients with sepsis or septic shock who underwent fluid resuscitation and comparison of one type of fluid therapy with one or more different types.

The researchers classified the fluid types into two broad categories: crystalloids and colloids. Crystalloids were described as either "balanced" or "unbalanced," depending on their mineral and anion composition. Balanced crystalloids, such as Ringer's lactate, contain an anion as a buffering agent and lower amounts of chloride to better approximate actual plasma; in contrast, un-balanced crystalloids, such as normal saline, contain higher levels of chloride and lower pH levels. Colloids included both natural and artificial substances (albumin, gelatin, and low- and high-molecular-weight hydroxyethyl starch) that increase plasma volume, although they carry risks of kidney damage and, in the case of albumin, hazards related to blood-product administration. A confidence assessment of each fluid type was made according to the "risk of bias, incoherence, imprecision, inconsistency, indirectness, and publication bias" in the studies.

Fourteen studies, with a total of 18,916 subjects, were included in the meta-analysis. In the 10 trials with direct comparisons between starches and crystalloids, higher mortality was noted with starches (high confidence). Data from four trials collectively showed lower mortality rates with the use of albumin, in comparison with crystalloids or starch (moderate confidence).

Additional analysis also found that albumin use was associated with lower mortality rates than saline and low-molecular-weight starch (moderate and low confidence, respectively). Balanced crystalloids also conferred an advantage over saline (low confidence) and both types of starches (moderate confidence).

The study's findings suggest that balanced crystalloids and albumin may be superior for fluid resuscitation therapy in septic patients. Further studies are needed to determine which of the solutions' individual properties, such as pH or chloride levels, affect fluid resuscitation efforts.-AK

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