Hammond, Naomi E; Zampieri, Fernando G; Di Tanna, Gian Luca; Garside, Tessa; Adigbli, Derick; Cavalcanti, Alexandre B; Machado, Flavia R; ... Delaney, Anthony; + view all Hammond, Naomi E; Zampieri, Fernando G; Di Tanna, Gian Luca; Garside, Tessa; Adigbli, Derick; Cavalcanti, Alexandre B; Machado, Flavia R; Micallef, Sharon; Myburgh, John; Ramanan, Mahesh; Rice, Todd W; Semler, Matthew W; Young, Paul J; Venkatesh, Balasubramanian; Finfer, Simon; Delaney, Anthony; - view fewer (2022) Balanced Crystalloids versus Saline in Critically Ill Adults — A Systematic Review with Meta-Analysis. NEJM Evidence , 1 (2) 10.1056/evidoa2100010.

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Abstract

BACKGROUND: The comparative efficacy and safety of balanced crystalloid solutions and saline for fluid therapy in critically ill adults remain uncertain. METHODS: We systematically reviewed randomized clinical trials (RCTs) comparing the use of balanced crystalloids with saline in critically ill adults. The primary outcome was 90-day mortality after pooling data from low-risk-of-bias trials using a random-effects model. We also performed a Bayesian meta-analysis to describe the primary treatment effect in probability terms. Secondary outcomes included the incidence of acute kidney injury (AKI), new treatment with renal replacement therapy (RRT), and ventilator-free and vasopressor-free days to day 28. RESULTS: We identified 13 RCTs, comprising 35,884 participants. From six trials (34,450 participants) with a low risk of bias, the risk ratio (RR) for 90-day mortality with balanced crystalloids versus saline was 0.96 (95% confidence interval [CI], 0.91 to 1.01; I2 = 12.1%); using vague priors, the posterior probability that balanced crystalloids reduce mortality was 89.5%. The RRs of developing AKI and of being treated with RRT with balanced crystalloids versus saline were 0.96 (95% CI, 0.89 to 1.02) and 0.95 (95% CI, 0.81 to 1.11), respectively. Ventilator-free days (mean difference, 0.18 days; 95% CI, −0.45 to 0.81) and vasopressor-free days (mean difference, 0.19 days; 95% CI, −0.14 to 0.51) were similar between groups. CONCLUSIONS: The estimated effect of using balanced crystalloids versus saline in critically ill adults ranges from a 9% relative reduction to a 1% relative increase in the risk of death, with a high probability that the average effect of using balanced crystalloids is to reduce mortality.

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