Conservative versus liberal fluid resuscitation for septic patients at risk for fluid overload: A systematic review with meta-analysis

Background: Intravenous fluid resuscitation forms a crucial part of the sepsis bundle. However, the perception is that patients with comorbidities such as congestive heart failure, chronic kidney disease, and cirrhosis receive lower volumes due to concerns regarding potential for fluid overload. We review outcomes relating to resuscitation with conservative versus liberal volumes in specific patient populations. Methods: We searched MEDLINE, Embase+Embase Classic, Cochrane library, Web of Science, CINAHL Complete, and ClinicalTrials.gov for studies that compared outcomes related to different volumes of resuscitation in adult patients with sepsis, along with congestive heart failure, chronic kidney disease, cirrhosis. The primary outcome was all-cause mortality up to 30 days post-discharge. Secondary outcomes included length of stay, intubation rates and duration, and use of vasopressors. Results: A total of 37 observational studies were included. We found no statistically significant difference in allcause mortality (Odds Ratio [OR] 1.01; 95 % Confidence Interval [CI] 0.86-1.19), rates of ICU admission (Risk Ratio [RR] 0.89; 95 % CI 0.70-1.11), hospital length of stay (Mean Difference [MD] -0.01; 95 % -0.18-0.15), ICU length of stay (MD -0.06; 95 % CI -0.30-0.18), intubation rates (OR 1.00; 95 % 0.76-1.32), duration of mechanical ventilation (MD 0.01; 95 % CI -0.31-0.32) or use of vasopressors (RR 0.81; 95 % CI 0.64-1.02). Conclusions: Among patients with comorbid conditions presenting with sepsis, we found no differences in outcomes related to the volume of fluid administered. Further evidence is needed to guide decisions regarding volume of fluid to administer in these patient populations given the lack of high certainty evidence.