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High or Low Fluid Volume in Sepsis? New Meta-analysis

November 21, 2023

Written by Caitlin Nicholson

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This updated systematic review and meta-analysis showed no statistically significant difference in all-cause mortality or serious adverse events in sepsis patients given low vs higher fluid volumes.

Volume of fluid resuscitation in sepsis continues to be dealer’s choice…
This study revised a prior systematic review and meta-analysis in an attempt to identify a difference in outcomes between patients with sepsis who received low volume fluid resuscitation vs high volume. The initial study included nine trials with a low certainty of evidence and found there was clinical equipoise. This updated review includes 4 more randomized controlled trials, for a total of 13 trials, increasing the number of patients from 621 to 4,006.

The primary outcomes assessed included all-cause-mortality and serious adverse events. The investigators found that there was little to no statistically significant difference in all-cause mortality between the patients in the low volume group vs patients in the high volume group: RR 0.99 (97%CI 0.89-1.10). Similarly, there was no significant difference between the two groups with regard to serious adverse events: RR 0.95 (97%CI 0.83-1.07).

There are significant limitations, most notably, “the separation of fluid volumes between the groups was unsuccessful in five trials.”  This was understandably challenging, given that only 6 of the trials included patients in the ED, and patients had received IV fluid prior to randomization in 9 of the 13 trials. There was also a difference in definitions of sepsis and septic shock among the trials, which certainly had some bearing on the outcomes.

How will this change my practice?
This group did a great job expanding on the prior study, but the evidence still doesn’t clearly favor one approach or the other. Sepsis lends itself to the art of medicine. In the last 10 years, there has been a trend towards lower volume fluid resuscitation, especially following the results of the Fluid Expansion as Supportive Therapy trial and the ARDS Clinical Trials Network RCT. As for my personal practice, I will customize fluid volume based on physical exam, POCUS, hemodynamics, initial response to therapy, and gestalt. Hopefully, future studies will bring greater clarity.

Lower vs Higher Fluid Volumes in Adult Patients With Sepsis: An Updated Systematic Review With Meta-Analysis and Trial Sequential Analysis. Chest. 2023 Oct;164(4):892-912. doi: 10.1016/j.chest.2023.04.036. Epub 2023 May 2.

What are your thoughts?