Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis

Ann Pharmacother. 2020 Jan;54(1):5-13. doi: 10.1177/1060028019866420. Epub 2019 Jul 31.

Abstract

Background: The optimal resuscitative fluid remains controversial. Objective: To assess the association between crystalloid fluid and outcomes in critically ill adults. Methods: Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, and Cochrane Central Register for Controlled Trials were searched from inception through July 2019. Cohort studies and randomized trials of critically ill adults provided predominantly nonperioperative fluid resuscitation with balanced crystalloids or 0.9% sodium chloride (saline) were included. Results: Thirteen studies (n = 30 950) were included. Balanced crystalloids demonstrated lower hospital or 28-/30-day mortality (risk ratio [RR] = 0.86; 95% CI = 0.75-0.99; I2 = 82%) overall, in observational studies (RR = 0.64; 95% CI = 0.41-0.99; I2 = 63%), and approached significance in randomized trials (RR = 0.94; 95% CI = 0.88-1.02; I2 = 0%). New acute kidney injury occurred less frequently with balanced crystalloids (RR = 0.91; 95% CI = 0.85-0.98; I2 = 0%), though progression to renal replacement therapy was similar (RR = 0.91; 95% CI = 0.79-1.04; I2 = 38%). In the sepsis cohort, odds of hospital or 28-/30-day mortality were similar, but the odds of major adverse kidney events occurring in the first 30 days were less with balanced crystalloids than saline (OR = 0.78; 95% CI = 0.66-0.91; I2 = 42%). Conclusion and Relevance: Resuscitation with balanced crystalloids demonstrated lower hospital or 28-/30-day mortality compared with saline in critically ill adults but not specifically those with sepsis. Balanced crystalloids should be provided preferentially to saline in most critically ill adult patients.

Keywords: balanced; crystalloid; fluid; lactated Ringer’s; plasma-lyte; resuscitation; saline; unbalanced.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Acute Kidney Injury / chemically induced
  • Acute Kidney Injury / therapy
  • Adult
  • Critical Illness
  • Crystalloid Solutions / administration & dosage*
  • Crystalloid Solutions / adverse effects
  • Fluid Therapy / methods*
  • Humans
  • Length of Stay
  • Observational Studies as Topic
  • Randomized Controlled Trials as Topic
  • Rehydration Solutions / administration & dosage*
  • Rehydration Solutions / adverse effects
  • Renal Replacement Therapy
  • Sepsis / mortality
  • Sepsis / therapy*
  • Sodium Chloride / administration & dosage*
  • Sodium Chloride / adverse effects

Substances

  • Crystalloid Solutions
  • Rehydration Solutions
  • Sodium Chloride