A network meta-analysis of 32 randomized controlled trials involving 28 888 adult patients with sepsis or septic shock found that balanced crystalloid solutions were associated with better outcomes than other resuscitation fluids, including lower mortality, reduced incidence of acute kidney injury, and shorter intensive care unit and hospital stays.

The investigators compared seven fluid types: balanced crystalloids (eg, lactated Ringer's solution, PlasmaLyte), normal saline, iso-oncotic albumin, hyperoncotic albumin, low-molecular-weight hydroxyethyl starch (L-HES), high-molecular-weight hydroxyethyl starch (HES), and gelatin.

Balanced crystalloids had the highest cumulative probability of reducing mortality, with a Surface Under the Cumulative Ranking Curve (SUCRA) value of 83.1%. Compared with saline, balanced crystalloids were associated with lower mortality (odds ratio [OR], 0.9; 95% CI, 0.78-0.99).

In 15 trials reporting acute kidney injury (AKI) outcomes (n = 13 742), balanced crystalloids were associated with a lower risk of AKI compared with L-HES (OR, 0.78; 95% CI, 0.58-0.99) and HES (OR, 0.54; 95% CI, 0.34-0.84). For AKI prevention specifically, gelatin had the highest SUCRA value (80.7%), followed by balanced crystalloids (76.8%). However, gelatin was associated with poorer outcomes for mortality and hospital length of stay.

For renal replacement therapy, hyperoncotic albumin ranked highest (SUCRA, 94.1%), while balanced crystalloids ranked second (67.5%). Compared with HES, balanced crystalloids were associated with reduced use of renal replacement therapy (OR, 0.48; 95% CI, 0.30-0.72).

Balanced crystalloids were also associated with the shortest intensive care unit and total hospital stays compared with all other fluid types. HES was associated with increased risks of mortality, AKI, and renal replacement therapy, as well as prolonged hospital stays.

The findings, which incorporate large-scale recent randomized controlled trials including those enrolling more than 10 000 and 5000 participants, contradict the 2021 Sepsis Surviving Campaign Guidelines that recommend crystalloids generally as first-line therapy. The study represents the third network meta-analysis specifically examining fluid resuscitation in septic shock and includes the latest available evidence through September 2024.

The study was registered with INPLASY (ID: 2024100049). The authors reported no conflicts of interest.

Source: Frontiers in Medicine