Balanced Crystalloids Excel in Sepsis Fluid Resuscitation
A network meta-analysis of randomized trials found that balanced crystalloids reduced 90-day mortality more than low-molecular-weight hydroxyethyl starch and saline in patients with sepsis or septic shock and ranked highest for reducing the need for renal replacement therapy (RRT) and blood transfusion.
METHODOLOGY:
To compare various fluid resuscitation strategies, researchers conducted a network meta-analysis of 28 randomized controlled trials, which included 8770 patients with sepsis or septic shock (mean ages, 3-73 years).
The intervention group received one or more of the following fluid supplements: Balanced crystalloids, saline, isooncotic albumin, hyperoncotic albumin, low-molecular-weight hydroxyethyl starch, high-molecular-weight hydroxyethyl starch, and gelatin. The control group received placebo or standard treatment.
The study outcomes were 28-day mortality, 90-day mortality, the incidence of acute kidney injury, and the need for RRT and blood transfusions after treatment.
TAKEAWAY:
Balanced crystalloids reduced 90-day mortality compared with low-molecular-weight hydroxyethyl starch (risk ratio [RR], 0.84) and saline (RR, 0.89) and reduced the need for RRT compared with high-molecular-weight hydroxyethyl starch (RR, 0.59; 0.3-0.99).
The surface under the cumulative ranking curve analysis showed that balanced crystalloids were the best fluid to reduce 28-day mortality (71.4%), 90-day mortality (86.3%), and the need for RRT (75.5%) and blood transfusions (72.2%).
The same analysis showed that hyperoncotic albumin was the most effective in reducing the incidence of acute kidney injury (74.5%).
IN PRACTICE:
"In conclusion, BC [balanced crystalloids] demonstrates superiority over both L-HES [low-molecular-weight hydroxyethyl starch] and saline in reducing mortality in sepsis and septic shock patients, while Hyper-Alb [hyperoncotic albumin] is most effective in minimizing renal injury," the authors wrote. "However, given the current limitations, further high-quality, multicenter, large-sample RCTs [randomized controlled trials] are essential for more comprehensive analyses," they added.
SOURCE:
The study was led by Jiao Long, Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China. It was published online on June 4, 2025, in The American Journal of Emergency Medicine.
LIMITATIONS:
Studies examining the combination of balanced salt solutions with colloids or albumin were scarce. Variability in the doses of resuscitation fluid across studies may have affected the consistency of the findings. Additionally, the studies included in the analysis were published only in English, which may have led to selection biases.
DISCLOSURES:
This study was not supported by any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declared no known competing financial interests or personal relationships that could have influenced the work reported in this paper.
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