Abstract

INTRODUCTION Fluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline. METHODS We searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. RESULTS Nine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR)=0.93, 95% confidence interval (CI)=0.86, 1.01, P=0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P=0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P=0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence. CONCLUSIONS Among critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding. TRIAL REGISTRATION A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42018094857).

Abstract

Objective: The aim of this study was to compare the effectiveness of different fluids on critically ill patients who need fluid resuscitation through a systematic review and network meta-analysis (NMA). Data sources: Electronic databases were searched up to March 2018 for randomized controlled trials comparing the effectiveness of different fluids in critically ill patients. The primary outcome was mortality, and the secondary outcomes were the incident of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). A Bayesian NMA was conducted, and the quality of evidence contributing to each network estimate was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria. Results: We deemed 49 trials eligible, including 40,910 participants. The quality of evidence was rated as moderate in most comparisons. There was no significant difference among resuscitation fluids in mortality. NMA at the 9-node level showed the most effective fluid was balanced crystalloid (BC) (80.79%, the ranking of resuscitation fluid based on cumulative probability plots and surface under the cumulative ranking curves [SUCRAs]). NMA at the 10-node level showed that the most effective fluid was Plasma-Lyte (77.52%). Results of sensitivity analyses in mortality did not reveal any significant changes in the findings for primary outcomes. High-molecular-weight hetastarch (H-HES) was associated with an increased incidence of AKI when compared with gelatin (odds ratio [OR], 0.43; 95% credibility interval [CrI], 0.19-0.94), low-molecular-weight hetastarch (L-HES; OR, 0.50; 95% CrI, 0.30-0.87), BC (OR, 0.55; 95% CrI, 0.34-0.88), and normal saline (OR, 0.56; 95% CrI, 0.34-0.93). Meanwhile, H-HES was also associated with an increased risk of receiving RRT when compared with BC (OR, 0.51; 95% CrI, 0.27-0.93) and normal saline (OR, 0.52; 95% CrI, 0.24-0.96). Conclusion: BCs, especially the Plasma-Lyte, are presumably the best choice for most critically ill patients who need fluid resuscitation. Meanwhile, the use of H-HES was associated with an increased incidence of AKI and risk of receiving RRT. Registration: PROSPERO (CRD42017072728).

Abstract

Severe bleeding (SB) in patients who underwent transcatheter aortic valve implantation (TAVI) could be fatal. Although multiple independent predictors of bleeding post-TAVI have been identified, the definitions of bleeding and predictors vary across studies. This study aimed to provide summary effect estimates for predictors of SB within 30 days post-TAVI. A systematic review of studies that reported the incidence of bleeding post-TAVI with raw data for predictors of interest was performed. Data on characteristics of study, patient, and procedure were extracted. Crude risk ratios (RRs) and 95% confidence intervals were calculated using random-effect model. Fifteen predictors on 65,209 patients from 47 studies were analyzed. The median rate of SB was 11% across studies. Seven factors (3 patient related and 4 procedure related) were recognized as predictors of early SB post-TAVI. Age ≥90 years (RR 1.17; p = 0.008), female (RR 1.13; p = 0.01), and sheath diameter >19 Fr (RR 1.19; p = 0.04) were weak predictors. Chronic kidney disease (RR 1.94; p <0.001) and transapical (TA) (RR 1.82; p <0.001) were moderate predictors that were almost associated with twofold risk. Vascular complication (RR 2.97; p <0.001) and circulatory support (RR 3.39; p <0.001) were strong predictors that were nearly associated with threefold risk. In conclusion, age, gender, chronic kidney disease, TA, sheath diameter, vascular complication, and circulatory support were all predictors of early SB post-TAVI in this meta-analysis, which provided possible guidance for prevention and management of SB related to TAVI.