Review question

We aimed to investigate whether liberal fluid therapy can lead to more beneficial or harmful effects compared to conservative fluid therapy for adults and children with severe sepsis or septic shock. We mainly evaluated the different effects of these two interventions on risk of death and occurrence of adverse events.

Background

Sepsis and septic shock are complications of infection. Patients in the intensive care unit (ICU) are more likely than others to be affected by this condition. Once affected, patients experience organ dysfunction, which in some cases may lead to death. Fluid therapy is often used as an important intervention for initial treatment of sepsis in adults and children.

Results

We searched the electronic databases on 16 January 2018. We identified no adult trials that met our inclusion criteria. We included three trials involving 3402 children. We identified three 'ongoing' trials that have not yet been published. Pooled results from two trials (involving 3288 children) show that liberal fluid therapy may increase risk of in‐hospital death by 38%, and risk of death at four‐week follow‐up by 39%. This means that for every 34 children receiving fluid therapy, one more in‐hospital death will occur in the liberal fluid therapy group than in the conservative fluid therapy group. Similarly, at four‐week follow‐up, one more death will occur in the liberal fluid therapy group than in the conservative fluid therapy group for every 29 children receiving fluid therapy. One small study reported inconclusive results on risk of in‐hospital death. We are uncertain whether there is a difference in adverse events (i.e. hepatomegaly, need for ventilation, allergic reaction, and neurological sequelae) between patients receiving liberal versus conservative fluid therapy.

One trial (involving 101 children) reported that conservative fluid therapy can shorten ICU stay and the duration of ventilation. However, we have very little confidence in this finding owing to the small sample size. We found no studies investigating adults with sepsis or septic shock.

Conclusion

Low‐ to high‐quality evidence shows that liberal fluid therapy may increase the death rate for children with sepsis or septic shock. Except for this finding, we are uncertain about the effects of liberal versus conservative fluid therapy on the risk of adverse events. We are also uncertain about the effects of these two interventions for adults with sepsis or septic shock due to lack of data. Future trials focusing on adult sepsis or septic shock in other settings, with a wider range of pathogens, are expected. Once published and assessed, the three 'ongoing' studies identified may alter the conclusions of this review.