title: Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis.
abstract: BACKGROUND
  It is unknown whether a conservative approach to fluid administration or deresuscitation (active removal of fluid using diuretics or renal replacement therapy) is beneficial following haemodynamic stabilisation of critically ill patients.
  
  
  OBJECTIVE
  To evaluate the efficacy and safety of conservative or deresuscitative fluid strategies in adults and children with acute respiratory distress syndrome (ARDS), sepsis or systemic inflammatory response syndrome (SIRS) in the post-resuscitation phase of critical illness.
  
  
  METHODS
  We searched Medline, EMBASE and the Cochrane central register of controlled trials from 1980 to June 2016, and manually reviewed relevant conference proceedings from 2009 to the present. Two reviewers independently assessed search results for inclusion and undertook data extraction and quality appraisal. We included randomised trials comparing fluid regimens with differing fluid balances between groups, and observational studies investigating the relationship between fluid balance and clinical outcomes.
  
  
  RESULTS
  Forty-nine studies met the inclusion criteria. Marked clinical heterogeneity was evident. In a meta-analysis of 11 randomised trials (2051 patients) using a random-effects model, we found no significant difference in mortality with conservative or deresuscitative strategies compared with a liberal strategy or usual care [pooled risk ratio (RR) 0.92, 95 % confidence interval (CI) 0.82-1.02, I2= 0 %]. A conservative or deresuscitative strategy resulted in increased ventilator-free days (mean difference 1.82 days, 95 % CI 0.53-3.10, I2= 9 %) and reduced length of ICU stay (mean difference -1.88 days, 95 % CI -0.12 to -3.64, I2= 75 %) compared with a liberal strategy or standard care.
  
  
  CONCLUSIONS
  In adults and children with ARDS, sepsis or SIRS, a conservative or deresuscitative fluid strategy results in an increased number of ventilator-free days and a decreased length of ICU stay compared with a liberal strategy or standard care. The effect on mortality remains uncertain. Large randomised trials are needed to determine optimal fluid strategies in critical illness.
authors.affiliation: Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK. jsilversides01@qub.ac.uk.|Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK. jsilversides01@qub.ac.uk.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Silversides
authors.affiliation: Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK.
authors.forename: Emmet
authors.initials: E
authors.lastname: Major
authors.affiliation: Department of Intensive Care, Southern Health and Social Care Trust, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Ferguson
authors.affiliation: Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK.
authors.forename: Emma E
authors.initials: EE
authors.lastname: Mann
authors.affiliation: Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.|Regional Intensive Care Unit, Department of Critical Care Services, Belfast Health and Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK.
authors.forename: Daniel F
authors.initials: DF
authors.lastname: McAuley
authors.affiliation: Interdepartmental Division of Critical Care, University of Toronto, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada.|Department of Critical Care Medicine, St Michael's Hospital, 30 Bond Street, Bond 4-014, Toronto, ON, M5B 1W8, Canada.
authors.forename: John C
authors.initials: JC
authors.lastname: Marshall
authors.affiliation: Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
authors.forename: Bronagh
authors.initials: B
authors.lastname: Blackwood
authors.affiliation: Interdepartmental Division of Critical Care, University of Toronto, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada.
authors.forename: Eddy
authors.initials: E
authors.lastname: Fan
mesh_terms: D000328:Adult; D016887:Cardiopulmonary Resuscitation; D002648:Child; D000072700:Conservative Treatment / Q000379:methods*; D016638:Critical Illness / Q000628:therapy*; D004232:Diuretics / Q000627:therapeutic use; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D016032:Randomized Controlled Trials as Topic; D017582:Renal Replacement Therapy; D012121:Respiration, Artificial / Q000009:adverse effects; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D018805:Sepsis / Q000628:therapy*; D018746:Systemic Inflammatory Response Syndrome / Q000628:therapy*
chemical_list: D004232:Diuretics
keywords: Critical Illness; Diuretics; Fluid therapy; Respiratory distress syndrome, adult; Sepsis; Systemic inflammatory response syndrome; Water–electrolyte balance