State Key Laboratory of Trauma, Burns and Combined Injury, Department 2, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China.
Shock. 2020 Jun;53(6):679-685. doi: 10.1097/SHK.0000000000001468.
The aim of this study was to assess the efficacy and safety of various resuscitation fluids in septic shock by adopting a network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing resuscitation fluids in septic shock were carried out by retrieving electronic databases. NMAs of 28-day mortality, 90-day mortality, incidence of acute kidney injury (AKI), and the need for renal replacement therapy (RRT) were conducted using the STATA 15.0 software. Probability-based ranking and surface under cumulative ranking (SUCRA) were performed to identify the optimal resuscitation fluid. Inconsistencies were evaluated by node-splitting analysis and a loop-specific approach. Furthermore, publication bias was analyzed by funnel plots. A total of 13 RCTs were enrolled in the analysis. The NMA results revealed that no significant differences were detected in the outcomes of 28-day mortality and 90-day mortality among various resuscitation fluids. The SUCRAs (the first indicates the best) of 28-day mortality showed that the hypertonic sodium chloride/hydroxyethyl starch 40 solution ranked the highest (93.8%), followed by the balanced solution (BS) (69.6%), and albumin (61.9%). On the other hand, the SUCRAs of 90-day mortality revealed that gelatin (GEL) ranked the highest (75.1%), followed by BS (55.1%), and NS (52.4%). The NMA results of AKI demonstrated that high-molecular-weight hydroxyethyl starch (H-HES) was associated with increased risk of AKI in comparison with GEL, BS, and L-HES. The SUCRAs of AKI showed that GEL ranked the highest (74.4%), followed by NS (64.9%), and BS (58.3%). In addition, the NMA results of RRT revealed that H-HES was associated with an increased need for RRT in comparison with BS and NS, and L-HES was associated with increased need of RRT in comparison with BS. The SUCRAs of RRT revealed that NS ranked the highest (91.6%), followed by BS (74.4%) and L-HES (36.1%). No significant inconsistencies were shown by the node-splitting analysis and no publication bias was demonstrated in the funnel plots. In conclusion, BS was determined as the preferred resuscitation fluid for septic shock. Moreover, the use of GEL requires further evaluation. H-HES was associated with a significant risk of AKI and RRT, whereas L-HES with an increased need for RRT compared with BS. Thus, both resuscitation fluids should be avoided for septic shock.
本研究旨在通过网络荟萃分析（NMA）评估各种复苏液在感染性休克中的疗效和安全性。通过检索电子数据库，开展了比较感染性休克复苏液的随机对照试验（RCT）。采用 STATA 15.0 软件对 28 天死亡率、90 天死亡率、急性肾损伤（AKI）发生率和肾脏替代治疗（RRT）需求进行 NMA。采用概率排序和累积排序曲面（SUCRA）确定最佳复苏液。通过节点分裂分析和环路特异性方法评估不一致性。此外，还通过漏斗图分析了发表偏倚。共纳入 13 项 RCT 进行分析。NMA 结果显示，各种复苏液在 28 天死亡率和 90 天死亡率方面无显著差异。28 天死亡率的 SUCRA（排名越靠前，效果越好）显示，高渗氯化钠/羟乙基淀粉 40 溶液排名最高（93.8%），其次是平衡液（BS）（69.6%）和白蛋白（61.9%）。另一方面，90 天死亡率的 SUCRA 显示明胶（GEL）排名最高（75.1%），其次是 BS（55.1%）和 NS（52.4%）。AKI 的 NMA 结果表明，与 GEL、BS 和 L-HES 相比，高分子量羟乙基淀粉（H-HES）与 AKI 风险增加相关。AKI 的 SUCRA 显示 GEL 排名最高（74.4%），其次是 NS（64.9%）和 BS（58.3%）。此外，RRT 的 NMA 结果表明，与 BS 和 NS 相比，H-HES 与 RRT 需求增加相关，与 BS 相比，L-HES 与 RRT 需求增加相关。RRT 的 SUCRA 显示 NS 排名最高（91.6%），其次是 BS（74.4%）和 L-HES（36.1%）。节点分裂分析未显示显著不一致，漏斗图未显示发表偏倚。总之，BS 被确定为感染性休克的首选复苏液。此外，GEL 的使用需要进一步评估。与 BS 相比，H-HES 与 AKI 和 RRT 的风险增加相关，而 L-HES 与 RRT 的需求增加相关。因此，这两种复苏液都应避免用于感染性休克。
