ARDS Incidence and ARDS-Related Outcomes After Fluid Resuscitation With Hypertonic Saline When Compared to Isotonic Saline in Patients at High Risk of ARDS: A Meta-Analysis

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PURPOSE: Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) remains a significant cause of morbidity and mortality in hypovolemic and septic shock patients. Fluid resuscitation is the fundamental intervention in these patients and based on available data, the choice of fluid significantly impacts the clinical outcomes. At this time, Isotonic crystalloids are the most preferred fluids for resuscitation in these clinical scenarios. There are however studies that demonstrated beneficial effects with hypertonic saline as the initial resuscitation fluid. To the best of our knowledge there was no meta-analysis consolidating the available evidence for ARDS incidence and ARDS related outcomes in these patients that received hypertonic saline when compared to isotonic fluids. METHODS: A comprehensive literature search strategies were run on November 1, 2022 using a combination of keywords and standardized index terms for hypertonic saline and acute respiratory distress syndrome on various bibliographic databases. After limiting results to English language with some pediatric studies removed, a total of 1,226 citations were retrieved. Deduplication was performed in Covidence leaving 887 citations. 77 studies were identified during initial screening by two independent reviewers, out of which 7 met our inclusion and exclusion criteria and were included in our final analysis. Extraction of data and its synthesis was done by following the PRISMA guidelines for conducting meta-analysis. Three reviewers independently did the screening and data extraction. Odds ratios (ORs) and 95% Confidence intervals (CIs) were calculated to represent the estimated effect sizes using random effect models. RESULTS: A total of 7 studies including 1395 patients met our inclusion criteria. Overall, ARDS incidence did not differ between the groups (OR 0.53, 95% CI 0.16-1.71, p-value¼0.29, I2¼62%). After excluding study by Bulger et al during sensitivity analysis to reduce the heterogeneity the results suggested decreased incidence of ARDS in the hypertonic saline group when compared to the isotonic saline group (OR 0.28, 95% CI 0.10-0.74, p-value¼0.01, I2¼0%). There was no significant difference in all-cause mortality between both groups (5 studies, OR 0.93, 95% CI 0.63-1.35, p-value¼0.69, I2¼38%. There was also no statistically significant difference in length of ICU stay ( 5 studies, Mean difference (MD) -2.23, 95% CI -5.39 to 0.93, p-value¼0.17, I2¼85%) and Length of mechanical ventilation (2 studies, MD -3.44, 95% CI -7.03 to 0.15, p-value¼0.06, I2¼56%). CONCLUSIONS: This systematic review and meta-analysis, which included evidence from RCTs hypertonic saline compared with isotonic fluid showed trend for decreased incidence of ARDS in those who received hypertonic saline. It did not result in superior all-cause mortality, ICU length of stay or length of mechanical ventilation. CLINICAL IMPLICATIONS: Acute respiratory distress syndrome (ARDS) may occur during fluid resuscitation via the administration of excessive amounts of isotonic fluids in patients at higher risk of developing ARDS. We observed trend of decreasing incidence of ARDS after hypertonic saline use in patients at high risk of ARDS. This finding warrants the future design of randomized trials evaluating resuscitation strategies in the patients who is at higher risk of ARDS for practical implication




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Chest Annual Meeting 2023, October 8-11, 2023, Honolulu, HI