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Low- Versus High-Chloride Content Intravenous Solutions for Critically Ill and Perioperative Adult Patients: A Systematic Review and Meta-analysis

Kawano-Dourado, Leticia, MD*,†; Zampieri, Fernando G., MD*,‡; Azevedo, Luciano C. P., MD§,‖; Corrêa, Thiago D., MD; Figueiró, Mabel, BLS*; Semler, Matthew W., MD#; Kellum, John A., MD**; Cavalcanti, Alexandre B., MD*

doi: 10.1213/ANE.0000000000002641
Critical Care and Resuscitation: Meta-Analysis

BACKGROUND: To assess whether use of low-chloride solutions in unselected critically ill or perioperative adult patients for maintenance or resuscitation reduces mortality and renal replacement therapy (RRT) use when compared to high-chloride fluids.

METHODS: Systematic review and meta-analysis with random-effects inverse variance model. PubMed, Cochrane library, EMBASE, LILACS, and Web of Science were searched from inception to October 2016. Published and unpublished randomized controlled trials in any language that enrolled critically ill and/or perioperative adult patients and compared a low- to a highchloride solution for volume maintenance or resuscitation. The primary outcomes were mortality and RRT use. We conducted trial sequential analyses and assessed risk of bias of individual trials and the overall quality of evidence. Fifteen trials with 4067 patients, most at low risk of bias, were identified. Of those, only 11 and 10 trials had data on mortality and RRT use, respectively. A total of 3710 patients were included in the mortality analysis and 3724 in the RRT analysis.

RESULTS: No statistically significant impact on mortality (odds ratio, 0.90; 95% confidence interval, 0.69–1.17; P = .44; I 2 = 0%) or RRT use (odds ratio, 1.12; 95% confidence interval, 0.80–1.58; P = .52; I 2 = 0%) was found. Overall quality of evidence was low for both primary outcomes. Trial sequential analyses highlighted that the sample size needed was much larger than that available for properly powered outcome assessment.

CONCLUSIONS: The current evidence on low- versus high-chloride solutions for unselected critically ill or perioperative adult patients demonstrates no benefit, but suffers from considerable imprecision. We noted a limited exposure volume for study fluids and a relatively low risk of the populations in each study. Together with the relatively small pooled sample size, these data leave us underpowered to detect potentially important differences. Results from well-conducted, adequately powered randomized controlled trials examining sufficiently large fluid exposure are necessary.

Published ahead of print November 14, 2017.

From the *Research Institute, Hospital do Coração (HCor), São Paulo, Brazil

Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil

Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil

§Intensive Care Unit, Hospital Sirio Libanes, São Paulo, Brazil

Emergency Medicine Discipline, University of São Paulo Medical School, São Paulo, Brazil

Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil

#Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

**The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Published ahead of print November 14, 2017.

Accepted for publication October 6, 2017.

Funding: This meta-analysis was supported by the Brazilian Ministry of Health.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Leticia Kawano-Dourado, MD, Research Institute - Hospital do Coracao (HCor), Rua Abilio Soares 250, 12o andar, cep: 04005-000, São Paulo-SP, Brazil. Address e-mail to

© 2018 International Anesthesia Research Society
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