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Orbegozo D, Vincent JL, Creteur J, et al. Hypertonic Saline in Human Sepsis: A Systematic Review of Randomized Controlled Trials. Anesth Analg. 2019 Jun;128(6):1175-1184. doi: 10.1213/ANE.0000000000003955. (Systematic review)
Abstract

The role of hypertonic saline in sepsis remains unclear because clinical data are limited and the balance between beneficial and adverse effects is not well defined. In this systematic literature review, we searched PubMed and Embase to identify all randomized controlled trials up until January 31, 2018 in which hypertonic saline solutions of any concentration were used in patients of all ages with sepsis and compared to a cohort of patients receiving an isotonic fluid. We identified 8 randomized controlled trials with 381 patients who had received hypertonic saline. Lower volumes of hypertonic saline than of isotonic solutions were needed to achieve the desired hemodynamic goals (standardized mean difference, -0.702; 95% CI, -1.066 to -0.337; P < .001; moderate-quality evidence). Hypertonic saline administration was associated with a transient increase in sodium and chloride concentrations without adverse effects on renal function (moderate-quality evidence). Some data suggested a beneficial effect of hypertonic saline solutions on some hemodynamic parameters and the immunomodulatory profile (very low-quality evidence). Mortality rates were not significantly different with hypertonic saline than with other fluids (odds ratio, 0.946; 95% CI, 0.688-1.301; P = .733; low-quality evidence). In conclusion, in our meta-analysis of studies in patients with sepsis, hypertonic saline reduced the volume of fluid needed to achieve the same hemodynamic targets but did not affect survival.

Ratings
Discipline Area Score
Pediatric Emergency Medicine 6 / 7
Emergency Medicine 6 / 7
Internal Medicine 5 / 7
Intensivist/Critical Care 5 / 7
Comments from MORE raters

Emergency Medicine rater

As an ED doc, I am looking for an article on sepsis which says "this intervention improves survival". This is not that article. Giving a lot of fluids, giving less, giving hypertonic saline, giving steroids, following the exact goals of early goal-directed therapy, clearing lactic - I guess it's good to eliminate these ideas, but overall, I am not sure we're making progress.

Intensivist/Critical Care rater

This provides sufficiently convincing proof that the sodium concentration in the fluid support of patients with septic shock is not significant.

Intensivist/Critical Care rater

The present review assessed an important issue. Recent data advise against the use of colloids. There few options to replace the previous role of coloids (fluid with high osmolar propierties). In this way hipertonic saline could be a good option. However, in this review hipertonic saline did not achieve better performance than SS 0.9% in relevant patient center outcomes. Some questions related with the possible adverse effects of sodium and chloride burden remains unsolved.

Pediatric Emergency Medicine rater

Limited evidence suggesting no clinically relevant benefit.

Pediatric Emergency Medicine rater

As a pediatric emergency medicine physician, I find the safety of hypertonic saline and its impact on overall fluid use for resuscitation is interesting. The impact on hyperchloremia and persistent acidosis may have a bigger impact in peds, affecting its applicability.
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