Restrictive vs Liberal Fluid Strategy for Initial Resuscitation in Sepsis and Septic Shock: A Systematic Review and Meta-Analysis (2025)

Background: Fluid resuscitation is a cornerstone in the management of sepsis and septic shock, yet the optimal strategy remains controversial. Liberal strategies may restore tissue perfusion quickly but can increase the risk of fluid overload, pulmonary edema, and organ dysfunction. Restrictive strategies aim to limit fluid accumulation while maintaining adequate perfusion. Objective: This systematic review and meta-analysis aims to synthesize randomized controlled trials (RCTs) comparing restrictive versus liberal fluid strategies in adults with sepsis or septic shock, focusing on mortality, ICU outcomes, renal outcomes, and fluid balance. Methods: A comprehensive search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library up to October 2025. RCTs comparing restrictive versus liberal fluid strategies in adult patients were included. Data were extracted for mortality, ICU length of stay, ventilator-free days, renal replacement therapy (RRT), and cumulative fluid balance. Risk of bias was assessed using Cochrane RoB 2, and evidence certainty using GRADE. Meta-analysis was performed using random-effects models. Results: Twelve RCTs comprising 8,743 patients were included. Restrictive strategies reduced cumulative fluid balance and showed trends toward fewer ventilator and ICU days. Mortality differences between groups were not statistically significant. Conclusions: Restrictive fluid resuscitation is safe and may reduce complications associated with fluid overload without adversely affecting survival. Individualized, hemodynamic-guided fluid management remains recommended.