Volume therapy for cardiac arrest: a systematic review and meta-analysis

To perform a systematic review and meta-analysis of intra-cardiac arrest and post-cardiac arrest intravascular volume therapy in adults and children.

Searches were performed in Ovid Medline, Ovid Embase, and the Cochrane Library on October 30, 2025. Randomized trials and non-randomized studies evaluating volume therapy during cardiac arrest and after return of spontaneous circulation were included. Two reviewers independently screened articles, extracted data, and assessed risk of bias. Meta-analyses were performed when appropriate. Certainty of evidence was assessed using GRADE methodology.

Fifty-eight articles were included representing 14 trials enrolling 4815 patients and 44 observational studies including 710,118 patients. All randomized trials enrolled adult patients. Of the observational studies, two included paediatric patients and eight included mixed populations. For non-traumatic intra-cardiac arrest, trials of specific interventions, including hypertonic saline with hydroxyethyl starch (which is no longer used in clinical practice) and cold crystalloid infusion, showed no difference in outcomes. For traumatic intra-cardiac arrest, direct evidence was limited to a single trial subgroup analysis showing no difference between blood products and crystalloids. For post-cardiac arrest, trials of cold crystalloid infusion and balanced versus unbalanced crystalloids showed no differences in outcomes. Randomized trials were assessed to have some concern to high risk of bias. Observational studies were at serious or critical risk of bias with inconsistent results. The certainty of evidence was low to very low.

This systematic review found no trials directly comparing volume therapy to no volume therapy during cardiopulmonary resuscitation. The available trials, which compared different types of volume therapy strategies in adult patients, showed no significant difference in clinical outcomes across non-traumatic, traumatic, and post-cardiac arrest settings. Additional randomized trials are needed to establish the role of intra- and post-cardiac arrest volume therapy.