Balanced Crystalloids or Saline IV for Patients admitted to the ICU?
BACKGROUND AND PURPOSE:
Historically, 0.9% sodium chloride (saline) has been the most widely used IV solution
Some data to suggest association with hyperchloremic metabolic acidosis, acute kidney injury and death
Alternative is a balanced crystalloid solution, such as lactated Ringer’s solution
Closer electrolyte composition to plasma
Data suggests less acute kidney impairment and death but literature is inconsistent
Semler et al. (N Eng J Med 2018) sought to determine which intravenous fluid administration, balanced crystalloids or saline, results in better clinical outcomes in the ICU setting
Pragmatic, cluster-randomized, multiple-crossover trial of patients in the ICU
Adverse Renal Events Trial (SMART), which compared the use of balanced crystalloids with the use of saline in patients in medical (SMART-MED) and nonmedical (SMART-SURG) intensive care units (ICUs)
Participants: ≥18 years of age, admitted to participating ICU
Patients received either:
Balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A)
The primary outcome
Proportion of patients who met one or more criteria for a major adverse kidney event within 30 days
Composite of all-cause mortality, new renal-replacement therapy, or persistent renal dysfunction
Death before ICU discharge or at 30 days or 60 days | ICU-free days | ventilator-free days | vasopressor-free days | days alive and free of renal-replacement therapy during the 28 days after enrollment
Renal specific: New receipt of renal-replacement therapy | persistent renal dysfunction | acute kidney injury of stage 2 or higher | highest creatinine level during the hospital stay | change from baseline to the highest creatinine level | final creatinine level before hospital discharge
15,802 ICU patients were enrolled
7,924 patients were in balanced crystalloids group and 7860 patients were in the saline group
Median age 58 years
42.4% were women
Median volume of balanced crystalloids was 1000 ml and 1020 in the saline group
Primary outcome for adverse kidney events was higher in saline group (P=0.04)
balanced crystalloids (14.3%) compared to saline (15.4%)
In-hospital mortality, incidence of new renal-replacement therapy and persistent renal function did not differ significantly between groups, nor did other secondary outcomes
Among critically ill adults, balanced crystalloids for intravenous fluid administration reduced the rate of composite adverse outcome that included all-cause mortality, new renal-replacement therapy, or persistent renal dysfunction
Saline has higher chloride content that may be responsible for kidney injury
While the primary care difference was only a 1.1% difference, over treatment of millions admitted to ICUs, the difference becomes substantial
Clinical context is important and therefore clinicians had the option of using only saline when treating brain injury as balanced crystalloids may be too hypotonic
The authors acknowledge that the use of composite outcomes introduces confounding variables and additional studies are needed
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