Balanced Crystalloids in Sepsis: Are We There Yet?

Abstract

We read the post hoc analysis of the SMART (Isotonic Solutions and Major Adverse Renal Events Trial) trial with great interest,

Evaluation of Evidence, Pharmacology, and Interplay of Fluid Resuscitation and Vasoactive Therapy in Sepsis and Septic Shock

“…Most clinical evidence of the interaction between fluids and vasopressors comes from trials defining fluid administration relative to vasoactive exposure (30,31,39,40). In an openlabel trial of 99 patients, restricted volume therapy (defined as vasopressor commencement for MAP < 65 mm Hg after 1,000 mL IV fluids) showed no difference in mortality when compared with usual care (75).…”

“…Balanced crystalloids are more physiologic than sodium chloride, though the hypotonicity and buffering capacity of lactated ringers and potential for hypotension from acetate in plasmalyte-A may be concerns in specific patients with septic shock (28,29). Studies within the critically ill have shown lower risk of in-hospital or 30-day mortality, AKI, or major adverse kidney event in the first 30 days with the use of balanced crystalloids over sodium chloride solutions (MAKE30) were lower, even at low fluid volumes (1.5 L resuscitative fluid) (28)(29)(30)(31)(32). Unless patient-specific contraindications exist, a balanced crystalloid should be provided for IVF resuscitation in sepsis and septic shock.…”

“…A surge of evidence in recent years has identified hyperchloremia secondary to excess chloride-rich fluid administration to be an independent risk factor for AKI, multiorgan dysfunction, and mortality amongst patients with sepsis (35). Balanced crystalloids, such as plasma-lyte and lactated ringers, better mimic the electrolyte composition of human plasma and carry a lower risk of electrolyte imbalances, acid-base disturbances, and adverse renal outcomes (28)(29)(30)(31)(32).…”