Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis

Beran, Azizullah; Altorok, Nehaya; Srour, Omar; Malhas, Saif‐Eddin; Khokher, Waleed; Mhanna, Mohammed; Ayesh, Hazem; Aladamat, Nameer; Abuhelwa, Ziad; Srour, Khaled; Mahmood, Asif; Altorok, Nezam; Taleb, Mohammad; Assaly, Ragheb

doi:10.3390/jcm11071971

Cited by 21 publications

(16 citation statements)

References 48 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…As described previously at the 12th ADQI conference, the four phases of intravenous fluid therapy -resuscitation, optimization, stabilization and de-escalation -form an appropriate conceptual framework for tailoring fluid therapy to the individual patient context 70 . Although (balanced) crystalloids are often used, the recent BaSICS and PLUS trials and meta-analysis found no clinical benefit of balanced solutions over the use of 0.9% saline solutions [84][85][86][87] . The SMART trial reported that the use of balanced crystalloids significantly decreased major adverse kidney events at day 90 (MAKE 90 ) and a composite end point (death, KRT, or persistent kidney dysfunction) compared saline; however, only ~15% of the patient population had sepsis at baseline 88 .…”

Section: Consensus Statement 3mmentioning

confidence: 99%

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

et al. 2023

View full text Add to dashboard Cite

Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Definition and epidemiology of SA-AKI Definition of SA-AKI and sepsis-induced AKICurrently, no universally accepted definition of SA-AKI exists 15 . To support clinical guidelines, quality improvement initiatives, and future research, we propose that the presence of both sepsis (as currently defined in adults by the Sepsis-3 criteria) and AKI (as presently defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria) should define SA-AKI 1,16 (Box 1). SA-AKI is a heterogeneous syndrome that occurs as the consequence of either direct mechanisms related to infection or the host response to infection, or indirect mechanisms driven by unwanted sequelae of sepsis or sepsis therapies 17 . As such, the term SA-AKI operationally unifies the presence of AKI (according to clinical, biochemical and functional criteria) in the context of sepsis as a specific disease phenotype that is characterized by a specific trajectory and outcome 18,19 .Sepsis-induced AKI (SI-AKI) can be considered to be a subphenotype of SA-AKI, in which sepsis-induced mechanisms drive kidney damage directly. Thus, by definition, SI-AKI excludes injury that primarily develops as the indirect consequence of sepsis or sepsis therapies (for example, AKI caused by antimicrobial agent-induced nephrotoxicity or abdominal compartment syndrome) 20,21 . Importantly, mechanisms that underlie cellular and organ injury in ischaemic AKI or nephrotoxic AKI, such as microcirculation failure, inflammation and mitochondrial injury, might also contribute to SI-AKI. The limited availability of clinical tools such as biomarkers that can aid early identification complicate Many aspects of SA-AKI rema...

show abstract

Section: Consensus Statement 3mmentioning

confidence: 99%

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

et al. 2023

View full text Add to dashboard Cite

show abstract

“…In patients with AP secondary to hypercalcemia, normal saline should be used instead as ringer’s lactate contains 3 mEq/L calcium. While different guidelines make conflicting recommendations over the choice of crystalloids, normal saline is considered “less physiological” due to high sodium and lack of potassium[ 60 ]. Over-administration of normal saline may also lead to normal anion gap hyperchloremic acidosis in cases of persistent hypotension.…”

Section: Management Of Non-mild Apmentioning

confidence: 99%

Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies

Chan¹,

Shelat²

2022

World J Gastrointest Surg

View full text Add to dashboard Cite

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

show abstract

“…While other trials specifically evaluating fluid choice in sepsis are ongoing, 24 the totality of the pooled evidence to date still supports a weak recommendation for balanced crystalloids over saline, but it is increasingly clear that, for most patients, the magnitude of the effect is small. 25 The panel noted there was insufficient evidence to make a recommendation on the use of restrictive vs liberal fluid strategies in the first 24 hours of resuscitation in patients with sepsis, and stated that fluids should generally only be given in patients with signs of hypoperfusion. The subsequent publication of the CLASSIC (Conservative vs Liberal Fluid Therapy in Septic Shock) trial, which compared restrictive vs standard IV fluid therapy in patients with septic shock, did not show a difference between these 2 approaches in patient mortality or adverse events up to 90 days.…”

Section: Hemodynamic Management Fluid Managementmentioning

confidence: 99%

Surviving Sepsis Campaign Guidelines 2021: highlights for the practicing clinician

Oczkowski¹,

Alshamsi²,

Belley‐Côté³

et al. 2022

Polish Archives of Internal Medicine

View full text Add to dashboard Cite

ensure they would be applicable in both high-and low-resource settings. Secondly, while remaining intensive care unit (ICU)-focused, the 2021 Guidelines acknowledged the long-term impact of sepsis, including physical, psychological, and mental problems experienced by sepsis survivors and their families. A new section of the Guidelines was developed to address long-term outcomes and goals of care in sepsis, with an expanded patient and public involvement in the panel to provide input on the Guidelines and ensure they were consistent with patient and family needs, values, and preferences for care.In this paper, we outline the noteworthy aspects of each section of the 2021 Guidelines that represent a change from previous practice, address an important clinical question not previously discussed, or remain an area of persistent clinical challenge. Of note, we do not address issues related to the COVID-19 pandemic, Introduction Despite advances in rapid recognition and resuscitation, sepsis remains a major cause of morbidity and mortality worldwide, underscoring the need for continued research, education, and knowledge translation activities. 1,2 Since its inception in 2002, the Surviving Sepsis Campaign (SSC) has played a central role in improving the care of patients with sepsis. As a collaboration between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, with endorsement from many other national and international societies, the SSC Guidelines represent the currently accepted standard for sepsis care in adults. 3 The 2021 Guidelines build upon and advance the earlier versions in important ways. Firstly, they address sepsis as a global health threat. To this end, the leadership explicitly sought to increase diversity in the representative panelists as well as the recommendations themselves to

show abstract

Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis

Cited by 21 publications

References 48 publications

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies

Surviving Sepsis Campaign Guidelines 2021: highlights for the practicing clinician

Contact Info

Product

Resources

About