Balanced Crystalloids versus Saline in Noncritically Ill Adults

Abstract

BACKGROUND Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days — a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) — all censored at hospital discharge or 30 days, whichever occurred first. RESULTS A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P = 0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P = 0.01). CONCLUSIONS Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline.

Balanced Crystalloid Solution Versus Normal Saline on Biochemical Outcomes in Acute Medical and Surgical Patients

“…There was a significant difference in the change in chloride concentration noted (95% CI 0.34 -2.82, P = 0.0121), however this change is clinically insignificant. These findings are consistent with the recently published data from Self et al [8] in fluid administration for non-critically ill patients. Outcome measures used in their controlled trial were primarily clinical, although changes in serum biochemistry were also reported.…”

“…Nevertheless, our results strengthen the suspicion that there is no discernible difference in the use of NS compared to CSL infusions in outcomes relevant to kidney function, in non-critically ill patients. It is also worthy to note that our study represents the first Australian based cohort study in this field, extending the generalisability of the large-scale trial results demonstrated in the United States [8,10].…”

“…It is not known whether the concerns for HCMA are equally relevant in a general medical or surgical unit, with a different patient population. The investigation of non-critically ill patients has been recently reported in a large-scale randomized trial, however the outcomes measured in this study were primarily clinical outcomes: hospital-free days and adverse kidney events like death, renal-replacement therapy and persistent renal dysfunction [8]. Our study focuses on the intermediate biochemical measure of hyperchloremia, while…”

Surviving sepsis campaign: research priorities for sepsis and septic shock

“…Although a subgroup analysis showed a larger decrease (5.1%) in composite outcome in septic patients given balanced crystalloids, it is important to note that patients with sepsis or septic shock represented less than 15% of the ICU patients in this study [70]. Further, the percent of septic patients was not reported in the study on non-critically ill patients [71]. As such the applicability of these results to septic patients (who often require a greater amount of fluids, and suffer from a higher incidence of kidney dysfunction and have a higher risk of death) remains to be determined.…”

“…As such, the relevance of this study to septic patients is unclear. Recently, two large randomized controlled trials compared balanced crystalloids to 0.9% normal saline in 15,802 critically ill patients from 5 ICUs and 13,347 non-critically ill emergency department patients who were subsequently hospitalized outside of the ICU [70,71]. In critically ill patients, balanced crystalloids resulted in a statistically significant 1.1% decrease in the composite outcome of death from any cause, new renal-replacement therapy or persistent renal dysfunction.…”