Balanced versus chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study

Abstract

IntroductionWe sought to investigate whether the use of balanced solutions reduces the incidence of hyperchloraemic acidosis without increasing the risk for intracranial hypertension in patients with severe brain injury.MethodsWe conducted a single-centre, two-arm, randomised, double-blind, pilot controlled trial in Nantes, France. Patients with severe traumatic brain injury (Glasgow Coma Scale score ≤8) or subarachnoid haemorrhage (World Federation of Neurosurgical Society grade III or higher) who were mechanically ventilated were randomised within the first 12 hours after brain injury to receive either isotonic balanced solutions (crystalloid and hydroxyethyl starch; balanced group) or isotonic sodium chloride solutions (crystalloid and hydroxyethyl starch; saline group) for 48 hours. The primary endpoint was the occurrence of hyperchloraemic metabolic acidosis within 48 hours.ResultsForty-two patients were included, of whom one patient in each group was excluded (one consent withdrawn and one use of forbidden therapy). Nineteen patients (95%) in the saline group and thirteen (65%) in the balanced group presented with hyperchloraemic acidosis within the first 48 hours (hazard ratio = 0.28, 95% confidence interval [CI] = 0.11 to 0.70; P = 0.006). In the saline group, pH (P = .004) and strong ion deficit (P = 0.047) were lower and chloraemia was higher (P = 0.002) than in the balanced group. Intracranial pressure was not different between the study groups (mean difference 4 mmHg [-1;8]; P = 0.088). Seven patients (35%) in the saline group and eight (40%) in the balanced group developed intracranial hypertension (P = 0.744). Three patients (14%) in the saline group and five (25%) in the balanced group died (P = 0.387).ConclusionsThis study provides evidence that balanced solutions reduce the incidence of hyperchloraemic acidosis in brain-injured patients compared to saline solutions. Even if the study was not powered sufficiently for this endpoint, intracranial pressure did not appear different between groups.Trial registrationEudraCT 2008-004153-15 and NCT00847977The work in this trial was performed at Nantes University Hospital in Nantes, France.

Crystalloids and colloids in critical patient resuscitation

“…In a randomized, doubleblind study of 40 patients with severe traumatic brain injury (Glasgow coma score [GCS] ≤8) or subarachnoid hemorrhage (World Federation of Neurological Surgeons [WFNS] score ≥3), the incidence of hyperchloremic acidosis (primary outcome) was significantly lower with the use of a balanced solution than with the use of saline solution---though without differences in terms of the incidence of intracranial hypertension or mortality. 45 Likewise, in a randomized, double-blind clinical trial in patients with subarachnoid hemorrhage, the use of a balanced solution was associated to a lesser incidence of hyperchloremic acidosis, though without the appearance of hyponatremia or hypoosmolarity, which could have negative consequences in patients of this kind. 46 Lastly, a recent metaanalysis has evaluated the use of these balanced solutions, comparing them with saline solution in surgical patients.…”

Cristaloides y coloides en la reanimación del paciente crítico

“…En un ensayo aleatorizado y doble ciego realizado en 40 pacientes con traumatismo craneoencefálico grave (GCS ≤ 8 puntos) o hemorragia subaracnoidea (WFNS ≥ 3), la incidencia de acidosis hiperclorémica (objetivo primario) fue significativamente menor con el empleo de una solución balanceada que con el uso de suero salino, aunque sin diferencias en la existencia de hipertensión intracraneal o mortalidad 45 . Del mismo modo, en un ensayo clínico aleatorizado y doble ciego realizado en pacientes con hemorragia subaracnoidea, el empleo de una solución balanceada se asoció a una menor incidencia de acidosis hiperclorémica, pero sin aparición de hiponatremia o hipoosmolaridad, que podrían conllevar consecuencias negativas en este tipo de pacientes 46 .…”

Key Controversies in Colloid and Crystalloid Fluid Utilization

“…[66][67][68][69] In brain injury, where the slight hypotonicity of lactated Ringer's may be unfavorable in large volumes, an alternative balanced solution (Isofundine; 304 mOsmol/L) again resulted in less acid-base disturbances than normal saline. 70 Fluid selection in kidney transplantation is of particular interest, because both balanced solutions and normal saline could pose meaningful risks. A 2002 survey of kidney transplant centers found 0.9% sodium chloride was the most commonly selected perioperative IV fluid; this was attributed to apprehension about the use of potassium-containing solutions in patients with renal failure.…”