What is the ideal crystalloid?

Raghunathan, Karthik; Nailer, Patrick; Konoske, Ryan

doi:10.1097/mcc.0000000000000218

Cited by 23 publications

(10 citation statements)

References 35 publications

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“…We used lactated Ringer's as the balanced crystalloid, which has a near-physiologic strong ion difference 10 because it contains less chloride than saline, thereby reducing the risk of hyperchloremic metabolic acidosis. 11 Analysis was restricted to the first surgery for each patient. We excluded surgeries lasting less than 2 h, urgent/emergency procedures, and patients with American Society of Anesthesiologists (Schaumburg, Illinois) physical status score 5 or greater, chronic renal failure requiring preoperative dialysis, or missing preoperative creatinine values.…”

Section: Methodsmentioning

confidence: 99%

Saline versus Lactated Ringer’s Solution

et al. 2020

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Background: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline. Methods:The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury.results: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful.conclusions: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. (ANESTHESIOLOGY 2020; 132:614-24) What We Already Know about This Topic • Infusion of large volumes of saline causes hyperchloremic metabolic acidosis • A recent Cochrane review based on 18 small trials reported that major morbidity and mortality were comparable with perioperative saline or lactated Ringer's use What This Article Tells Us That is New• In a large single-center alternating cohort trial of patients having elective colorectal or orthopedic surgery, there was no clinically meaningful difference in the risk of a composite of in-hospital mortality and major postoperative complications including renal, respiratory, infectious, and hemorrhagic complications A bout 51 million inpatient surgeries were performed in the United States in 2010, based on National Hospital Discharge Survey. 1 Nearly all surgeries require intravenous crystalloid fluids for drug administration and vascular volume repletion. Saline (0.9% sodium chloride; "normal saline") is a commonly used crystalloid, but it has a much higher chloride concentration than human plasma, and is thus u...

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Section: Methodsmentioning

confidence: 99%

Saline versus Lactated Ringer’s Solution

et al. 2020

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“…Besides the focus on hemodynamic targets to be achieved in critically ill patients, researchers have shifted their attention to the effects of different categories and types of fluids. Looking from afar at the never-ending debate on the potential benefit of colloids vs. crystalloids [2], we have moved towards the evidence that even the type of both colloids and crystalloids may affect patient-centred clinical outcomes, including survival [3,4].…”

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confidence: 99%

Intravenous balanced solutions: from physiology to clinical evidence

Länger

Santini

Scotti

et al. 2015

Anaesthesiol Intensive Ther

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Abstract"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental alteration of renal function associated with hyperchloremia. Despite efforts made towards its identification, the ideal balanced solution, with minimal effects on acid-base status, low chloride content, and adequate tonicity, is not yet available. After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solutions on renal function in critically-ill patients (SPLIT trial, the 0.9% saline vs. Plasma-Lyte 148 for Intensive Care Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions; secondly, by summarizing their potential pathophysiologic effects; and lastly, by presenting the clinical evidence available to support their use at the present time.

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“…In the SOAP study, positive balance on the third day after the onset of infection was associated with higher mortality in the PICU in the subgroup of patients with sepsis, among which 40% had septic shock. [9][10][11][12][13][14][15][16] The mechanisms by which the increase in FO influence the prognosis of patients with septic shock are still under debate, it is considered that a positive accumulated fluid balance is associated with the development of systemic hypoperfusion, tissue edema, respiratory and renal system failure; Studies carried out by Flori and collaborators concluded that persistently positive balance is deleterious in pediatric patients with acute lung injury, since it causes more days in mechanical ventilation and greater mortality, regardless of the magnitude of the oxygenation failure or severity of organic dysfunction. Along the same lines, Arikan and collaborators demonstrated similar findings, although in this study the time of ventilatory assistance was not considered.…”

Section: Discussionmentioning

confidence: 99%

Fluid Overload in Children with Severe Sepsis and Septic Shock

Raul¹,

Diaz²

2019

AJP

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Fluid therapy is one pillar of the treatment of septic shock, however, a hydric≥10% of the weight or Fluid Overload (FO>10%) is associated with poor hospital outcomes. The present study aims to determine the FO in patients with septic shock, and its main associations in terms of mortality and morbidity. An observational and descriptive study was conducted in 49 hospitalized children with septic shock in the PICU of the Manuel Ascencio Villarroel Children's Hospital (MAVCH); The patients were divided into two groups according to the FO>10% (22 patients) and<10% (18 patients), for their descriptive analysis we included comparison of means and calculation of the OR. Regarding the water requirements, we observed that the group with FO>10% a mean of 5681ml; while in the group with ISCH<10% the mean was 3297.8ml (p=0.19) during first 72 hours, showing greater overload with the administration of colloids and blood products (p=0.02, p=0.004). Regarding hospital outcomes, was found morbidity associated with FO>10% (respiratory dysfunction, vasopressor requirement and renal replacement therapy); The length of hospitalization and FO were not different in groups (p=0.60), but there was higher mortality of patients with FO>10% (p=0.01, OR: 5.57 IC95% 1.4-21.8). Fluids therapy of in the patient with septic shock constitutes one of the first-line hemodynamic treatments, however in limited resources settings, overload should be avoided, mainly due to associated morbidity during the first 72 hours.

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What is the ideal crystalloid?

Abstract: Crystalloids, like other types of intravenous fluids, are drugs with important effects on clinical outcomes that may be mediated by osmolality, chloride content, and SID.

Cited by 23 publications

References 35 publications

Saline versus Lactated Ringer’s Solution

Saline versus Lactated Ringer’s Solution

Intravenous balanced solutions: from physiology to clinical evidence

Fluid Overload in Children with Severe Sepsis and Septic Shock

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