154 compared to 54 mmol per liter of sodium in intravenous maintenance fluid therapy for adult patients undergoing major thoracic surgery (TOPMAST): a single-center randomized controlled double-blind trial

Abstract

Purpose: To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders. Methods: We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints. Findings: We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI − 0.2-30.4%, p = 0.05). Conclusions: In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.

Crystalloid and Colloid Compositions and Their Impact

“…Acute, hospital acquired hyponatremia has been associated with the administration of hypotonic, maintenance type fluids in human patients (39,42,43). Randomized controlled trials comparing isotonic crystalloids with hypotonic crystalloids as ongoing maintenance fluid therapy in adult humans and pediatric patients have shown isotonic crystalloids to be safe and is associated with a lower incidence of hyponatremia (44)(45)(46)(47).…”

Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep

“…Many clinicians suggest to use isotonic maintenance fluids in order to avoid the risk of hyponatremia and cerebral edema [40]. On the contrary, other authors promote the use of hypotonic fluids in order to avoid "water and salt intoxication" [41,42].…”

Clinical physiology aspects of chloremia in fluid therapy: a systematic review

“…In a study with 15,802 intensive care patients, Self et al found lower rates of renal failure, use of dialysis, and lower total mortality in those receiving fluid therapy with balanced crystalloid solutions (Self et al 2018 ). Regarding the development of hyperchloremia, solutions associated with a certain risk are not only those used for volume replacement as part of initial circulatory resuscitation (Bandak and Kashani 2017 ; Sen et al 2017 ) but, also, solutions employed for the dilution and reconstitution of the drugs administered (e.g., antibiotics), vitamin therapy, flushing catheters and sets, and so on (Van Regenmortel et al 2019 ; Van Regenmortel et al 2018 ). The effect of the implementation of new strategies reducing the rates of administering high-chloride solutions was well documented in the study of Yuons et al, where the implementation of control measures in fluid therapy (administration of Hartman’s solution, Plasmalyte, and 20% albumin with low Cl − content instead of the uncontrolled administration of various types of solutions) was followed by a statistically significant decrease in the rates of acute renal failure and the use of dialysis (Yunos et al 2012 ).…”