Assessing Toxicity of Intravenous Crystalloids in Critically Ill Patients

Kellum, John A.; Shaw, Andrew

doi:10.1001/jama.2015.12390

Cited by 35 publications

(17 citation statements)

References 19 publications

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“…In contrast, the more recent and controlled SPLIT trial (double-blind and double-crossover) compared normal saline with PlasmaLyte in 2278 ICU-patients and found no differences in the incidences of AKI or RRT [48]. Of note, this study did not report serum chloride concentrations and a relatively small volume (median of 2 l) was infused in patients with moderate severity of disease [49]. Finally, and quite surprisingly, no sample size calculations were performed [48].…”

Section: Comparing Solutionsmentioning

confidence: 90%

Intravenous fluids: balancing solutions

Hoorn

2016

J Nephrol

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The topic of intravenous (IV) fluids may be regarded as “reverse nephrology”, because nephrologists usually treat to remove fluids rather than to infuse them. However, because nephrology is deeply rooted in fluid, electrolyte, and acid-base balance, IV fluids belong in the realm of our specialty. The field of IV fluid therapy is in motion due to the increasing use of balanced crystalloids, partly fueled by the advent of new solutions. This review aims to capture these recent developments by critically evaluating the current evidence base. It will review both indications and complications of IV fluid therapy, including the characteristics of the currently available solutions. It will also cover the use of IV fluids in specific settings such as kidney transplantation and pediatrics. Finally, this review will address the pathogenesis of saline-induced hyperchloremic acidosis, its potential effect on outcomes, and the question if this should lead to a definitive switch to balanced solutions.

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Section: Comparing Solutionsmentioning

confidence: 90%

Intravenous fluids: balancing solutions

Hoorn

2016

J Nephrol

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“…Although the protocol was well executed, a significant limitation of this study were the relatively small (median 2000 cc) resuscitation volumes received by patients in both groups as well as the lesser disease severity in these patients (mean Acute Physiology and Chronic Health Evaluation [APACHE] II score 14, overall mortality 8%) compared to patients in other trials. As mentioned in editorial comments, the small fluid volume and lower patient acuity probably precluded the ability to detect any differences in outcomes between the two treatment groups (51). …”

Section: Crystalloidsmentioning

confidence: 99%

Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock

Chang

Holcomb

2016

Shock

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Sepsis results in disruption of the endothelial glycocalyx layer and damage to the microvasculature, resulting in interstitial accumulation of fluid and subsequently edema. Fluid resuscitation is a mainstay in the initial treatment of sepsis, but the choice of fluid is unclear. The ideal resuscitative fluid is one which restores intravascular volume while minimizing edema; unfortunately, edema and edema-related complications are common consequences of current resuscitation strategies. Crystalloids are recommended as first-line therapy, but the type of crystalloid is not specified. There is increasing evidence that normal saline is associated with increased mortality and kidney injury; balanced crystalloids may be a safer alternative. Albumin is similar to crystalloids in terms of outcomes in the septic population but is costlier. Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients. In the trauma population, the shift to plasma-based resuscitation with decreased use of crystalloid and colloid in the treatment of hemorrhagic shock has led to decreased inflammatory and edema-mediated complications. Studies are needed to determine if these benefits also occur with a similar resuscitation strategy in the setting of sepsis.

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“…Secondly, the median administered volume of each fluid was low quite low (about 2,000 mL in both the B and S-groups; P=0.63) during the ICU stay, and most of the fluid administration occurred during the first 24 hours as clearly underlined by the accompanying Editorial (11). In view of this observation, some general pathophysiological considerations should be highlighted: (I) the restricted fluid therapy, when adequately balanced between hypovolemia and excessive weight gain, has shown to be, per se, useful in reducing AKI incidence (12)-this approach, carefully applied in Young's study might have somehow blunted the negative effects of the nephrotoxic fluid; (II) the possibility of infusing low volumes of fluids may indirectly confirm the low severity of illness of enrolled patients and a good integrity of the endothelial glycocalix and microcirculation (13)-this is generally not the case in conditions of severe inflammatory states (e.g., sepsis); (III) the development of metabolic acidosis [also described as hyperchloremic acidosis or strong ion difference acidosis (14)], as well as the decrease in kidney cortical perfusion were demonstrated after rapid administration (bolus) of 2,000 mL of saline in healthy subjects (15,16) or after 70 mL/Kg in 2 hrs after surgery (17).…”

mentioning

confidence: 94%

“…Possibly, although the SPLIT trial has been specifically designed to test the effects of two different fluid preparations on renal function, the authors did not investigate subclinical forms of renal dysfunction that might be induced by chloride-rich solutions (19). It is well known that the so called renal functional reserve, in healthy subjects, must be exhausted before serum creatinine increases (11,20). Since creatinine has a much lower sensitivity than other recently identified biomarkers, it could be supposed that different methods of investigation, could have revealed renal reserve reduction, otherwise missed by the simple creatinine rise (21).…”

mentioning

confidence: 99%