Balanced crystalloids versus saline in critically ill patients

Abstract

Objective: To compare the safety of balanced crystalloids and saline among critically ill patients in intensive care unit (ICU). Methods: The Medline, EMBASE, Web of Science, Cochrane Library databases were systematically searched from the inception dates to May 17, 2020 in order to identify randomized controlled trials which evaluated the safety of balanced crystalloids and saline in critically ill patients. The primary outcome was major adverse kidney events within 30 days (MAKE30). The second outcomes included 30-day mortality, ICU mortality, In-hospital mortality, ICU length of stay, hospital length of stay, creatinine highest before discharge (mg/dl) and needs for renal replacement therapy (RRT). Results: A total of nine randomized controlled trials involving 19,578 critical ill patients fulfilled the inclusion criteria. The outcomes of this meta-analysis showed that balanced crystalloids treatment shared the same risk of MAKE30 with saline treatment among critical ill patients [RR = 0.95; 95%CI, 0.88 to 1.01; Z = 1.64 ( P = .102)]. The clinical mortality which included 30-day mortality [RR = 0.92; 95%CI, 0.85 to 1.01; Z = 1.78 ( P = .075)], ICU mortality [RR = 0.92; 95%CI, 0.83 to 1.02; Z = 1.67 ( P = .094)] and In-hospital mortality [RR = 0.93; 95%CI, 0.71 to 1.21; Z = 0.55 ( P = .585)] were similar between balanced crystalloids treatment and saline treatment among critical ill patients. Patients who received balanced crystalloids treatment or saline treatment needed the same length of ICU stay [WMD = 0.00; 95%CI, −0.09 to 0.10; Z = 0.09 ( P = .932)] and hospital stay [WMD = 0.59; 95%CI, −0.33 to 1.51; Z = 1.26 ( P = .209)]. Critical ill patients who received balanced crystalloids treatment or saline treatment had the same level of creatinine highest before discharge [WMD = 0.01; 95%CI, −0.02 to 0.04; Z = 0.76 ( P = .446)] and needs for RRT [RR = 1.04; 95%CI, 0.75 to 1.43; Z = 0.21 ( P = .830)] . Similar results were obtained in subgroups of trials stratified according to the age of patients (children or adults). Conclusions: When compared with saline, balanced crystalloids could not reduce the risk of MAKE30, 30-day mortality, ICU mortality and in-hospital mortality, could not reduce the length of ICU stay, length of hospital stay, the level of creatinine highest before discharge and the needs for RRT among critical ill children and adults. Therefore, it was still too early for balanced crystalloids to replace normal saline among critical ill patients.

Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis

“…However, by contrast, a recent meta-analysis involving 13 RCTs showed that balanced crystalloid solutions can reduce mortality in critically ill adults. Our analysis concluded that there was no evident difference in MAKE30 between these two groups, similar to previous studies [ 46 , 47 ]. It was detected that the balanced crystalloid solutions could not decrease the MAKE30 rate of ICU patients.…”

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…In contrast to 0.9% sodium chloride, balanced electrolyte solutions comprise physiological or near-physiological concentrations of chloride and may therefore be advantageous [ 162 ]. Whereas a large RCT including 15,802 critically ill patients comparing balanced crystalloids versus 0.9% sodium chloride showed a lower rate of the composite outcome “death from any cause, new renal-replacement therapy or persistent renal dysfunction” when balanced crystalloids were used [ 163 ], one recently published RCT [ 164 ] and two meta-analyses comparing the effect of balanced crystalloids versus 0.9% saline for resuscitation of critically ill adults did not show a difference in mortality, acute kidney failure or length of hospital stay [ 165 , 166 ]. Nevertheless, knowing that further studies in trauma patients are warranted to clarify which crystalloid solution is the best for initial trauma management, the authors of this guideline favour a balanced electrolyte solution as the initial crystalloid solution in trauma patients.…”

Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis

“…Several meta-analyses have investigated the effect of BC vs. NS among critically ill patients [ 5 , 6 , 15 , 16 , 34 , 35 ]. Most meta-analyses showed no difference between BC and NS in mortality, the incidence of AKI, and the need for RRT among critically ill patients [ 5 , 15 , 16 , 35 ].…”

“…Several meta-analyses have investigated the effect of BC vs. NS among critically ill patients [ 5 , 6 , 15 , 16 , 34 , 35 ]. Most meta-analyses showed no difference between BC and NS in mortality, the incidence of AKI, and the need for RRT among critically ill patients [ 5 , 15 , 16 , 35 ]. Hammond et al [ 6 ] in 2020 demonstrated a lower mortality rate with BC than NS; however, no difference was observed in mortality on the subgroup of RCTs.…”

“…All previous meta-analyses focused on critically ill patients rather than septic patients [ 5 , 6 , 15 ]. A recent meta-analysis by Hammond et al [ 16 ] (included 13 trials) found similar 90-day mortality, AKI, and the need for RRT between BC and NS in critically ill patients.…”