Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients

Zampieri, Fernando G.; Machado, Flávia Ribeiro; Biondi, Rodrigo Santos; Freitas, Flávio Geraldo Rezende; Veiga, Viviane Cordeiro; Figueiredo, Rodrigo Cruvinel; Lovato, Wilson José; Amêndola, Cristina Prata; Neto, Ary Serpa; Paranhos, Jorge L R; Guedes, Marco Antonio Va; Lúcio, Eraldo; Oliveira-Júnior, Lúcio C; Lisboa, Thiago; Lacerda, Fábio Holanda; Maia, Israel Silva; Grion, Cíntia Magalhães Carvalho; Assunção, Murillo Santucci César de; Manoel, Airton L O; Silva-Júnior, João Manoel da; Duarte, Péricles Almeida Delfino; Soares, Rafael Marques; Miranda, Tamiris Abait; Lima, Lucas Mori de; Gurgel, Rodrigo M; Paisani, Denise M.; Corrêa, Thiago Domingos; Azevedo, Luciano César Pontes; Kellum, John A.; Damiani, Lucas Petri; Silva, Nilton Brandão da; Cavalcanti, Alexandre Biasi; investigators, BaSICS

doi:10.1001/jama.2021.11684

Cited by 117 publications

(80 citation statements)

References 21 publications

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“…Subsequently, we excluded 21 studies because of lack of appropriate outcome or population (included non-sepsis patients), secondary paper of included study, or conference abstracts of included or excluded studies. Eventually, 15 studies [ 11 , 12 , 13 , 14 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ] met our inclusion criteria and were included in the meta-analysis. Figure 1 shows the PRISMA flow chart that illustrates how the final studies were selected.…”

Section: Resultsmentioning

confidence: 99%

“…In addition, in the SMART randomized controlled trial (RCT) in 2018 comparing NS to BC, the sepsis cohort was associated with lower 30-day mortality with BC compared to NS (odds ratio (OR) 0.90, 95% CI, 0.67, 0.94) [ 10 ]. However, more recent studies have been published comparing the effect of BC vs. NS on clinical outcomes in patients with sepsis and revealed conflicting findings [ 11 , 12 , 13 , 14 ].…”

Section: Introductionmentioning

confidence: 99%

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

Beran

Altorok

Srour

et al. 2022

JCM

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The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81–0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79–0.95), and AKI (RR 0.85, 95% CI 0.77–0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90–1.03), need for RRT (RR 0.91, 95% CI 0.76–1.08), and ICU LOS (MD −0.25 days, 95% CI −3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82–1.02), AKI (RR 0.71, 95% CI 0.47–1.06), and need for RRT (RR 0.71, 95% CI 0.36–1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Beran

Altorok

Srour

et al. 2022

JCM

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“…Self et al [28] found that NS was related to major adverse kidney events within 30 days in noncritically ill adults compared with balanced crystalloids. In contrast, Zampieri et al [29] found no significant difference between balanced crystalloids and NS in critically ill patients. Moreover, a trial conducted by Cheung-Flynn et al [30] showed that NS contributed to glycocalyx degradation in a pig model of a hemorrhagic shock compared with a balanced crystalloid (Plasma-Lyte).…”

Section: Effects Of Different Resuscitation Fluids On the Glycocalyxmentioning

confidence: 88%

Resuscitation fluids as drugs: targeting the endothelial glycocalyx

Wang

Zhang²,

Liu³

et al. 2022

Chinese Medical Journal

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Fluid resuscitation is an essential intervention in critically ill patients, and its ultimate goal is to restore tissue perfusion. Critical illnesses are often accompanied by glycocalyx degradation caused by inflammatory reactions, hypoperfusion, shock, and so forth, leading to disturbed microcirculatory perfusion and organ dysfunction. Therefore, maintaining or even restoring the glycocalyx integrity may be of high priority in the therapeutic strategy. Like drugs, however, different resuscitation fluids may have beneficial or harmful effects on the integrity of the glycocalyx. The purpose of this article is to review the effects of different resuscitation fluids on the glycocalyx. Many animal studies have shown that normal saline might be associated with glycocalyx degradation, but clinical studies have not confirmed this finding. Hydroxyethyl starch (HES), rather than other synthetic colloids, may restore the glycocalyx. However, the use of HES also leads to serious adverse events such as acute kidney injury and bleeding tendencies. Some studies have suggested that albumin may restore the glycocalyx, whereas others have suggested that balanced crystalloids might aggravate glycocalyx degradation. Notably, most studies did not correct the effects of the infusion rate or fluid volume; therefore, the results of using balanced crystalloids remain unclear. Moreover, mainly animal studies have suggested that plasma may protect and restore glycocalyx integrity, and this still requires confirmation by high-quality clinical studies.

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“…These fluids (eg, Ringer's lactate, Hartmann's solution) have minimal effects on pH but are relatively hypotonic which can exacerbate edema particularly cerebral edema in the injured brain. 56 The potential utility of hypertonic crystalloids in TBI is twofold; they are potent vascular compartment expanders, and they can reduce cerebral edema. A recent RCT compared the effect of continuous hypertonic saline (20%) for 48 hours with standard hospital care on 359 patients.…”

Section: Circulation: the Optimal Resuscitation Fluidmentioning

confidence: 99%

“…These fluids (eg, Ringer’s lactate, Hartmann’s solution) have minimal effects on pH but are relatively hypotonic which can exacerbate edema particularly cerebral edema in the injured brain. 56 …”

Section: Circulation: the Optimal Resuscitation Fluidmentioning

confidence: 99%

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

El-Swaify

Refaat

Ali

et al. 2022

Trauma Surg Acute Care Open

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Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.

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Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients

Cited by 117 publications

References 21 publications

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

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

Resuscitation fluids as drugs: targeting the endothelial glycocalyx

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

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