Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study

Pfortmueller, Carmen A.; Funk, Georg; Reiterer, Christian; Schrott, Andrea; Zotti, Oliver; Kabon, Barbara; Fleischmann, Edith; Lindner, Gregor

doi:10.1016/j.bja.2017.11.088

Cited by 50 publications

(29 citation statements)

References 45 publications

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“…Based on observed point estimates, the current study found that patients with sepsis assigned to balanced crystalloids rather than saline appeared to receive lower doses of vasopressors and experience lower plasma lactate concentrations after ICU admission. Two prior randomized trials among adults undergoing surgery have reported lower vasopressor requirements among patients assigned to receive balanced crystalloids compared with saline (37,38). If these effects were confirmed in future studies of critically ill patients, additional research focusing on whether these effects are due to saline-associated acidosis on vasculature (14,18) or release of inflammatory mediators (10, 16) could be undertaken.…”

Section: Discussionmentioning

confidence: 96%

Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial

Brown

Wang²,

Coston³

et al. 2019

Am J Respir Crit Care Med

122

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Rationale: Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown. Objectives: To compare the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis. Methods: Secondary analysis of patients from SMART (Isotonic Solutions and Major Adverse Renal Events Trial) admitted to the medical ICU with an International Classification of Diseases, 10th Edition, Clinical Modification System code for sepsis, using multivariable regression to control for potential confounders. Measurements and Main Results: Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio [aOR], 0.74; 95% confidence interval [CI], 0.59-0.93; P = 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 6 12 vs. 19 6 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 6 12 vs. 19 6 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group. Conclusions: Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline. Clinical trial registered with www.clinicaltrials.gov (NCT02444988).

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Section: Discussionmentioning

confidence: 96%

Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial

Brown

Wang²,

Coston³

et al. 2019

Am J Respir Crit Care Med

122

View full text Add to dashboard Cite

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“…A second trial conducted in 15 802 critically ill patients also found that balanced crystalloids were associated with fewer major adverse kidney events than normal saline. A recent trial comparing normal saline with buffered solutions in patients undergoing major abdominal surgery was terminated prematurely because of the increased need for vasopressor therapy in the saline group, possibly related to hyperchloraemic metabolic acidosis. Among balanced fluids, data are still lacking to guide selection of the optimal buffer (lactate or acetate).…”

Section: Perioperative Phasementioning

confidence: 99%

Perioperative fluid management for major elective surgery

Heming

Moine

Coscas

et al. 2020

British Journal of Surgery

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Background Adequate fluid balance before, during and after surgery may reduce morbidity. This review examines current concepts surrounding fluid management in major elective surgery. Method A narrative review was undertaken following a PubMed search for English language reports published before July 2019 using the terms ‘surgery’, ‘fluids’, ‘fluid therapy’, ‘colloids’, ‘crystalloids’, ‘albumin’, ‘starch’, ‘saline’, ‘gelatin’ and ‘goal directed therapy’. Additional reports were identified by examining the reference lists of selected articles. Results Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative phase. Zero‐balance fluid therapy should be aimed for. In high‐risk patients, individualized haemodynamic management should be titrated through the use of goal‐directed therapy. The optimal type of fluid to be administered during major surgery remains to be determined. Conclusion Perioperative fluid management is a key challenge during major surgery. Individualized volume optimization by means of goal‐directed therapy is warranted during high‐risk surgery. In most patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional research on the optimal type of fluid for use during major surgery is needed.

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“…[ 5 , 8 , 9 ] In a study by Pfortmueller et al, the use of 0.9%S in high-risk patients undergoing major abdominal surgery was associated with the need to use catecholamines more frequently, while replacing 0.9%S with BCs reduced the need for these drugs by 50%. [ 25 ]…”

Section: Discussionmentioning

confidence: 99%

Clinical practice on intra-operative fluid therapy in Poland

Szczepańska

Pluta²,

Krzych³

2020

Medicine

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Intra-operative fluid therapy (IFT) is the cornerstone of peri-operative management as it may significantly influence the treatment outcome. Therefore, we sought to evaluate nationwide clinical practice regarding IFT in Poland. A cross-sectional, multicenter, point-prevalence study was performed on April 5, 2018, in 31 hospitals in Poland. Five hundred eighty-seven adult patients undergoing non-cardiac surgery were investigated. The volume and type of fluids transfused with respect to the patient and procedure risk were assessed. The study group consisted of 587 subjects, aged 58 (interquartile range [IQR] 40–67) years, including 142 (24%) American Society of Anesthesiology Physical Status (ASA-PS) class III+ patients. The median total fluid dose was 8.6 mL kg −1 h −1 (IQR 6–12.5), predominantly including balanced crystalloids (7.0 mL kg −1 h −1 , IQR 4.9–10.6). The dose of 0.9% saline was low (1.6 mL kg −1 h −1 , IQR 0.8–3.7). Synthetic colloids were used in 66 (11%) subjects. The IFT was dependent on the risk involved, while the transfused volumes were lower in ASA-PS III+ patients, as well as in high-risk procedures ( P < .05). The practice of IFT is liberal but is adjusted to the preoperative risk. The consumption of synthetic colloids and 0.9% saline is low.

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Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study

Abstract: EudraCT 2014-004867-19, NCT 02414555.

Cited by 50 publications

References 45 publications

Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial

Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial

Perioperative fluid management for major elective surgery

Clinical practice on intra-operative fluid therapy in Poland

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