101
|
Hammond DA, Lam SW, Rech MA, Smith MN, Westrick J, Trivedi AP, Balk RA. Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:5-13. [DOI: 10.1177/1060028019866420] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: The optimal resuscitative fluid remains controversial. Objective: To assess the association between crystalloid fluid and outcomes in critically ill adults. Methods: Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, and Cochrane Central Register for Controlled Trials were searched from inception through July 2019. Cohort studies and randomized trials of critically ill adults provided predominantly nonperioperative fluid resuscitation with balanced crystalloids or 0.9% sodium chloride (saline) were included. Results: Thirteen studies (n = 30 950) were included. Balanced crystalloids demonstrated lower hospital or 28-/30-day mortality (risk ratio [RR] = 0.86; 95% CI = 0.75-0.99; I2 = 82%) overall, in observational studies (RR = 0.64; 95% CI = 0.41-0.99; I2 = 63%), and approached significance in randomized trials (RR = 0.94; 95% CI = 0.88-1.02; I2 = 0%). New acute kidney injury occurred less frequently with balanced crystalloids (RR = 0.91; 95% CI = 0.85-0.98; I2 = 0%), though progression to renal replacement therapy was similar (RR = 0.91; 95% CI = 0.79-1.04; I2 = 38%). In the sepsis cohort, odds of hospital or 28-/30-day mortality were similar, but the odds of major adverse kidney events occurring in the first 30 days were less with balanced crystalloids than saline (OR = 0.78; 95% CI = 0.66-0.91; I2 = 42%). Conclusion and Relevance: Resuscitation with balanced crystalloids demonstrated lower hospital or 28-/30-day mortality compared with saline in critically ill adults but not specifically those with sepsis. Balanced crystalloids should be provided preferentially to saline in most critically ill adult patients.
Collapse
|
102
|
Affiliation(s)
- Hans-Joachim Priebe
- Department of Anesthesia and Critical Care, University Hospital Freiburg, Freiburg, Germany,
| |
Collapse
|
103
|
Goad NT, Bakhru RN, Pirkle JL, Kenes MT. Association of Hyperchloremia With Unfavorable Clinical Outcomes in Adults With Diabetic Ketoacidosis. J Intensive Care Med 2019; 35:1307-1313. [PMID: 31342846 DOI: 10.1177/0885066619865469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Hyperchloremia is associated with worsened outcomes in various clinical situations; however, data are limited in patients with diabetic ketoacidosis (DKA). The purpose of this study was to determine the effect of hyperchloremia on time to DKA resolution. METHODS We conducted a retrospective cohort study of adult patients admitted with incident DKA from January 2013 through October 2017 and stratified by the development of hyperchloremia versus maintaining normochloremia. The primary outcome was time to final DKA resolution. Secondary outcomes included time to initial DKA resolution, incidence of acute kidney injury (AKI) on admission, in-hospital development of AKI, and hospital length of stay (LOS). RESULTS Of the 102 patients included, 52 developed hyperchloremia. Patients with hyperchloremia had longer times to final DKA resolution compared to those with normochloremia (median 22.3 [interquartile range, IQR, 15.2-36.9] vs 14.2 [IQR 8.8-21.1] hours; P = .001). Time to initial DKA resolution was also longer in patients who developed hyperchloremia compared to those who did not (median 16.3 vs 10.9 hours; P = .024). More patients with hyperchloremia developed in-hospital AKI (26.9% vs 8.0%; P = .01). Median hospital LOS was significantly longer in the hyperchloremia cohort (P < .001). On Cox regression analysis, time to DKA resolution was significantly longer with each 1 mmol/L increase in serum chloride (HR 0.951; P < .001). CONCLUSION The presence of hyperchloremia in patients with DKA was associated with increased time to DKA resolution, risk of in-hospital AKI, and hospital LOS. Further evaluation of the avoidance or treatment of hyperchloremia in DKA is needed.
Collapse
Affiliation(s)
- Nathan T Goad
- Department of Pharmacy, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Rita N Bakhru
- Department of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - James L Pirkle
- Department of Nephrology, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Michael T Kenes
- Department of Pharmacy, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| |
Collapse
|
104
|
Antequera Martín AM, Barea Mendoza JA, Muriel A, Sáez I, Chico‐Fernández M, Estrada‐Lorenzo JM, Plana MN. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev 2019; 7:CD012247. [PMID: 31334842 PMCID: PMC6647932 DOI: 10.1002/14651858.cd012247.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fluid therapy is one of the main interventions provided for critically ill patients, although there is no general consensus regarding the type of solution. Among crystalloid solutions, 0.9% saline is the most commonly administered. Buffered solutions may offer some theoretical advantages (less metabolic acidosis, less electrolyte disturbance), but the clinical relevance of these remains unknown. OBJECTIVES To assess the effects of buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. SEARCH METHODS We searched the following databases to July 2018: CENTRAL, MEDLINE, Embase, CINAHL, and four trials registers. We checked references, conducted backward and forward citation searching of relevant articles, and contacted study authors to identify additional studies. We imposed no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) with parallel or cross-over design examining buffered solutions versus intravenous 0.9% saline in a critical care setting (resuscitation or maintenance). We included studies on participants with critical illness (including trauma and burns) or undergoing emergency surgery during critical illness who required intravenous fluid therapy. We included studies of adults and children. We included studies with more than two arms if they fulfilled all of our inclusion criteria. We excluded studies performed in persons undergoing elective surgery and studies with multiple interventions in the same arm. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. We assessed our intervention effects using random-effects models, but when one or two trials contributed to 75% of randomized participants, we used fixed-effect models. We reported outcomes with 95% confidence intervals (CIs). MAIN RESULTS We included 21 RCTs (20,213 participants) and identified three ongoing studies. Three RCTs contributed 19,054 participants (94.2%). Four RCTs (402 participants) were conducted among children with severe dehydration and dengue shock syndrome. Fourteen trials reported results on mortality, and nine reported on acute renal injury. Sixteen included trials were conducted in adults, four in the paediatric population, and one trial limited neither minimum or maximum age as an inclusion criterion. Eight studies involving 19,218 participants were rated as high methodological quality (trials with overall low risk of bias according to the domains: allocation concealment, blinding of participants/assessors, incomplete outcome data, and selective reporting), and in the remaining trials, some form of bias was introduced or could not be ruled out.We found no evidence of an effect of buffered solutions on in-hospital mortality (odds ratio (OR) 0.91, 95% CI 0.83 to 1.01; 19,664 participants; 14 studies; high-certainty evidence). Based on a mortality rate of 119 per 1000, buffered solutions could reduce mortality by 21 per 1000 or could increase mortality by 1 per 1000. Similarly, we found no evidence of an effect of buffered solutions on acute renal injury (OR 0.92, 95% CI 0.84 to 1.00; 18,701 participants; 9 studies; low-certainty evidence). Based on a rate of 121 per 1000, buffered solutions could reduce the rate of acute renal injury by 19 per 1000, or result in no difference in the rate of acute renal injury. Buffered solutions did not show an effect on organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; 266 participants; 5 studies; very low-certainty evidence). Evidence on the effects of buffered solutions on electrolyte disturbances varied: potassium (mean difference (MD) 0.09, 95% CI -0.10 to 0.27; 158 participants; 4 studies; very low-certainty evidence); chloride (MD -3.02, 95% CI -5.24 to -0.80; 351 participants; 7 studies; very low-certainty evidence); pH (MD 0.04, 95% CI 0.02 to 0.06; 200 participants; 3 studies; very low-certainty evidence); and bicarbonate (MD 2.26, 95% CI 1.25 to 3.27; 344 participants; 6 studies; very low-certainty evidence). AUTHORS' CONCLUSIONS We found no effect of buffered solutions on preventing in-hospital mortality compared to 0.9% saline solutions in critically ill patients. The certainty of evidence for this finding was high, indicating that further research would detect little or no difference in mortality. The effects of buffered solutions and 0.9% saline solutions on preventing acute kidney injury were similar in this setting. The certainty of evidence for this finding was low, and further research could change this conclusion. Patients treated with buffered solutions showed lower chloride levels, higher levels of bicarbonate, and higher pH. The certainty of evidence for these findings was very low. Future research should further examine patient-centred outcomes such as quality of life. The three ongoing studies once published and assessed may alter the conclusions of the review.
Collapse
Affiliation(s)
- Alba M Antequera Martín
- La Princesa HospitalInternal Medicine DepartmentDiego de León, 62MadridSpain28006
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
| | - Jesus A Barea Mendoza
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | - Alfonso Muriel
- Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP)Clinical Biostatistics UnitCarretera de Colmenar Km 9.100MadridSpain28034
| | - Ignacio Sáez
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | - Mario Chico‐Fernández
- 12 de Octubre HospitalIntensive Care DepartmentAvda de Cordoba, s/n, 28041MadridSpain
| | | | - Maria N Plana
- Hospital Universitario Príncipe de Asturias. CIBER Epidemiology and Public Health (CIBERESP)Department of Preventive Medicine and Public HealthCtra. Alcalá‐Meco s/nAlcalá de HenaresMadridMadridSpain28805
| | | |
Collapse
|
105
|
Hawkins WA, Smith SE, Newsome AS, Carr JR, Bland CM, Branan TN. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract 2019; 33:863-873. [PMID: 31256705 PMCID: PMC7675763 DOI: 10.1177/0897190019853979] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Intravenous fluids (IVFs) are the most common drugs administered in the intensive care unit. Despite the ubiquitous use, IVFs are not benign and carry significant risks associated with under- or overadministration. Hypovolemia is associated with decreased organ perfusion, ischemia, and multi-organ failure. Hypervolemia and volume overload are associated with organ dysfunction, delayed liberation from mechanical ventilation, and increased mortality. Despite appropriate provision of IVF, adverse drug effects such as electrolyte abnormalities and acid-base disturbances may occur. The management of volume status in critically ill patients is both dynamic and tenuous, a process that requires frequent monitoring and high clinical acumen. Because patient-specific considerations for fluid therapy evolve across the continuum of critical illness, a standard approach to the assessment of fluid needs and prescription of IVF therapy is necessary. We propose the principle of "fluid stewardship," guided by 4 rights of medication safety: right patient, right drug, right route, and right dose. The successful implementation of fluid stewardship will aid pharmacists in making decisions regarding IVF therapy to optimize hemodynamic management and improve patient outcomes. Additionally, we highlight several areas of focus for future research, guided by the 4 rights construct of fluid stewardship.
Collapse
Affiliation(s)
- W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA.,Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - John R Carr
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, GA, USA
| | - Christopher M Bland
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, GA, USA.,Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, GA, USA
| | - Trisha N Branan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| |
Collapse
|
106
|
Impact of Point-of-Care Ultrasound in the Emergency Department on Care Processes and Outcomes in Critically Ill Nontraumatic Patients. Crit Care Explor 2019; 1:e0019. [PMID: 32166263 PMCID: PMC7063915 DOI: 10.1097/cce.0000000000000019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. Outcomes data on point-of-care ultrasound (POCUS) in critically ill patients are lacking. This study examines the association between POCUS in the emergency department and outcomes in critically ill patients.
Collapse
|
107
|
Weiss SL, Balamuth F, Thurm CW, Downes KJ, Fitzgerald JC, Laskin BL. Major Adverse Kidney Events in Pediatric Sepsis. Clin J Am Soc Nephrol 2019; 14:664-672. [PMID: 31000518 PMCID: PMC6500940 DOI: 10.2215/cjn.12201018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Major adverse kidney events, a composite of death, new kidney replacement therapy, or persistent kidney dysfunction, is a potential patient-centered outcome for clinical trials in sepsis-associated kidney injury. We sought to determine the incidence of major adverse kidney events within 30 days and validate this end point in pediatric sepsis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective observational study using the Pediatric Health Information Systems Plus database of patients >6 months to <18 years old with a diagnosis of severe sepsis/septic shock; orders for bacterial blood culture, antibiotics, and at least one fluid bolus on hospital day 0/1; and known hospital disposition between January 2007 and December 2011. The primary outcome was incidence of major adverse kidney events within 30 days. Major adverse kidney events within 30 days were validated against all-cause mortality at hospital discharge, hospital length of stay, total hospital costs, hospital readmission within 30 days and 1 year, and lowest eGFR between 3 months and 1 year after discharge. We reported incidence of major adverse kidney events within 30 days with 95% confidence intervals using robust SEM and used multivariable logistic regression to test the association of major adverse kidney events within 30 days with hospital costs and mortality. RESULTS Of 1685 admissions, incidence of major adverse kidney events within 30 days was 9.6% (95% confidence interval, 8.1% to 11.0%), including 4.5% (95% confidence interval, 3.5% to 5.4%) death, 1.7% (95% confidence interval, 1.1% to 2.3%) kidney replacement therapy, and 5.8% (95% confidence interval, 4.7% to 6.9%) persistent kidney dysfunction. Patients with versus without major adverse kidney events within 30 days had higher all-cause mortality at hospital discharge (28% versus 1%; P<0.001), higher total hospital costs ($61,188; interquartile range, $21,272-140,356 versus $28,107; interquartile range, $13,056-72,697; P<0.001), and higher proportion with eGFR<60 ml/min per 1.73 m2 between 3 months and 1 year after discharge (19% versus 4%; P=0.001). Major adverse kidney events within 30 days was not associated with length of stay or readmissions. CONCLUSIONS In children with sepsis, major adverse kidney events within 30 days are common, feasible to measure, and a promising end point for future clinical trials.
Collapse
Affiliation(s)
- Scott L Weiss
- Departments of Anesthesiology and Critical Care and .,Pediatric Sepsis Program at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Mitochondrial and Epigenomic Medicine at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Kevin J Downes
- Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Julie C Fitzgerald
- Departments of Anesthesiology and Critical Care and.,Pediatric Sepsis Program at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin L Laskin
- Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
108
|
Lima MF, Neville IS, Cavalheiro S, Bourguignon DC, Pelosi P, Malbouisson LMS. Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial. J Neurosurg Anesthesiol 2019; 31:30-35. [PMID: 29912723 DOI: 10.1097/ana.0000000000000515] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. METHODS In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. RESULTS Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [-1.0; 3.0] mmol/L; P<0.001). Saline use also resulted in increased post-preopΔBE (-4.4 [-5.0; -2.3] vs. -0.4 [-2.7; 1.3] mmol/L; P<0.001) and hyperchloremic acidosis incidence (6/25 [24%] vs. 0; P=0.022) compared with balanced crystalloid. Brain relaxation score was comparable between groups. CONCLUSIONS In children undergoing brain tumor resection, saline infusion increased variation in serum chloride compared with balanced crystalloid. These findings support the use of balanced crystalloid solutions in children undergoing brain tumor resection.
Collapse
Affiliation(s)
- Mariana F Lima
- Departments of Anesthesiology.,Department of Anesthesiology
| | - Iuri S Neville
- Neurosurgery, Hospital das Clínicas, University of São Paulo
| | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
| | | |
Collapse
|
109
|
Effects of chloride content of intravenous crystalloid solutions in critically ill adult patients: a meta-analysis with trial sequential analysis of randomized trials. Ann Intensive Care 2019; 9:30. [PMID: 30758680 PMCID: PMC6374495 DOI: 10.1186/s13613-019-0506-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/04/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intravenous crystalloid solutions are administered commonly for critically ill patients. We performed this meta-analysis of randomized trials with trial sequential analysis (TSA) to evaluate effects of chloride content of intravenous crystalloid solutions on clinical outcomes among critically ill adult patients. METHODS Electronic databases were searched up to June 1, 2018, for randomized trials of use of balanced crystalloids versus 0.9% saline solutions in critically ill adult patients. The outcome variables included mortality, renal outcomes, serum content alterations and organ function. Subgroup analysis was conducted according to patient settings, types or volume of crystalloid fluid, or among sepsis versus non-sepsis, TBI versus non-TBI or subpopulations by the categories of baseline kidney function. Random errors were evaluated by trial sequential analysis. RESULTS Eight studies with 19,301 patients were analyzed. A trend of in-hospital survival benefit with no statistical difference could be observed with balanced crystalloids compared with 0.9% saline (RR 0.92, 95% CI 0.85-1.0, p = 0.06). The use of balanced crystalloid solutions was associated with longer RRT-free days (SMD 0.09, 95% CI 0.06-0.12, p < 0.001), less risk of increase in serum concentrations of chloride (SMD - 1.23, 95% CI - 1.59 to - 0.87, p < 0.001) and sodium (SMD - 1.28, 95% CI - 1.65 to - 0.92, p < 0.001), less risk of decline in serum base deficit (SMD - 0.58, 95% CI - 0.98 to - 0.18, p = 0.004), longer ventilator-free days (SMD 0.08, 95% CI 0.05-0.11, p < 0.001) and vasopressor-free days (SMD 0.04, 95% CI 0.00-0.07, p = 0.02). Subgroup analysis showed that balanced crystalloid solutions were associated with a reduced in-hospital mortality rate among septic patients (RR 0.86, 95% CI 0.75-0.98; p = 0.02) and non-traumatic brain injury patients (RR 0.90, 95% CI 0.82-0.99, p = 0.02), while the TSA results indicated a larger sample size is still in need. CONCLUSIONS Limited evidence supported statistical survival benefit with balanced crystalloid solutions, while it benefited in reducing organ support duration and fluctuations in serum electrolyte and base excess and was associated with decreased in-hospital mortality in subpopulation with sepsis and non-TBI. Large-scale rigorous randomized trials with better designs are needed to provide robust evidence for clinical management. Trial registration The protocol for this meta-analysis was registered on PROSPERO: International prospective register of systematic reviews (CRD42018102661), https://www.crd.york.ac.uk/prospero/#recordDetails.
Collapse
|
110
|
Honore PM, Barreto Gutierrez L, Spapen HD. Renal protection in sepsis: Is hypertonic sodium (lactate) the solution? Ann Intensive Care 2019; 9:28. [PMID: 30737559 PMCID: PMC6368633 DOI: 10.1186/s13613-019-0505-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/01/2019] [Indexed: 01/29/2023] Open
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann/Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium.
| | - Leonel Barreto Gutierrez
- ICU Department, Centre Hospitalier Universitaire Brugmann/Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Herbert D Spapen
- Ageing and Pathology Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
111
|
Hecker A, Reichert M, Reuß CJ, Schmoch T, Riedel JG, Schneck E, Padberg W, Weigand MA, Hecker M. Intra-abdominal sepsis: new definitions and current clinical standards. Langenbecks Arch Surg 2019; 404:257-271. [DOI: 10.1007/s00423-019-01752-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
|
112
|
Semler MW, Janz DR, Casey JD, Self WH, Rice TW. Conservative Fluid Management After Sepsis Resuscitation: A Pilot Randomized Trial. J Intensive Care Med 2019; 35:1374-1382. [PMID: 30630380 DOI: 10.1177/0885066618823183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE The feasibility and clinical outcomes of conservative fluid management after sepsis resuscitation remain unknown. OBJECTIVES To evaluate the effect of a conservative fluid management protocol on fluid balance and intensive care unit (ICU)-free days among patients with sepsis. METHODS In a single-center phase II/III randomized trial, we enrolled adults with suspected infection, ≥2 systemic inflammatory response syndrome criteria, and either shock (mean arterial pressure <60 mm Hg or vasopressors) or respiratory insufficiency (mechanical ventilation or oxygen saturation <97% and fraction of inspired oxygen ≥0.3). Patients were randomized 1:1 to usual care or a conservative fluid management protocol. The protocol restricted intravenous fluid administration during shock to treatment of oliguria or increasing vasopressor requirement. In the absence of shock, loop diuretic infusion targeted equal fluid input and output each study day. The primary outcomes were mean daily fluid balance (phase II) and ICU-free days (phase III). RESULTS At the completion of phase II (n = 30), the difference in mean daily fluid balance between groups (-398 mL) was less than the prespecified threshold (-500 mL) and the trial was stopped. Patients in the conservative fluid management (n = 15) and usual care (n = 15) groups experienced similar cumulative fluid input (8450 mL vs 7049 mL; P = .90) of which only 14% was intravenous crystalloid or colloid. Loop diuretic infusion occurred more frequently in the conservative fluid management group (40% vs 0%; P = .02), and cumulative fluid output was 10 645 mL in the conservative fluid management group compared to 6286 mL in the usual care group (P = .39). Hemodynamic, respiratory, and renal function did not differ between the groups. CONCLUSIONS In this phase II trial, a conservative fluid management protocol did not decrease mean daily fluid balance by more than 500 mL among patients with sepsis. REGISTRATION Clinicaltrials.gov; NCT02159079.
Collapse
Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David R Janz
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
113
|
Jayashree M, Williams V, Iyer R. Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives. Diabetes Metab Syndr Obes 2019; 12:2355-2361. [PMID: 31814748 PMCID: PMC6858801 DOI: 10.2147/dmso.s194944] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/24/2019] [Indexed: 12/19/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a preventable life-threatening complication of type 1 diabetes. Fluids form a crucial component of DKA therapy, goals being the restoration of intravascular, interstitial and intracellular compartments. Hydration reduces hyperglycemia by decreased counter-regulatory hormones, enhanced renal glucose clearance and augmented insulin sensitivity. However, for the last several decades, fluids in DKA have been subject of intense debate owing to their possible role in causation of cerebral edema (CE). Rehydration protocols have been modified to prevent major osmotic shifts, correct electrolyte imbalances and avoid cerebral or pulmonary edema. In DKA, a conservative deficit assumption ranging from 6.5% to 8.5% is preferred. Normal saline (0.9%) has been the traditional fluid of choice, for both, volume resuscitation and deficit replacement in DKA. However, the risk of AKI with its liberal chloride content remains a contentious issue. On the other hand, balanced crystalloids with restricted chloride content need more exploration in children with DKA, both with respect to DKA resolution and AKI. Although fluids are an integral part of DKA management, a fine balance is needed to avoid under-hydration or over-hydration during DKA management. In this narrative review, we discuss the current perspectives on fluids in pediatric DKA.
Collapse
Affiliation(s)
- Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence: Muralidharan Jayashree Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, IndiaTel +91 172 275 5311Fax +91-172-2744401 Email
| | - Vijai Williams
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajalakshmi Iyer
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
114
|
Kawano-Dourado L, Zampieri FG, Azevedo LCP, Corrêa TD, Figueiró M, Semler MW, Kellum JA, Cavalcanti AB. Low- Versus High-Chloride Content Intravenous Solutions for Critically Ill and Perioperative Adult Patients: A Systematic Review and Meta-analysis. Anesth Analg 2018; 126:513-521. [PMID: 29189271 DOI: 10.1213/ane.0000000000002641] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND To assess whether use of low-chloride solutions in unselected critically ill or perioperative adult patients for maintenance or resuscitation reduces mortality and renal replacement therapy (RRT) use when compared to high-chloride fluids. METHODS Systematic review and meta-analysis with random-effects inverse variance model. PubMed, Cochrane library, EMBASE, LILACS, and Web of Science were searched from inception to October 2016. Published and unpublished randomized controlled trials in any language that enrolled critically ill and/or perioperative adult patients and compared a low- to a highchloride solution for volume maintenance or resuscitation. The primary outcomes were mortality and RRT use. We conducted trial sequential analyses and assessed risk of bias of individual trials and the overall quality of evidence. Fifteen trials with 4067 patients, most at low risk of bias, were identified. Of those, only 11 and 10 trials had data on mortality and RRT use, respectively. A total of 3710 patients were included in the mortality analysis and 3724 in the RRT analysis. RESULTS No statistically significant impact on mortality (odds ratio, 0.90; 95% confidence interval, 0.69-1.17; P = .44; I = 0%) or RRT use (odds ratio, 1.12; 95% confidence interval, 0.80-1.58; P = .52; I = 0%) was found. Overall quality of evidence was low for both primary outcomes. Trial sequential analyses highlighted that the sample size needed was much larger than that available for properly powered outcome assessment. CONCLUSIONS The current evidence on low- versus high-chloride solutions for unselected critically ill or perioperative adult patients demonstrates no benefit, but suffers from considerable imprecision. We noted a limited exposure volume for study fluids and a relatively low risk of the populations in each study. Together with the relatively small pooled sample size, these data leave us underpowered to detect potentially important differences. Results from well-conducted, adequately powered randomized controlled trials examining sufficiently large fluid exposure are necessary.
Collapse
Affiliation(s)
- Leticia Kawano-Dourado
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil.,Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Fernando G Zampieri
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Luciano C P Azevedo
- Intensive Care Unit, Hospital Sirio Libanes, São Paulo, Brazil.,Emergency Medicine Discipline, University of São Paulo Medical School, São Paulo, Brazil
| | - Thiago D Corrêa
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mabel Figueiró
- From the Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | |
Collapse
|
115
|
Abstract
Asthma is among the most common chronic diseases worldwide and is a significant contributor to the global health burden, highlighting the urgent need for primary prevention. This article outlines several practical and conceptual challenges that accompany primary prevention efforts. It advocates for improved predictive modeling to identify those at high-risk of developing asthma using automated algorithms within electronic medical records systems and explanatory modeling to refine understanding of causal pathways. Understanding the many issues that are likely to affect the success of primary prevention efforts helps the community of individuals invested in asthma prevention organize efforts and maximize their impact.
Collapse
|
116
|
Ma P, Wang B, Zhang J, Shen X, Yu L, Dou X. Balanced crystalloids for intravenous fluid therapy in critically ill and non-critically ill patients: A protocol for systematic review and network meta-analyses. Medicine (Baltimore) 2018; 97:e13683. [PMID: 30572491 PMCID: PMC6320151 DOI: 10.1097/md.0000000000013683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The balanced crystalloids have become a substitute for saline for fluid resuscitation. Some studies have investigated the clinical effect and adverse event of differently balanced crystalloids, but they have no consistent conclusions. This study aims to assess and compare the effect of differently balanced crystalloids for intravenous fluid therapy in critically ill and non-critically ill patients using network meta-analysis (NMA). METHODS Electronic databases including PubMed, EMBASE, Cochrane Library, Web of Science, Clinical Trials.gov, and the International Clinical Trials Registry Platform (ICTRP) will be searched from inception to April 2018. We will include randomized controlled trials (RCTs) that reported the effect and adverse event of balanced crystalloids. Risk of bias assessment of the included RCTs will be conducted according to the Cochrane Handbook 5.1.0. A Bayesian NMA will be performed using R software. GRADE will be used to explore the quality of evidence. RESULTS The results of this NMA will be published in a peer-reviewed journal. CONCLUSION This NMA will summarize the direct and indirect evidence to assess the effect of differently balanced crystalloids. ETHICS AND DISSEMINATION Ethics approval and patient consent are not required as this study is an NMA based on published studies. PROSPERO REGISTRATION NUMBER CRD42018093818.
Collapse
Affiliation(s)
- Peifen Ma
- Department of Nursing, Lanzhou University Second Hospital
- School of Nursing, Lanzhou University
| | - Bo Wang
- Department of Nursing, Rehabilitation Center Hospital of Gansu Province
| | - Jun Zhang
- School of Nursing, Gansu University of Chinese Medicine
| | - Xiping Shen
- Institute of Epidemiology and Health Statistics, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liping Yu
- Department of Nursing, Rehabilitation Center Hospital of Gansu Province
| | - Xinman Dou
- Department of Nursing, Lanzhou University Second Hospital
| |
Collapse
|
117
|
Claret PG, Oberlin M, Martinez M, Epifanie S, Lefort H, Le Conte P. Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
118
|
Zarbock A, Koyner JL, Hoste EAJ, Kellum JA. Update on Perioperative Acute Kidney Injury. Anesth Analg 2018; 127:1236-1245. [DOI: 10.1213/ane.0000000000003741] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
119
|
Small volume resuscitation with 20% albumin in intensive care: physiological effects. Intensive Care Med 2018; 44:1797-1806. [DOI: 10.1007/s00134-018-5253-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/28/2018] [Indexed: 01/30/2023]
|
120
|
Heyland DK, Patel J, Bear D, Sacks G, Nixdorf H, Dolan J, Aloupis M, Licastro K, Jovanovic V, Rice TW, Compher C. The Effect of Higher Protein Dosing in Critically Ill Patients: A Multicenter Registry-Based Randomized Trial: The EFFORT Trial. JPEN J Parenter Enteral Nutr 2018; 43:326-334. [PMID: 30260486 DOI: 10.1002/jpen.1449] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/22/2018] [Indexed: 01/22/2023]
Abstract
Current randomized trials and observational studies evaluating higher versus lower protein doses in critically ill patients yield inconclusive results. Because of few studies and methodologic limitations, clinical guidelines suggest a wide range of protein intake based on weak evidence. Clinical equipoise about protein dosing exists. The purpose of the current manuscript is to provide the rationale and protocol for a randomized controlled trial (RCT) of 4000 critically ill patients randomly allocated to receive a higher or lower protein dose. We propose a global, volunteer-driven, registry-based RCT involving >100 intensive care units (ICUs). We will enroll mechanically ventilated patients with high nutrition risk, identified by low (≤25) or high (≥35) body mass index, moderate to severe malnutrition, frailty, sarcopenia, or when >96-hour duration of mechanical ventilation is expected. Exclusion criteria include patients who are >96 hours since initiation of mechanical ventilation, moribund, or pregnant, and where the clinician lacks clinical equipoise regarding protein dose. The intervention consists of higher (≥2.2 g/kg/d) or lower (≤1.2 g/kg/d) protein dose, achieved by enteral nutrition, parenteral nutrition, or both. The primary outcome will be 60-day mortality. Key secondary outcomes include time-to-discharge alive from hospital, ICU and hospital survival, and length of stay. As this is research based on existing medical practice, we will apply for a waiver of informed consent, where possible. The large sample size is a reflection of the small signal we expect to see in this large, pragmatic trial.
Collapse
Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine and Department of Public Health Sciences, Queen's University, and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Danielle Bear
- Department of Critical Care, Department of Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Gordon Sacks
- Auburn University Harrison School of Pharmacy, Auburn, Alabama, USA
| | - Heidi Nixdorf
- Trillium Health Partners, Credit Valley Hospital, Mississauga, Canada
| | - Jennifer Dolan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Marianne Aloupis
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kate Licastro
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Vera Jovanovic
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| |
Collapse
|
121
|
Liu C, Mao Z, Hu P, Hu X, Kang H, Hu J, Yang Z, Ma P, Zhou F. Fluid resuscitation in critically ill patients: a systematic review and network meta-analysis. Ther Clin Risk Manag 2018; 14:1701-1709. [PMID: 30254452 PMCID: PMC6143126 DOI: 10.2147/tcrm.s175080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective The aim of this study was to compare the effectiveness of different fluids on critically ill patients who need fluid resuscitation through a systematic review and network meta-analysis (NMA). Data sources Electronic databases were searched up to March 2018 for randomized controlled trials comparing the effectiveness of different fluids in critically ill patients. The primary outcome was mortality, and the secondary outcomes were the incident of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). A Bayesian NMA was conducted, and the quality of evidence contributing to each network estimate was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria. Results We deemed 49 trials eligible, including 40,910 participants. The quality of evidence was rated as moderate in most comparisons. There was no significant difference among resuscitation fluids in mortality. NMA at the 9-node level showed the most effective fluid was balanced crystalloid (BC) (80.79%, the ranking of resuscitation fluid based on cumulative probability plots and surface under the cumulative ranking curves [SUCRAs]). NMA at the 10-node level showed that the most effective fluid was Plasma-Lyte (77.52%). Results of sensitivity analyses in mortality did not reveal any significant changes in the findings for primary outcomes. High-molecular-weight hetastarch (H-HES) was associated with an increased incidence of AKI when compared with gelatin (odds ratio [OR], 0.43; 95% credibility interval [CrI], 0.19–0.94), low-molecular-weight hetastarch (L-HES; OR, 0.50; 95% CrI, 0.30–0.87), BC (OR, 0.55; 95% CrI, 0.34–0.88), and normal saline (OR, 0.56; 95% CrI, 0.34–0.93). Meanwhile, H-HES was also associated with an increased risk of receiving RRT when compared with BC (OR, 0.51; 95% CrI, 0.27–0.93) and normal saline (OR, 0.52; 95% CrI, 0.24–0.96). Conclusion BCs, especially the Plasma-Lyte, are presumably the best choice for most critically ill patients who need fluid resuscitation. Meanwhile, the use of H-HES was associated with an increased incidence of AKI and risk of receiving RRT. Registration PROSPERO (CRD42017072728).
Collapse
Affiliation(s)
- Chao Liu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Pan Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Xin Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Hongjun Kang
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Jie Hu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| | - Zhifang Yang
- Beijing Institute of Pharmacology and Toxicology, Beijing, People's Republic of China
| | - Penglin Ma
- Department of Critical Care Medicine, the 309th Hospital of Chinese People's Liberation Army, Beijing, People's Republic of China,
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China, .,National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China,
| |
Collapse
|
122
|
Janssens U. Flüssigkeitsersatz bei kritisch kranken Patienten. Med Klin Intensivmed Notfmed 2018; 113:490-493. [DOI: 10.1007/s00063-018-0423-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
|
123
|
McIntyre L, Taljaard M, McArdle T, Fox-Robichaud A, English SW, Martin C, Marshall J, Menon K, Muscedere J, Cook DJ, Weijer C, Saginur R, Maybee A, Iyengar A, Forster A, Graham ID, Hawken S, McCartney C, Seely AJE, Stiell IG, Thavorn K, Fergusson DA. FLUID trial: a protocol for a hospital-wide open-label cluster crossover pragmatic comparative effectiveness randomised pilot trial. BMJ Open 2018; 8:e022780. [PMID: 30139908 PMCID: PMC6112401 DOI: 10.1136/bmjopen-2018-022780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION 0.9% saline and Ringer's lactate are the two most common resuscitation crystalloid fluids. 0.9% saline may lead to hyperchloraemic metabolic acidosis and may be associated with impaired kidney function and death. Few large multicentre randomised trials have been conducted to evaluate the effect of these two fluids on clinically important outcomes. METHODS FLUID is a pragmatic pilot cluster randomised crossover trial in which four hospitals will be randomised to normal saline or Ringer's lactate for 14 weeks, then crossover to the alternative fluid for the subsequent 14 weeks after 1 to 3 week transition. With waiver of informed consent, all adult and paediatric patients admitted to participating sites will be included in the FLUID trial except for neonates. Primary feasibility outcome is study fluid protocol adherence (target:≥80%). Secondary feasibility outcomes include time to research ethics board (REB) approval and readiness to trial initiation (≤3 months from REB submission and approval). Primary (composite of death or re-admission to hospital in first 90 days of index hospitalisation) and secondary clinical outcomes for the future large FLUID trial will be described. Protocol adherence will be collected by site at specified time points. All clinical data will be obtained at patient level through provincial health administrative data held at the Institute for Clinical Evaluative Sciences (ICES). Event rates for the primary and secondary outcomes will be described using frequencies and proportions with 95% CIs. Intracluster and interperiod correlation coefficients will be calculated from population-level data available at ICES. ETHICS AND DISSEMINATION The study protocol has been approved by the Ottawa Health Science Research Ethics Board. The FLUID pilot will determine feasibility, and ICES data across all potential sites in Ontario will allow calculation of sample size parameter estimates to inform the design and implementation of the large trial. TRIAL REGISTRATION NUMBER NCT02721485; Pre-results.
Collapse
Affiliation(s)
- Lauralyn McIntyre
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tracy McArdle
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Shane W English
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Claudio Martin
- Division of Critical Care Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - John Marshall
- Department of Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kusum Menon
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine, Clinical Epidemiology and Biostatistics, St Joseph’s Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, Ontario, Canada
| | - Raphael Saginur
- Department of Medicine, The Ottawa Hospital (Infectious Diseases), University of Ottawa, Ottawa, Ontario, Canada
| | - Alies Maybee
- Patient Engagement Advisory Board, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- The Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian D Graham
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven Hawken
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Colin McCartney
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew JE Seely
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
124
|
Zayed YZM, Aburahma AMY, Barbarawi MO, Hamid K, Banifadel MRN, Rashdan L, Bachuwa GI. Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis. J Intensive Care 2018; 6:51. [PMID: 30140441 PMCID: PMC6098635 DOI: 10.1186/s40560-018-0320-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/07/2018] [Indexed: 02/03/2023] Open
Abstract
Objectives Intravenous fluids are one of the most used medical therapy for patients, especially critically ill patients. We conducted a meta-analysis comparing between balanced crystalloids and normal saline in critically ill patients and its effect on various clinical outcomes. Design Meta-analysis and systematic review of randomized clinical trials (RCTs). Methods and data source Electronic search was performed using PubMed, Cochrane library, and clinical trials.gov from inception through March 1, 2018, with inclusion of prospective studies that investigated one of the primary outcomes which were acute kidney injury (AKI) and in-hospital mortality while secondary outcomes were intensive care unit (ICU) mortality and new renal replacement therapy (RRT). Results Six RCTs were included. Total of 19,332 patients were included in the final analysis. There was no significant difference in in-hospital mortality (11.5% vs 12.2%; OR 0.92; 95% CI 0.85-1.01; P = 0.09; I2 = 0%), incidence of AKI (12% vs 12.7%, OR 0.92; 95% CI 0.84-1.01; P = 0.1; I2 = 0), overall ICU mortality (OR 0.9, 95% CI 0.81-1.01, P = 0.08, I2 = 0%), or need for new RRT (OR 0.92, 95% CI 0.67-1.28, P = 0.65, I2 = 38%) between balanced crystalloids and isotonic saline in critically ill patients. Conclusion Balanced crystalloids and isotonic saline have no difference on various clinical outcomes including in-hospital mortality, AKI, overall ICU mortality, and new RRT. Further powerful clinical trials are required to determine the relationship between crystalloid fluid type and clinical outcomes.
Collapse
Affiliation(s)
- Yazan Z M Zayed
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA.,East Lansing, USA
| | - Ahmed M Y Aburahma
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA
| | - Mahmoud O Barbarawi
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA
| | - Kewan Hamid
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA
| | - Momen R N Banifadel
- 2Internal Medicine Department, University of Toledo College of Medicine and Life Sciences, Toledo, OH USA
| | - Laith Rashdan
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA
| | - Ghassan I Bachuwa
- Internal Medicine Department, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI USA
| |
Collapse
|
125
|
González-Castro A, Ortiz-Lasa M, Rodriguez-Borregan JC, Escudero-Acha P, Chicote E, Suberviola B, Blanco C, Peñasco Y, Jiménez Alfonso A, Llorca J, Dierssen-Soto T. Meta-analysis of the effects of normal saline on mortality in intensive care. ACTA ACUST UNITED AC 2018; 66:3-9. [PMID: 30100089 DOI: 10.1016/j.redar.2018.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/15/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND OBJECTIVE To evaluate, by means of a meta-analysis, the effect of normal saline on mortality in intensive care patients, when compared with the use of balanced crystalloids. MATERIAL AND METHOD Published controlled clinical trials, randomised and sequential prospective studies in time, evaluating the mortality when physiological saline was used in patients admitted to intensive care units. Electronic search was performed in Medline, Embase, Cochrane Library, ISI Proceedings, and Web of Science, as well as a manual search of selected references. An independent evaluation was performed by 2 investigators. Discrepancies were resolved by consensus in the working group. Contingency tables were performed, and the OR with confidence intervals of each study were obtained. Heterogeneity was assessed by I2. Publication bias was assessed using funnel plot and Egger test. RESULTS A total of 8 articles were selected for the meta-analysis of mortality, which included a total of 20,684 patients. A significant association was observed between the use of saline and mortality in intensive care patients (OR 1.0972; 95% CI 1.0049-1.1979), when compared to the use of balanced crystalloids. No statistical evidence of publication bias (Egger, P=.5349) was found. In the sensitivity analysis, none of the studies substantially modified the overall outcome if it was eliminated from the meta-analysis. CONCLUSIONS There may be an increase in mortality associated with the use of saline in patients admitted to intensive care when comparing with the use of balanced crystalloids.
Collapse
Affiliation(s)
- A González-Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España.
| | - M Ortiz-Lasa
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - J C Rodriguez-Borregan
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - P Escudero-Acha
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - E Chicote
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - B Suberviola
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - C Blanco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Y Peñasco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - A Jiménez Alfonso
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - J Llorca
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina de la Universidad de Cantabria, Santander, España
| | - T Dierssen-Soto
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina de la Universidad de Cantabria, Santander, España
| |
Collapse
|
126
|
|
127
|
Insidious Harm of Medication Diluents as a Contributor to Cumulative Volume and Hyperchloremia. Crit Care Med 2018; 46:1217-1223. [DOI: 10.1097/ccm.0000000000003191] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
128
|
Abstract
Among critically ill adults, sepsis remains both common and lethal. In addition to antibiotics and source control, fluid resuscitation is a fundamental sepsis therapy. The physiology of fluid resuscitation for sepsis, however, is complex. A landmark trial found early goal-directed sepsis resuscitation reduced mortality, but 3 recent multicenter trials did not confirm this benefit. Multiple trials in resource-limited settings have found increased mortality with early fluid bolus administration in sepsis, and the optimal approach to early sepsis resuscitation across settings remains unknown. After initial resuscitation, excessive fluid administration may contribute to edema and organ dysfunction. Using dynamic variables such as passive leg raise testing can predict a patient's hemodynamic response to fluid administration better than static variables such as central venous pressure. Whether using measures of "fluid responsiveness" to guide fluid administration improves patient outcomes, however, remains unknown. New evidence suggests improved patient outcomes with the use of balanced crystalloids compared to saline in sepsis. Albumin may be beneficial in septic shock, but other colloids such as starches, dextrans, and gelatins appear to increase the risk of death and acute kidney injury. For the clinician caring for patients with sepsis today, the initial administration of 20 mL/kg of intravenous balanced crystalloid, followed by consideration of the risks and benefits of subsequent fluid administration represents a reasonable approach. Additional research is urgently needed to define the optimal dose, rate, and composition of intravenous fluid during the management of patients with sepsis and septic shock.
Collapse
Affiliation(s)
- Ryan M Brown
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
129
|
Duffy RA, Foroozesh MB, Loflin RD, Ie SR, Icard BL, Tegge AN, Nogueira JR, Kuehl DR, Smith DC, Loschner AL. Normal saline versus Normosol™-R in sepsis resuscitation: A retrospective cohort study. J Intensive Care Soc 2018; 20:223-230. [PMID: 31447915 DOI: 10.1177/1751143718786113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To determine the effect of Normosol™-R as compared to normal saline on the outcomes of acute kidney injury and the need for renal replacement therapy in the resuscitation phase of sepsis. Design Our study is a retrospective before-and-after cohort study. Setting The study occurred at a 700-bed tertiary academic level 1-trauma center. Patients A total of 1218 patients were enrolled through emergency department admissions. The normal saline (before) cohort was defined as the dates between 1 March and 30 September 2014 and the Normosol™-R (after) cohort was assessed from 1 March to 30 September 2015. Interventions None. Measurements and main results Intravenous fluid volumes received during the first 24 h, 72 h, and total hospital stays were compared. Sodium, chloride, potassium, and bicarbonate levels at 72 h were also compared. The medical coded diagnosis of acute kidney failure, need for renal replacement therapy, hospital LOS, ICU admission, ICU LOS, in-hospital mortality, and need for mechanical ventilation were all compared. There was no significant difference in intravenous fluid volumes between groups. Regression modelling controlling for baseline characteristics and 24-h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol™-R cohort were found to have a lower rate of hyperchloremia at 72 h post-admission (28% vs. 13%, P < 0.0001). There was a trend toward a decrease in the hospital and ICU LOS in the Normosol™-R cohort; however, the data were not statistically significant. Conclusions This study was unable to detect any difference in outcomes between sepsis patients who received intravenous fluid resuscitation with either a balanced crystalloid (Normosol™-R) or normal saline, except for a decreased rate of hyperchloremia.
Collapse
Affiliation(s)
- Ryan A Duffy
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Mathab B Foroozesh
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Robert D Loflin
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Susanti R Ie
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Bradley L Icard
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Allison N Tegge
- Department of Statistics, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA
| | - Jonathan R Nogueira
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Dan C Smith
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| | - Anthony L Loschner
- Department of Pulmonary, Critical Care and Sleep Medicine, Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, VA, USA
| |
Collapse
|
130
|
Kwong YD, Liu KD. Selection of Intravenous Fluids. Am J Kidney Dis 2018; 72:900-902. [PMID: 29980374 DOI: 10.1053/j.ajkd.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/12/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Yuenting D Kwong
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco CA
| | - Kathleen D Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco CA; Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, San Francisco CA.
| |
Collapse
|
131
|
Abstract
Asthma is increasingly recognised as a heterogeneous group of diseases with similar clinical presentations rather than a singular disease entity. Asthma was historically categorised by clinical symptoms; however, newer methods of subgrouping, describing and categorising the disease have sub-defined asthma. These sub-definitions are intermittently called phenotypes or endotypes, but the real meanings of these words are poorly understood. Novel treatments are currently and increasingly available, partly in the monoclonal antibody environment, and also some physical therapies (bronchial thermoplasty), but additionally small molecules are not far away from clinical practice. Understanding the disease pathogenesis and the mechanism of action more completely may enable identification of treatable traits, biomarkers, mediators and modifiable therapeutic targets. However, there remains a danger that clinicians become preoccupied with the concept of endotypes and biomarkers, ignoring therapies that are hugely effective but have no companion biomarker. This review discusses our understanding of the concept of phenotypes and endotypes in appreciating and managing the heterogeneous condition that is asthma. We consider the role of functional imaging, physiology, blood-, sputum- and breath-based biomarkers and clinical manifestations that could be used to produce a personalised asthma profile, with implications on prognosis, pathophysiology and most importantly specific therapeutic responses. With the advent of increasing numbers of biological therapies and other interventional options such as bronchial thermoplasty, the importance of targeting expensive therapies to patients with the best chance of clinical response has huge health economic importance.
Collapse
Affiliation(s)
- Katrina Dean
- University Hospital South Manchester, Manchester, UK
| | - Robert Niven
- Manchester Academic Health Science Centre, The University of Manchester and University Hospital South Manchester, Manchester, UK.
| |
Collapse
|
132
|
Jain S. Sepsis: An Update on Current Practices in Diagnosis and Management. Am J Med Sci 2018; 356:277-286. [PMID: 30286823 DOI: 10.1016/j.amjms.2018.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
Despite several advancements in care over the last few decades, sepsis continues to carry a high morbidity and mortality burden in the United States. With its varied presentations, cases of sepsis are likely to be encountered by general practitioners in both inpatient and outpatient settings. In the recent years, there has been much debate about the appropriate criteria to diagnose patients with sepsis with a concurrent change in management guidelines. This article reviews definitions, diagnosis and treatment guidelines in current practice in the management of patients with sepsis.
Collapse
Affiliation(s)
- Snigdha Jain
- Division of Hospital Medicine, UT Southwestern Medical Center, Dallas, Texas.
| |
Collapse
|
133
|
Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, Teboul JL, Rice TW, Mythen M, Monnet X. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018; 8:66. [PMID: 29789983 PMCID: PMC5964054 DOI: 10.1186/s13613-018-0402-x] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the “four D’s” of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?” In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.
Collapse
Affiliation(s)
- Manu L N G Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium. .,Faculteit Geneeskunde en Farmacie, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Niels Van Regenmortel
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Bernd Saugel
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Brecht De Tavernier
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Pieter-Jan Van Gaal
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | | | - Jean-Louis Teboul
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
| | - Todd W Rice
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Monty Mythen
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xavier Monnet
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
| |
Collapse
|
134
|
Abstract
BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration among critically ill adults. Which results in better clinical outcomes remains unknown. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A®), according to the randomization of the unit to which they were admitted. The primary outcome was Major Adverse Kidney Events within 30 days (MAKE30), i.e., the composite of death, new renal replacement therapy, or persistent creatinine elevation ≥ 200% of baseline – all censored at the first of hospital discharge or 30 days. RESULTS: In the balanced crystalloid group, 1,139 patients (14.3%) experienced MAKE30, compared to 1,211 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval, 0.84–0.99; conditional odds ratio, 0.90; 95% confidence interval, 0.82–0.99; P=0.04). Thirty-day in-hospital mortality was 10.3% in the balanced crystalloid group and 11.1% in the saline group (P=0.06). The incidence of new renal replacement therapy was 2.5% and 2.9% respectively (P=0.08), and the incidence of persistent creatinine elevation was 6.4% and 6.6% respectively (P=0.60). CONCLUSIONS: Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration appeared to reduce the composite outcome of in-hospital mortality, new renal replacement therapy, and persistent renal dysfunction compared with the use of saline. (SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779.)
Collapse
Affiliation(s)
| | | | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
135
|
Another nail in the saline coffin. Br J Anaesth 2018; 120:1432-1434. [PMID: 29793612 DOI: 10.1016/j.bja.2018.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 02/21/2018] [Accepted: 02/23/2018] [Indexed: 11/23/2022] Open
|
136
|
Joannidis M, Klein SJ, John S, Schmitz M, Czock D, Druml W, Jörres A, Kindgen-Milles D, Kielstein JT, Oppert M, Schwenger V, Willam C, Zarbock A. [Prevention of acute kidney injury in critically ill patients : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:358-369. [PMID: 29594317 DOI: 10.1007/s00063-018-0413-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) has both high mortality and morbidity. OBJECTIVES To prevent the occurrence of AKI, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations stated in this paper are based on the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines, the published statements of the "Working Group on Prevention, AKI section of the European Society of Intensive Care Medicine" and the expert knowledge and clinical experience of the authors. RESULTS Currently there are no approved clinically effective drugs for the prevention of AKI. Therefore the mainstay of prevention is the optimization of renal perfusion by improving the mean arterial pressure (>65 mm Hg, higher target may be considered in hypertensive patients). This can be done by vasopressors, preferably norepinephrine and achieving or maintaining euvolemia. Hyperhydration that can lead to AKI itself should be avoided. In patients with maintained diuresis this can be done by diuretics that are per se no preventive drug for AKI. Radiocontrast enhanced imaging should not be withheld from patients at risk for AKI; if indicated, however, the contrast media should be limited to the smallest possible volume.
Collapse
Affiliation(s)
- M Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - S J Klein
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität Nürnberg, Klinikum Nürnberg-Süd, Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - M Schmitz
- Klinik für Nephrologie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W Druml
- Department für Innere Medizin III, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Heinrich-Heine-Universität, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J T Kielstein
- Medizinische Klinik V, Nephrologie
- Rheumatologie
- Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Willam
- Nephrologie und Hypertensiologie, Medizinische Klinik 4, Erlangen, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| |
Collapse
|
137
|
Filis C, Vasileiadis I, Koutsoukou A. Hyperchloraemia in sepsis. Ann Intensive Care 2018; 8:43. [PMID: 29589205 PMCID: PMC5869346 DOI: 10.1186/s13613-018-0388-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/17/2018] [Indexed: 12/21/2022] Open
Abstract
Chloride represents—quantitatively—the most prevalent, negatively charged, strong plasma electrolyte. Control of chloride concentration is a probable major mechanism for regulating the body’s acid–base balance and for maintaining homeostasis of the entire internal environment. The difference between the concentrations of chloride and sodium constitutes the major contributor to the strong ion difference (SID); SID is the key pH regulator in the body, according to the physicochemical approach. Hyperchloraemia resulting from either underlying diseases or medical interventions is common in intensive care units. Recent studies have demonstrated the importance of hyperchloraemia in metabolic acidosis and in other pathophysiological disorders present in sepsis. The aim of this narrative review is to present the current knowledge about the effects of hyperchloraemia, in relation to the underlying pathophysiology, in septic patients.
Collapse
Affiliation(s)
- Christos Filis
- 3rd Department of Internal Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Respiratory Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece.
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Respiratory Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece
| |
Collapse
|
138
|
Van Regenmortel N, Verbrugghe W, Roelant E, Van den Wyngaert T, Jorens PG. Maintenance fluid therapy and fluid creep impose more significant fluid, sodium, and chloride burdens than resuscitation fluids in critically ill patients: a retrospective study in a tertiary mixed ICU population. Intensive Care Med 2018; 44:409-417. [PMID: 29589054 PMCID: PMC5924672 DOI: 10.1007/s00134-018-5147-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/08/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Research on intravenous fluid therapy and its side effects, volume, sodium, and chloride overload, has focused almost exclusively on the resuscitation setting. We aimed to quantify all fluid sources in the ICU and assess fluid creep, the hidden and unintentional volume administered as a vehicle for medication or electrolytes. METHODS We precisely recorded the volume, sodium, and chloride burdens imposed by every fluid source administered to 14,654 patients during the cumulative 103,098 days they resided in our 45-bed tertiary ICU and simulated the impact of important strategic fluid choices on patients' chloride burdens. In septic patients, we assessed the impact of the different fluid sources on cumulative fluid balance, an established marker of morbidity. RESULTS Maintenance and replacement fluids accounted for 24.7% of the mean daily total fluid volume, thereby far exceeding resuscitation fluids (6.5%) and were the most important sources of sodium and chloride. Fluid creep represented a striking 32.6% of the mean daily total fluid volume [median 645 mL (IQR 308-1039 mL)]. Chloride levels can be more effectively reduced by adopting a hypotonic maintenance strategy [a daily difference in chloride burden of 30.8 mmol (95% CI 30.5-31.1)] than a balanced resuscitation strategy [daily difference 3.0 mmol (95% CI 2.9-3.1)]. In septic patients, non-resuscitation fluids had a larger absolute impact on cumulative fluid balance than did resuscitation fluids. CONCLUSIONS Inadvertent daily volume, sodium, and chloride loading should be avoided when prescribing maintenance fluids in view of the vast amounts of fluid creep. This is especially important when adopting an isotonic maintenance strategy.
Collapse
Affiliation(s)
- Niels Van Regenmortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium. .,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerp, Belgium.
| | - Walter Verbrugghe
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), Clinical Research Center Antwerp, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Philippe G Jorens
- Department of Intensive Care Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| |
Collapse
|
139
|
Hammond DA, Baumgartner L, Cooper C, Donahey E, Harris SA, Mercer JM, Morris M, Patel MK, Plewa-Rusiecki AM, Poore AA, Szaniawski R, Horner D. Major publications in the critical care pharmacotherapy literature: January-December 2017. J Crit Care 2018; 45:239-246. [PMID: 29496373 DOI: 10.1016/j.jcrc.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2017. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 32 journals monthly for impactful articles and reviewed 115 during 2017. Two meta-analyses and eight original research trials were reviewed here from those included in the monthly CCPLU. Meta-analyses on early, goal-directed therapy for septic shock and statin therapy for acute respiratory distress syndrome were summarized. Original research trials that were included evaluate thrombolytic therapy in severe stroke, hyperoxia and hypertonic saline in septic shock, intraoperative ketamine for prevention of post-operative delirium, intravenous ketorolac dosing regimens for acute pain, angiotensin II for vasodilatory shock, dabigatran reversal with idarucizumab, bivalirudin versus heparin monotherapy for myocardial infarction, and balanced crystalloids versus saline fluid resuscitation. CONCLUSION This clinical review provides perspectives on impactful critical care pharmacotherapy publications in 2017.
Collapse
Affiliation(s)
- Drayton A Hammond
- Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, United States.
| | - Laura Baumgartner
- Touro University California College of Pharmacy, 1310 Club Drive, Vallejo, CA 94592, United States
| | - Craig Cooper
- Roosevelt University College of Pharmacy, 430 S. Michigan Avenue, Chicago, IL 60605, United States.
| | - Elisabeth Donahey
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL 60153, United States.
| | - Serena A Harris
- Eskenazi Health, 720 Eskenazi Avenue, Indianapolis, IN 46202, United States.
| | - Jessica M Mercer
- Roper St Francis Healthcare, 2095 Henry Tecklenburg Drive, Charleston, SC 29414, United States
| | - Mandy Morris
- University of California, San Francisco Medical Center, 533 Parnassus Ave., Box 0622, San Francisco, CA 94143, United States.
| | - Mona K Patel
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, 630 West 168th Street, NY, New York 10032, United States.
| | - Angela M Plewa-Rusiecki
- John H. Stroger, Jr. Hospital of Cook County, 1901 West Harrison Street, LL175, Chicago, IL 60612, United States.
| | - Alia A Poore
- Cleveland Clinic Fairview Hospital, 18101 Lorain Road, Cleveland, OH 44111, United States.
| | - Ryan Szaniawski
- Froedtert & the Medical College of Wisconsin - Community Memorial Hospital, W180 N8085 Town Hall Rd, Menomonee Falls, WI 53226, United States.
| | - Deanna Horner
- United Healthcare Medicare and Retirement - Part D STARs, 2655 Warrenville Road, 3rd floor, Downers Grove, IL 60515, United States.
| |
Collapse
|
140
|
Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
Collapse
Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
141
|
Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med 2018; 378:819-828. [PMID: 29485926 PMCID: PMC5846618 DOI: 10.1056/nejmoa1711586] [Citation(s) in RCA: 384] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01). CONCLUSIONS Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT-ED ClinicalTrials.gov number, NCT02614040 .).
Collapse
Affiliation(s)
- Wesley H Self
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Matthew W Semler
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Jonathan P Wanderer
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Li Wang
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Daniel W Byrne
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Sean P Collins
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Corey M Slovis
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Christopher J Lindsell
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Jesse M Ehrenfeld
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Edward D Siew
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Andrew D Shaw
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Gordon R Bernard
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| | - Todd W Rice
- From the Departments of Emergency Medicine (W.H.S., S.P.C., C.M.S.), Anesthesiology (J.P.W., J.M.E., A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), and Biostatistics (L.W., D.W.B., C.J.L.), the Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine (M.W.S., G.R.B., T.W.R.), and the Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury Research (E.D.S.), Vanderbilt University Medical Center, Nashville
| |
Collapse
|
142
|
Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med 2018; 378:829-839. [PMID: 29485925 PMCID: PMC5846085 DOI: 10.1056/nejmoa1711584] [Citation(s) in RCA: 780] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60). CONCLUSIONS Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779 .).
Collapse
Affiliation(s)
- Matthew W Semler
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Wesley H Self
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jonathan P Wanderer
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jesse M Ehrenfeld
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Li Wang
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Daniel W Byrne
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Joanna L Stollings
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Avinash B Kumar
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Christopher G Hughes
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Antonio Hernandez
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Oscar D Guillamondegui
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Addison K May
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Liza Weavind
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jonathan D Casey
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Edward D Siew
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Andrew D Shaw
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Gordon R Bernard
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Todd W Rice
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| |
Collapse
|
143
|
Duburcq T, Durand A, Tournoys A, Gnemmi V, Gmyr V, Pattou F, Jourdain M, Tamion F, Besnier E, Préau S, Parmentier-Decrucq E, Mathieu D, Poissy J, Favory R. Sodium lactate improves renal microvascular thrombosis compared to sodium bicarbonate and 0.9% NaCl in a porcine model of endotoxic shock: an experimental randomized open label controlled study. Ann Intensive Care 2018; 8:24. [PMID: 29445877 PMCID: PMC5812960 DOI: 10.1186/s13613-018-0367-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 02/01/2018] [Indexed: 12/29/2022] Open
Abstract
Background Sodium lactate seemed to improve fluid balance and avoid fluid overload. The objective of this study was to determine if these beneficial effects can be at least partly explained by an improvement in disseminated intravascular coagulation (DIC)-associated renal microvascular thrombosis. Methods Ancillary work of an interventional randomized open label controlled experimental study. Fifteen female “Large White” pigs (2 months old) were challenged with intravenous infusion of E. coli endotoxin. Three groups of five animals were randomly assigned to receive different fluids: a treatment group received sodium lactate 11.2% (SL group); an isotonic control group received 0.9% NaCl (NC group); a hypertonic control group, with the same amount of osmoles and sodium than SL group, received sodium bicarbonate 8.4% (SB group). Glomerular filtration rate (GFR) markers, coagulation and inflammation parameters were measured over a 5-h period. Immediately after euthanasia, kidneys were withdrawn for histological study. Statistical analysis was performed with nonparametric tests and the Dunn correction for multiple comparisons. A p < 0.05 was considered significant. Results The direct immunofluorescence study revealed that the percentage of capillary sections thrombosed in glomerulus were significantly lesser in SL group [5 (0–28) %] compared to NC [64 (43–79) %, p = 0.01] and SB [64 (43–79), p = 0.03] groups. Alterations in platelet count and fibrinogen level occurred earlier and were significantly more pronounced in both control groups compared to SL group (p < 0.05 at 210 and 300 min). The increase in thrombin–antithrombin complexes was significantly higher in NC [754 (367–945) μg/mL; p = 0.03] and SB [463 (249–592) μg/mL; p = 0.03] groups than in SL group [176 (37–265) μg/mL]. At the end of the experiment, creatinine clearance was significantly higher in SL group [55.46 (30.07–67.85) mL/min] compared to NC group [1.52 (0.17–27.67) mL/min, p = 0.03]. Conclusions In this study, we report that sodium lactate improves DIC-associated renal microvascular thrombosis and preserves GFR. These findings could at least partly explain the better fluid balance observed with sodium lactate infusion.
Collapse
Affiliation(s)
- Thibault Duburcq
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.
| | - Arthur Durand
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,LIRIC Inserm U995 Glycation: From Inflammation to Aging, 59000, Lille, France
| | | | - Viviane Gnemmi
- Centre de Biologie Pathologie, CHU Lille, 59000, Lille, France
| | - Valery Gmyr
- INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - François Pattou
- INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - Mercedes Jourdain
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Emmanuel Besnier
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Sebastien Préau
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Erika Parmentier-Decrucq
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Daniel Mathieu
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Julien Poissy
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Raphaël Favory
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,LIRIC Inserm U995 Glycation: From Inflammation to Aging, 59000, Lille, France
| |
Collapse
|
144
|
Glassford NJ, Bellomo R. Does Fluid Type and Amount Affect Kidney Function in Critical Illness? Crit Care Clin 2018; 34:279-298. [PMID: 29482907 DOI: 10.1016/j.ccc.2017.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common, although commonly used clinical diagnostic markers are imperfect. Intravenous fluid administration remains a cornerstone of therapy worldwide, but there is minimal evidence of efficacy for the use of fluid bolus therapy outside of specific circumstances, and emerging evidence associates fluid accumulation with worse renal outcomes and even increased mortality among critically ill patients. Artificial colloid solutions have been associated with harm, and chloride-rich solutions may adversely affect renal function. Large trials to provide guidance regarding the optimal fluid choices to prevent or ameliorate AKI, and promote renal recovery, are urgently required.
Collapse
Affiliation(s)
- Neil J Glassford
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC 3084, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Australian and New Zealand Intensive Care Research Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC 3084, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Australian and New Zealand Intensive Care Research Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; School of Medicine, The University of Melbourne, Grattan Street and Royal Parade, Melbourne, VIC 3010, Australia.
| |
Collapse
|
145
|
Zhou FH, Liu C, Mao Z, Ma PL. Normal saline for intravenous fluid therapy in critically ill patients. Chin J Traumatol 2018; 21:11-15. [PMID: 29429774 PMCID: PMC6114124 DOI: 10.1016/j.cjtee.2017.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 07/05/2017] [Accepted: 10/13/2017] [Indexed: 02/04/2023] Open
Abstract
The efficacy and safety of normal saline (NS) for fluid therapy in critically ill patients remain controversy. In this review, we summarized the evidence of randomized controlled trials (RCTs) which compared NS with other solutions in critically ill patients. The results showed that when compared with 6% hydroxyethyl starch (HES), NS may reduce the onset of acute kidney injury (AKI). However, there is no significant different in mortality and incidence of AKI when compared with 10% HES, albumin and buffered crystalloid solution. Therefore, it is important to prescribe intravenous fluid for patients according to their individual condition.
Collapse
Affiliation(s)
- Fei-Hu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Chao Liu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Peng-Lin Ma
- Department of Critical Care Medicine, 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China,Corresponding author.
| |
Collapse
|
146
|
Intravenous fluids: effects on renal outcomes. Br J Anaesth 2018; 120:397-402. [PMID: 29406188 DOI: 10.1016/j.bja.2017.11.090] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 12/23/2022] Open
Abstract
Intravenous fluid therapy is the most commonly prescribed inpatient medication in hospitals around the world. Intravenous fluids are drugs and have an indication, a dose, and expected and unintended effects. The type and amount of fluid given to patients are both important, and can either hasten or slow recovery depending on how they are administered. This narrative review provides a brief summary of the effect of intravenous fluid administration on kidney function and on renal outcome measures of relevance to both patients and clinicians. Several large clinical trials of fluid therapy are currently underway, the results of which are likely to change clinical practice.
Collapse
|
147
|
Pikoulis E, Salem KM, Avgerinos ED, Pikouli A, Angelou A, Pikoulis A, Georgopoulos S, Karavokyros I. Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting. Front Surg 2017; 4:73. [PMID: 29312951 PMCID: PMC5742177 DOI: 10.3389/fsurg.2017.00073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/20/2017] [Indexed: 01/12/2023] Open
Abstract
Early management of vascular injury, starting at the field, is imperative for survival no less than any operative maneuver. Contemporary prehospital management of vascular trauma, including appropriate fluid and volume infusion, tourniquets, and hemostatic agents, has reversed the historically known limb hemorrhage as a leading cause of death. In this context, damage control (DC) surgery has evolved to DC resuscitation (DCR) as an overarching concept that draws together preoperative and operative interventions aiming at rapidly reducing bleeding from vascular disruption, optimizing oxygenation, and clinical outcomes. This review addresses contemporary DCR techniques from the prehospital to the surgical setting, focusing on civilian vascular injuries.
Collapse
Affiliation(s)
- Emmanouil Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anastasia Pikouli
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Anastasios Angelou
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Antreas Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Sotirios Georgopoulos
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ioannis Karavokyros
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| |
Collapse
|
148
|
Cubro H, Kashani K, Gajic O. Learning Health Care System: Pragmatic Comparison of Crystalloid Choice in a Medical Intensive Care Unit. Am J Respir Crit Care Med 2017; 195:1287-1289. [PMID: 28504605 DOI: 10.1164/rccm.201610-2093ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hajrunisa Cubro
- 1 Division of Nephrology and Hypertension Mayo Clinic, Rochester, Minnesota.,2 Department of Obstetrics and Gynecology General Hospital Sarajevo, Bosnia and Herzegovina
| | - Kianoush Kashani
- 3 Division of Nephrology and Hypertension Mayo Clinic Rochester, Minnesota and
| | - Ognjen Gajic
- 4 Division of Pulmonary and Critical Care Mayo Clinic Rochester, Minnesota
| |
Collapse
|
149
|
Pragmatic studies for acute kidney injury: Consensus report of the Acute Disease Quality Initiative (ADQI) 19 Workgroup. J Crit Care 2017; 44:337-344. [PMID: 29274596 DOI: 10.1016/j.jcrc.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 12/26/2022]
Abstract
PURPOSE Acute kidney injury (AKI) has become a major medical and financial burden in China along with the rest of the world. There have been considerable advances in the understanding of the epidemiology and pathogenesis of AKI. However, there is no consensus regarding the optimal care for patients. The Acute Disease Quality Initiative (ADQI) 19 meeting focused on identifying and designing relevant and achievable AKI-related studies in China. MATERIALS & METHODS The working group developed a list of preliminary questions and objectives and performed analysis of the existing literature. Relevant studies were identified through a literature search using the MEDLINE database and bibliographies of relevant research and review articles. We then used a two-step Delphi process to prioritize a research agenda and proposed specific study designs to address unmet needs. RESULTS Important gaps in existing knowledge were identified and pragmatic studies were proposed in three distinct areas: care bundles for AKI prevention, renal replacement therapy (RRT) for AKI, and fluid management. In addition, the use of biomarkers to guide clinical trials was discussed. CONCLUSIONS Consensus was reached on a research agenda for AKI with a specific focus on pragmatic trials in China.
Collapse
|
150
|
Abstract
Over the past few years, chloride has joined the league of essential electrolytes for critically ill patients. Dyschloremia can occur secondary to various etiologic factors before and during patient admission in the intensive care unit. Some cases are disease-related; others, treatment-related. Chloride abnormalities were shown in animal models to have adverse effects on arterial blood pressure, renal blood flow, and inflammatory markers, which have led to several clinical investigations. Hyperchloremia was studied in several settings and correlated to different outcomes, including death and acute kidney injury. Baseline hypochloremia, to a much lesser extent, has been studied and associated with similar outcomes. The chloride content of resuscitation fluids was also a subject of clinical research. In this review, we describe the effect of dyschloremia on outcomes in critically ill patients. We review the major studies assessing the chloride content of resuscitation fluids in the critically ill patient.
Collapse
Affiliation(s)
- Ghassan Bandak
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Research Group, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|