1
|
Zhuang K, Yang HT, Long YQ, Liu H, Ji FH, Peng K. Dexmedetomidine and acute kidney injury after non-cardiac surgery: A meta-analysis with trial sequential analysis. Anaesth Crit Care Pain Med 2024; 43:101359. [PMID: 38395357 DOI: 10.1016/j.accpm.2024.101359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after surgery and is associated with detrimental outcomes. This systematic review and meta-analysis evaluated perioperative dexmedetomidine on AKI and renal function after non-cardiac surgery. METHODS PubMed, Embase, and Cochrane Library databases were searched until August 2023 for randomised trials comparing dexmedetomidine with normal saline on AKI and renal function in adults undergoing non-cardiac surgery. The primary outcome was the incidence of AKI (according to Kidney Disease Improving Global Outcomes or Acute Kidney Injury Network criteria). Meta-analysis was performed using a random-effect model. We conducted sensitivity analysis, trial sequential analysis (TSA), and Grading of Recommendations Assessment, Development and Evaluation level of evidence. RESULTS Twenty-three trials involving 2440 patients were included. Dexmedetomidine administration, as compared to normal saline, significantly reduced the incidence of AKI (7.4% vs. 13.2%; risk ratio = 0.57, 95% CI = 0.40-0.83, P = 0.003, I2 = 0%; a high level of evidence); TSA and sensitivity analyses suggested the robustness of this outcome. For the renal function and inflammation parameters, dexmedetomidine decreased serum creatinine, blood urea nitrogen, cystatin C, tumour necrosis factor-α, and interleukin-6, and increased urine output and estimated glomerular filtration rate. Additionally, dexmedetomidine reduced postoperative nausea and vomiting and length of hospital stay. Dexmedetomidine was associated with an increased rate of bradycardia, but not hypotension. CONCLUSION Dexmedetomidine administration reduced the incidence of AKI and improved renal function after non-cardiac surgery. Based on a high level of evidence, dexmedetomidine is recommended as a component of perioperative renoprotection. REGISTRATION International Prospective Register of Systematic Reviews; Registration number: CRD42022299252.
Collapse
Affiliation(s)
- Kai Zhuang
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hao-Tian Yang
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yu-Qin Long
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anaesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Fu-Hai Ji
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Department of Anaesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Institute of Anaesthesiology, Soochow University, Suzhou, Jiangsu, China.
| |
Collapse
|
2
|
Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
Collapse
Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
| | | | | |
Collapse
|
3
|
Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
Collapse
|
4
|
Sankar J, Muralidharan J, Lalitha AV, Rameshkumar R, Pathak M, Das RR, Nadkarni VM, Ismail J, Subramanian M, Nallasamy K, Dev N, Kumar UV, Kumar K, Sharma T, Jaravta K, Thakur N, Aggarwal P, Jat KR, Kabra SK, Lodha R. Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med 2023; 51:1449-1460. [PMID: 37294145 DOI: 10.1097/ccm.0000000000005952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN Parallel-group, blinded multicenter trial. SETTING PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS Children up to 15 years of age with septic shock. METHODS Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.
Collapse
Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - A V Lalitha
- Department of Pediatrics Intensive Care, St Johns' Medical College Bengaluru, India
| | | | - Mona Pathak
- Research and Development Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Javed Ismail
- Pediatric Intensive Care Unit, NMC Royal Hospital Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mahadevan Subramanian
- Division of Pediatric Critical Care, Department of Pediatrics, JIPMER, Puducherry, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - Nishanth Dev
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - U Vijay Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Taniya Sharma
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Jaravta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Thakur
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | | | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
5
|
Vignarajah M, Berg A, Abdallah Z, Arora N, Javidan A, Pitre T, Fernando SM, Spence J, Centofanti J, Rochwerg B. Intraoperative use of balanced crystalloids versus 0.9% saline: a systematic review and meta-analysis of randomised controlled studies. Br J Anaesth 2023; 131:463-471. [PMID: 37455198 DOI: 10.1016/j.bja.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The evidence regarding optimal crystalloid use in the perioperative period remains unclear. As the primary aim of this study, we sought to summarise the data from RCTs examining whether use of balanced crystalloids compared with 0.9% saline (saline) leads to differences in patient-important outcomes. METHODS We searched Ovid MEDLINE, Embase, the Cochrane library, and Clinicaltrials.gov, from inception until December 15, 2022, and included RCTs that intraoperatively randomised adult participants to receive either balanced fluids or saline. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences (MDs), along with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool, and certainty of evidence using GRADE. RESULTS Of 5959 citations, we included 38 RCTs (n=3776 patients). Pooled analysis showed that intraoperative use of balanced fluids compared with saline had an uncertain effect on postoperative mortality analysed at the longest point of follow-up (RR 1.51, 95% CI: 0.42-5.36) and postoperative need for renal replacement therapy (RR 0.95, 95% CI: 0.56-1.59), both very low certainty. Furthermore, use of balanced crystalloids probably leads to a higher postoperative serum pH (MD 0.05, 95% CI: 0.04-0.06), moderate certainty. CONCLUSIONS Use of balanced crystalloids, compared with saline, in the perioperative setting has an uncertain effect on mortality and need for renal replacement therapy but probably improves postoperative acid-base status. Further research is needed to determine whether balanced crystalloid use affects patient-important outcomes. CLINICAL TRIAL REGISTRATION CRD42022367593.
Collapse
Affiliation(s)
| | - Annie Berg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zahra Abdallah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Naman Arora
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
6
|
Panchal V, Sivasubramanian BP, Samala Venkata V. Crystalloid Solutions in Hospital: A Review of Existing Literature. Cureus 2023; 15:e39411. [PMID: 37362468 PMCID: PMC10287545 DOI: 10.7759/cureus.39411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.
Collapse
Affiliation(s)
- Viraj Panchal
- Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Barath Prashanth Sivasubramanian
- Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, USA
- Internal Medicine, ESIC Medical College & PGIMSR, Chennai, IND
| | | |
Collapse
|
7
|
Monnet X, Lai C, Teboul JL. How I personalize fluid therapy in septic shock? Crit Care 2023; 27:123. [PMID: 36964573 PMCID: PMC10039545 DOI: 10.1186/s13054-023-04363-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/17/2023] [Indexed: 03/26/2023] Open
Abstract
During septic shock, fluid therapy is aimed at increasing cardiac output and improving tissue oxygenation, but it poses two problems: it has inconsistent and transient efficacy, and it has many well-documented deleterious effects. We suggest that there is a place for its personalization according to the patient characteristics and the clinical situation, at all stages of circulatory failure. Regarding the choice of fluid for volume expansion, isotonic saline induces hyperchloremic acidosis, but only for very large volumes administered. We suggest that balanced solutions should be reserved for patients who have already received large volumes and in whom the chloremia is rising. The initial volume expansion, intended to compensate for the constant hypovolaemia in the initial phase of septic shock, cannot be adapted to the patient's weight only, as suggested by the Surviving Sepsis Campaign, but should also consider potential absolute hypovolemia induced by fluid losses. After the initial fluid infusion, preload responsiveness may rapidly disappear, and it should be assessed. The choice between tests used for this purpose depends on the presence or absence of mechanical ventilation, the monitoring in place and the risk of fluid accumulation. In non-intubated patients, the passive leg raising test and the mini-fluid challenge are suitable. In patients without cardiac output monitoring, tests like the tidal volume challenge, the passive leg raising test and the mini-fluid challenge can be used as they can be performed by measuring changes in pulse pressure variation, assessed through an arterial line. The mini-fluid challenge should not be repeated in patients who already received large volumes of fluids. The variables to assess fluid accumulation depend on the clinical condition. In acute respiratory distress syndrome, pulmonary arterial occlusion pressure, extravascular lung water and pulmonary vascular permeability index assess the risk of worsening alveolar oedema better than arterial oxygenation. In case of abdominal problems, the intra-abdominal pressure should be taken into account. Finally, fluid depletion in the de-escalation phase is considered in patients with significant fluid accumulation. Fluid removal can be guided by preload responsiveness testing, since haemodynamic deterioration is likely to occur in patients with a preload dependent state.
Collapse
Affiliation(s)
- Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Christopher Lai
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| |
Collapse
|
8
|
Kanjee Z, Berg K, Bell TD, Reynolds EE. How Would You Resuscitate This Patient With Septic Shock? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:253-259. [PMID: 36780653 DOI: 10.7326/m22-3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Sepsis is a potentially life-threatening systemic dysregulatory response to infection, and septic shock occurs when sepsis leads to systemic vasodilation and subsequent tissue hypoperfusion. The Surviving Sepsis Campaign published updated guidelines in 2021 on the management of sepsis and septic shock. Here, in the context of a patient with septic shock, 2 critical care specialists discuss and debate conditional guideline recommendations on using lactate to guide resuscitation, the use of balanced crystalloids versus normal saline, and the use of corticosteroids.
Collapse
Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
| | - Katherine Berg
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.B.)
| | - Taison D Bell
- Division of Pulmonary and Critical Care Medicine, and Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia (T.D.B.)
| | - Eileen E Reynolds
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
| |
Collapse
|
9
|
Catahay JA, Polintan ET, Casimiro M, Notarte KI, Velasco JV, Ver AT, Pastrana A, Macaranas I, Patarroyo-Aponte G, Lo KB. Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis. Heart Lung 2022; 54:74-79. [PMID: 35358905 DOI: 10.1016/j.hrtlng.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited. OBJECTIVES To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS. METHODS The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] (p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78-0.74; p = 0.12) with heterogeneity of 85%. CONCLUSION Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.
Collapse
Affiliation(s)
| | | | - Michael Casimiro
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Kin Israel Notarte
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | | | | | - Adriel Pastrana
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Imee Macaranas
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Gabriel Patarroyo-Aponte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, USA
| |
Collapse
|
10
|
Zhao J, Li M, Tan C. Efficacy of N-acetylcysteine in Preventing Acute Kidney Injury and Major Adverse Cardiac Events After Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis. Front Med (Lausanne) 2022; 9:795839. [PMID: 35814787 PMCID: PMC9256973 DOI: 10.3389/fmed.2022.795839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 05/12/2022] [Indexed: 12/29/2022] Open
Abstract
Background The effect of N-acetylcysteine (NAC), an antioxidant, on preventing acute kidney injury (AKI) and major adverse cardiac events (MACE) remains controversial. Therefore, we conducted this meta-analysis and trial sequential analysis to evaluate its efficacy on cardiac surgery-related adverse events. Methods PubMed, Embase, and Cochrane Library were searched for relevant studies from inception to June 2021. We selected randomized controlled trials comparing NAC with controls in patients undergoing cardiac surgery. Results Twenty-five studies including 2,444 patients met the inclusion criteria. The pooled results showed that there was no significant difference in the incidence of AKI between the NAC and control groups [relative risk (RR) = 0.91, 95% confidence interval (CI) = 0.77, 1.08, P = 0.28], but the trial sequential analysis (TSA) could not confirm this result. No difference was observed in the need for renal replacement therapy (RRT), all-cause mortality, MACE, length of stay in the intensive care unit (ICU), and length of stay in the hospital. Results of subgroup analysis results showed that intravenous infusion instead of oral NAC could significantly reduce the incidence of AKI and arrhythmia (RR = 0.84, 95% CI = 0.71, 0.99, P = 0.03, I2 = 3% and RR = 0.74, 95% CI = 0.61, 0.91, P = 0.004, I2 = 48%, respectively). Conclusion Intravenous administration of NAC can reduce the incidence of AKI and arrhythmia in patients after cardiac surgery, but cannot reduce all-cause mortality, AMI, cardiac insufficiency, and the number of patients using RRT. Oral NAC has no significant effect on the outcomes of patients after cardiac surgery.
Collapse
Affiliation(s)
| | - Maowei Li
- No. 988th Hospital of Joint Logistic Support Force of PLA, Zhengzhou, China
| | - Chen Tan
- Hebei Yanda Hospital, Langfang, China
- *Correspondence: Chen Tan
| |
Collapse
|
11
|
Dong WH, Yan WQ, Song X, Zhou WQ, Chen Z. Fluid resuscitation with balanced crystalloids versus normal saline in critically ill patients: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2022; 30:28. [PMID: 35436929 PMCID: PMC9013977 DOI: 10.1186/s13049-022-01015-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background Intravenous fluids are used commonly for almost all intensive care unit (ICU) patients, especially for patients in need of resuscitation. The selection and use of resuscitation fluids may affect the outcomes of patients; however, the optimal resuscitative fluid remains controversial. Methods We systematically searched PubMed, Embase, and CENTRAL. Studies comparing balanced crystalloids and normal saline in ICU patients were selected. We used the Cochrane Collaboration tool to assess the risk of bias in studies. The primary outcome was mortality at the longest follow-up. Secondary outcomes included the incidence of acute kidney injury (AKI) and new renal replacement therapy (RRT). Results A total of 35,456 patients from eight studies were included. There was no significant difference between balanced crystalloid solutions and saline in mortality (risk ratio [RR]: 0.96; 95% confidence interval [CI]:0.92–1.01). The subgroup analysis with traumatic brain injury (TBI) showed lower mortality in patients receiving normal saline (RR:1.25; 95% CI 1.02–1.54). However, in patients with non-TBI, balanced crystalloid solutions achieved lower mortality than normal saline (RR: 0.94; 95% CI 0.90–0.99). There was no significant difference in moderate to severe AKI (RR: 0.96; 95% CI 0.90–1.01) or new RRT (RR: 0.94; 95% CI 0.84–1.04). Conclusions Compared with normal saline, balanced crystalloids may not improve the outcomes of mortality, the incidence of AKI, and the use of RRT for critically ill patients. However, balanced crystalloids reduce the risk of death in patients with non-TBI but increase the risk of death in those with TBI. Large-scale rigorous randomized trials with better designs are needed, especially for specific patient populations. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01015-3.
Collapse
|
12
|
Beran A, Altorok N, Srour O, Malhas SE, Khokher W, Mhanna M, Ayesh H, Aladamat N, Abuhelwa Z, Srour K, Mahmood A, Altorok N, Taleb M, Assaly R. Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11071971. [PMID: 35407578 PMCID: PMC8999853 DOI: 10.3390/jcm11071971] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81-0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79-0.95), and AKI (RR 0.85, 95% CI 0.77-0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90-1.03), need for RRT (RR 0.91, 95% CI 0.76-1.08), and ICU LOS (MD -0.25 days, 95% CI -3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82-1.02), AKI (RR 0.71, 95% CI 0.47-1.06), and need for RRT (RR 0.71, 95% CI 0.36-1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.
Collapse
Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Correspondence: ; Tel.: +1-469-348-1347
| | - Nehaya Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Saif-Eddin Malhas
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo, Toledo, OH 43606, USA;
| | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Khaled Srour
- Department of Critical Care Medicine, Henry Ford Health System, Detroit, MI 48202, USA;
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nezam Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Rheumatology, University of Toledo, Toledo, OH 43606, USA
| | - Mohammad Taleb
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| |
Collapse
|
13
|
Fu Z, Geng X, Chi K, Song C, Wu D, Liu C, Hong Q. Efficacy and Safety of Daprodustat Vs rhEPO for Anemia in Patients With Chronic Kidney Disease: A Meta-Analysis and Trial Sequential Analysis. Front Pharmacol 2022; 13:746265. [PMID: 35359863 PMCID: PMC8961323 DOI: 10.3389/fphar.2022.746265] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/17/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction: Daprodustat, a novel hypoxia-inducible factor prolyl-hydroxylase inhibitor (HIF-PHI), its efficacy and safety remain unclear. Thus, we conducted this meta-analysis aiming at investigating its efficacy and safety on the treatment of patients with chronic kidney disease (CKD)-related anemia. Methods: We systematically searched for relevant studies in PubMed, Embase, Cochrane Library and Clinical Trial Registries databases from inception until December 2021. We selected randomized controlled trials comparing daprodustat with recombinant human erythropoietin (rhEPO) in anemia patients with CKD with or without dialysis. Results: Seven studies including 7933 patients met the inclusion criteria. For both nondialysis-dependent (NDD-) CKD and dialysis-dependent (DD-) CKD patients, the pooled results showed that there was no significant difference in the changes in hemoglobin levels between the daprodustat and rhEPO groups (mean difference (MD) = −0.01, 95% confidence interval (CI) = −0.38, 0.35, p = 0.95; MD = 0.15, 95% CI = −0.29, 0.60, p = 0.50; respectively). In addition, a significant increase in transferrin saturation (TSAT), total iron binding capacity (TIBC) and total iron was observed in daprodustat groups compared with rhEPO groups in DD-CKD patients (p < 0.05). As for safety, the overall frequency of adverse events was similar between the daprodustat and rhEPO groups in DD-CKD patients (relative risk (RR) = 0.99, 95%CI = 0.92, 1.06, p = 0.76), and the trial sequential analysis (TSA) confirmed this result. But for NDD-CKD patients, the incidence of adverse events in the daprodustat groups was significantly higher than that of rhEPO groups (RR = 1.04, 95%CI = 1.01,1.07, p = 0.02), while the TSA corrected this result. No trend of increasing incidence of serious adverse events was found in all daprodustat treated patients, but the TSA could not confirm this result. Conclusion: Although daprodustat was noninferior to rhEPO in correcting anemia in both NDD-CKD and DD-CKD patients, it seemed to have a better effect on optimizing iron metabolism in DD-CKD patients. Daprodustat may be a promising alternative for the treatment of anemia in patients with CKD. However, due to the lack of included studies, future researches are needed to further evaluate the therapeutic effect of daprodustat. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42021229636.
Collapse
Affiliation(s)
- Zhangning Fu
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xiaodong Geng
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Kun Chi
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Chengcheng Song
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Di Wu
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Chao Liu
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
- *Correspondence: Chao Liu, ; Quan Hong,
| | - Quan Hong
- Medical School of Chinese PLA, Beijing, China
- Department of Nephrology, State Key Laboratory of Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, National Clinical Research Center for Kidney Diseases, Beijing, China
- *Correspondence: Chao Liu, ; Quan Hong,
| |
Collapse
|
14
|
Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, Delaney A, Gallagher M, Gattas D, Li Q, Mackle D, Mysore J, Saxena M, Taylor C, Young P, Myburgh J. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med 2022; 386:815-826. [PMID: 35041780 DOI: 10.1056/nejmoa2114464] [Citation(s) in RCA: 118] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain. METHODS In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay. RESULTS A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups. CONCLUSIONS We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; PLUS ClinicalTrials.gov number, NCT02721654.).
Collapse
Affiliation(s)
- Simon Finfer
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Sharon Micallef
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Naomi Hammond
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Leanlove Navarra
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Rinaldo Bellomo
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Laurent Billot
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Anthony Delaney
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Martin Gallagher
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - David Gattas
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Qiang Li
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Diane Mackle
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Jayanthi Mysore
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Manoj Saxena
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Colman Taylor
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Paul Young
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - John Myburgh
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| |
Collapse
|
15
|
Lehr AR, Rached-d'Astous S, Barrowman N, Tsampalieros A, Parker M, McIntyre L, Sampson M, Menon K. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2022; 23:181-191. [PMID: 34991134 PMCID: PMC8887852 DOI: 10.1097/pcc.0000000000002890] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The ideal crystalloid fluid bolus therapy for fluid resuscitation in children remains unclear, but pediatric data are limited. Administration of 0.9% saline has been associated with hyperchloremic metabolic acidosis and acute kidney injury. The primary objective of this systematic review was to compare the effect of balanced versus unbalanced fluid bolus therapy on the mean change in serum bicarbonate or pH within 24 hours in critically ill children. DATA SOURCES We searched MEDLINE including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, CENTRAL Trials Registry of the Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. STUDY SELECTION Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guidelines, we retrieved all controlled trials and observational cohort studies comparing balanced and unbalanced resuscitative fluids in critically ill children. The primary outcome was the change in serum bicarbonate or blood pH. Secondary outcomes included the prevalence of hyperchloremia, acute kidney injury, renal replacement therapy, and mortality. DATA EXTRACTION Study screening, inclusion, data extraction, and risk of bias assessments were performed independently by two authors. DATA SYNTHESIS Among 481 references identified, 13 met inclusion criteria. In the meta-analysis of three randomized controlled trials with a population of 162 patients, we found a greater mean change in serum bicarbonate level (pooled estimate 1.60 mmol/L; 95% CI, 0.04-3.16; p = 0.04) and pH level (pooled mean difference 0.03; 95% CI, 0.00-0.06; p = 0.03) after 4-12 hours of rehydration with balanced versus unbalanced fluids. No differences were found in chloride serum level, acute kidney injury, renal replacement therapy, or mortality. CONCLUSIONS Our systematic review found some evidence of improvement in blood pH and bicarbonate values in critically ill children after 4-12 hours of fluid bolus therapy with balanced fluid compared with the unbalanced fluid. However, a randomized controlled trial is needed to establish whether these findings have an impact on clinical outcomes before recommendations can be generated.
Collapse
Affiliation(s)
- Anab Rebecca Lehr
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Soha Rached-d'Astous
- Division of Emergency Medicine, Department of Pediatrics, University of Montreal, CHU Sainte Justine, Montreal, QC, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Melissa Parker
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
- Division of Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Margaret Sampson
- Library Services, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Kusum Menon
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| |
Collapse
|
16
|
Back to BaSICS. Ann Emerg Med 2022; 79:216-217. [DOI: 10.1016/j.annemergmed.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
17
|
Hammond NE, Zampieri FG, Di Tanna GL, Garside T, Adigbli D, Cavalcanti AB, Machado FR, Micallef S, Myburgh J, Ramanan M, Rice TW, Semler MW, Young PJ, Venkatesh B, Finfer S, Delaney A. Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis. NEJM EVIDENCE 2022; 1:EVIDoa2100010. [PMID: 38319180 DOI: 10.1056/evidoa2100010] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: The comparative efficacy and safety of balanced crystalloid solutions and saline for fluid therapy in critically ill adults remain uncertain. METHODS: We systematically reviewed randomized clinical trials (RCTs) comparing the use of balanced crystalloids with saline in critically ill adults. The primary outcome was 90-day mortality after pooling data from low-risk-of-bias trials using a random-effects model. We also performed a Bayesian meta-analysis to describe the primary treatment effect in probability terms. Secondary outcomes included the incidence of acute kidney injury (AKI), new treatment with renal replacement therapy (RRT), and ventilator-free and vasopressor-free days to day 28. RESULTS: We identified 13 RCTs, comprising 35,884 participants. From six trials (34,450 participants) with a low risk of bias, the risk ratio (RR) for 90-day mortality with balanced crystalloids versus saline was 0.96 (95% confidence interval [CI], 0.91 to 1.01; I2 = 12.1%); using vague priors, the posterior probability that balanced crystalloids reduce mortality was 89.5%. The RRs of developing AKI and of being treated with RRT with balanced crystalloids versus saline were 0.96 (95% CI, 0.89 to 1.02) and 0.95 (95% CI, 0.81 to 1.11), respectively. Ventilator-free days (mean difference, 0.18 days; 95% CI, −0.45 to 0.81) and vasopressor-free days (mean difference, 0.19 days; 95% CI, −0.14 to 0.51) were similar between groups. CONCLUSIONS: The estimated effect of using balanced crystalloids versus saline in critically ill adults ranges from a 9% relative reduction to a 1% relative increase in the risk of death, with a high probability that the average effect of using balanced crystalloids is to reduce mortality. (PROSPERO number, CRD42021243399.)
Collapse
Affiliation(s)
- Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo
- D'Or Research and Education Institute, São Paulo
| | - Gian Luca Di Tanna
- BioStatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney
| | - Tessa Garside
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Derick Adigbli
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | | | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Department of Intensive Care, St. George Hospital, Sydney
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Queensland, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- School of Public Health, The George Institute for Global Health, Imperial College, London
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| |
Collapse
|
18
|
Liu C, Fu Z, Jiang J, Chi K, Geng X, Mao Z, Song C, Sun G, Hong Q, Cai G, Chen X, Sun X. Safety and Efficacy of Roxadustat for Anemia in Patients With Chronic Kidney Disease: A Meta-Analysis and Trial Sequential Analysis. Front Med (Lausanne) 2021; 8:724456. [PMID: 34532333 PMCID: PMC8438137 DOI: 10.3389/fmed.2021.724456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Roxadustat, a hypoxia-inducible factor prolyl-hydroxylase inhibitor (HIF-PHI), has been used to treat anemia in patients with chronic kidney disease (CKD). However, its safety and efficacy remain controversial. Methods: The PubMed, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries databases were searched for relevant studies published up to April 2021. We identified randomized controlled trials (RCTs) comparing roxadustat with placebo or erythropoiesis-stimulating agents (ESAs) in anemia patients with CKD with or without dialysis. Results: Eleven studies including 6,631 patients met the inclusion criteria. In non-dialysis-dependent (NDD-) and dialysis-dependent (DD-) CKD patients, the total adverse events were not significantly different between the roxadustat and control (placebo for NDD-CKD patients and ESA for DD-CKD patients) groups [relative risk (RR) = 1.02, 95% confidence interval (CI) = 1.00, 1.04, P = 0.08, and RR = 1.22, 95% CI = 0.91, 1.64, P = 0.18, respectively], and the trial sequential analysis (TSA) confirmed the result in the NDD-CKD groups. No significant differences in hyperkalemia and infection incidences were found between roxadustat and placebo in the DD-CKD groups. The pooled results showed that roxadustat significantly increased the hemoglobin response rate compared with placebo in the NDD-CKD group and had an effect similar to that of ESA in the DD-CKD group. However, iron metabolism parameters did not seem to be obviously optimized by roxadustat. Conclusion: Roxadustat can be safely used in CKD patients. Oral roxadustat was more effective than placebo as a therapy for anemia in NDD-CKD patients and non-inferior to ESA in correcting anemia in DD-CKD patients. However, additional clinical trials are still needed to further prove whether roxadustat can optimize iron metabolism.
Collapse
Affiliation(s)
- Chao Liu
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Zhangning Fu
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Jiawei Jiang
- Department of Critical Care Medicine, Tianjin Medical University First Center Clinical College, Tianjin, China
| | - Kun Chi
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xiaodong Geng
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Chengcheng Song
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Guannan Sun
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Quan Hong
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Guangyan Cai
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| |
Collapse
|
19
|
Low- versus High-Chloride Content Intravenous Solutions for Perioperative Patients: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3571397. [PMID: 33490269 PMCID: PMC7801087 DOI: 10.1155/2021/3571397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 11/23/2022]
Abstract
Background Studies have shown complications of normal saline infusion because of its high-chloride content. Therefore, in the present study, we aimed to explore whether the use of low- versus high-chloride solutions benefited the unselected and specifically perioperative patients and was associated with different outcomes. Methods Studies on the use of low- versus high-chloride content intravenous solutions for perioperative patients, published up to July 15, 2019, were systematically reviewed, and primary and secondary outcomes were quantitatively summarized. Results A total of 14 eligible randomized controlled trials with 943 perioperative patients were included. Five studies reported all-cause mortality, and eight studies provided detailed data on renal replacement therapy (RRT). The pooled result suggested no statistically significant difference in the effect of low- versus high-chloride solutions on all-cause mortality (risk ratio (RR) = 1.39; 95%confidence interval (CI) = 0.23–8.26) and RRT (RR = 1.05; 95%CI = 0.63–1.76). The pooled results on acute kidney injury (AKI) and the use of allogenic blood transfusion (P > 0.05) were similar. Conclusion Among specific perioperative patients, the use of low- versus high-chloride content intravenous solutions did not reduce the all-cause mortality, risk of severe AKI, or rate of RRT use. Further large randomized clinical trials are needed to confirm or refute this finding.
Collapse
|
20
|
Sahu S, Sam A, Ponnappan K. Fluid management in kidney disease patients for nontransplant and transplantation surgeries. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_203_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
21
|
McIlroy DR, Murphy D, Shotwell MS, Bhatia D. Peak Serum Chloride and Hyperchloremia in Patients Undergoing Cardiac Surgery Is Not Explained by Chloride-Rich Intravenous Fluid Alone: A Post-Hoc Analysis of the LICRA Trial. J Cardiothorac Vasc Anesth 2020; 35:1321-1331. [PMID: 32863142 DOI: 10.1053/j.jvca.2020.07.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/30/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES With the exception of 0.9% saline, little is known about factors that may contribute to increased serum chloride concentration (SCl-) in patients undergoing cardiac surgery. For the present study, the authors sought to characterize the association between administered chloride load from intravenous fluid and other perioperative variables, with peak perioperative SCl-. DESIGN Secondary analysis of data from a previously published controlled clinical trial in which patients were assigned to a chloride-rich or chloride-limited perioperative fluid strategy (NCT02020538). SETTING Academic medical center. PARTICIPANTS The study comprised 1,056 adult patients with normal preoperative SCl- undergoing cardiac surgery. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Peak perioperative SCl- and hyperchloremia, defined as peak SCl- >110 mmol/L, were selected as co-primary endpoints. Regression modeling identified factors independently associated with these endpoints. Mean (standard deviation) peak perioperative SCl- was 114 (5) mmol/L, and hyperchloremia occurred in 824 (78.0%) of the cohort. In addition to administered volume of 0.9% saline, multivariate linear and logistic regression modeling consistently associated preoperative SCl- (regression coefficient 0.5; 95% confidence interval [CI] 0.4-0.6 mmol/L; odds ratio 1.60; 95% CI 1.41-1.82 per 1 mmol/L increase) and cardiopulmonary bypass duration (regression coefficient 0.1; 95% CI 0.1-0.2 mmol/L; odds ratio 1.12; 95% CI 1.06-1.19 per 10 minutes) with both co-primary outcomes. Multivariate modeling only explained approximately 50% of variability in peak SCl-. CONCLUSIONS The present study's data identified an association for both 0.9% saline administration and other nonfluid variables with peak perioperative SCl- and hyperchloremia. Stand-alone strategies to limit administration of chloride-rich intravenous fluid may have limited ability to prevent hyperchloremia in this setting.
Collapse
Affiliation(s)
- David R McIlroy
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia; Vanderbilt University Medical Center, Nashville, TN.
| | - Deirdre Murphy
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | | | - Dhiraj Bhatia
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Regolisti G, Maggiore U, Rossi GM, Cabassi A, Fiaccadori E. Hyperchloremia and acute kidney injury: a spurious association or a worrisome reality? Intern Emerg Med 2020; 15:187-189. [PMID: 31650432 DOI: 10.1007/s11739-019-02213-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/03/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Giuseppe Regolisti
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy.
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Giovanni Maria Rossi
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Aderville Cabassi
- UO Clinica e Terapia Medica, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| |
Collapse
|
23
|
Zwager CL, Tuinman PR, de Grooth HJ, Kooter J, Ket H, Fleuren LM, Elbers PWG. Why physiology will continue to guide the choice between balanced crystalloids and normal saline: a systematic review and meta-analysis. Crit Care 2019; 23:366. [PMID: 31752973 PMCID: PMC6868741 DOI: 10.1186/s13054-019-2658-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Crystalloids are the most frequently prescribed drugs in intensive care medicine and emergency medicine. Thus, even small differences in outcome may have major implications, and therefore, the choice between balanced crystalloids versus normal saline continues to be debated. We examined to what extent the currently accrued information size from completed and ongoing trials on the subject allow intensivists and emergency physicians to choose the right fluid for their patients. METHODS Systematic review and meta-analysis with random effects inverse variance model. Published randomized controlled trials enrolling adult patients to compare balanced crystalloids versus normal saline in the setting of intensive care medicine or emergency medicine were included. The main outcome was mortality at the longest follow-up, and secondary outcomes were moderate to severe acute kidney injury (AKI) and initiation of renal replacement therapy (RRT). Trial sequential analyses (TSA) were performed, and risk of bias and overall quality of evidence were assessed. Additionally, previously published meta-analyses, trial sequential analyses and ongoing large trials were analysed for included studies, required information size calculations and the assumptions underlying those calculations. RESULTS Nine studies (n = 32,777) were included. Of those, eight had data available on mortality, seven on AKI and six on RRT. Meta-analysis showed no significant differences between balanced crystalloids versus normal saline for mortality (P = 0.33), the incidence of moderate to severe AKI (P = 0.37) or initiation of RRT (P = 0.29). Quality of evidence was low to very low. Analysis of previous meta-analyses and ongoing trials showed large differences in calculated required versus accrued information sizes and assumptions underlying those. TSA revealed the need for extremely large trials based on our realistic and clinically relevant assumptions on relative risk reduction and baseline mortality. CONCLUSIONS Our meta-analysis could not find significant differences between balanced crystalloids and normal saline on mortality at the longest follow-up, moderate to severe AKI or new RRT. Currently accrued information size is smaller, and the required information size is larger than previously anticipated. Therefore, completed and ongoing trials on the topic may fail to provide adequate guidance for choosing the right crystalloid. Thus, physiology will continue to play an important role for individualizing this choice.
Collapse
Affiliation(s)
- Charlotte L Zwager
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jos Kooter
- Department of Internal Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hans Ket
- University Library, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| |
Collapse
|
24
|
Redant S, Legrand M, Langman Y, Garcia Aguilar A, Kaefer K, De Bels D, Attou R, Kashani K, Honore PM. Urgent need for a randomized controlled trial with only septic patients! Ann Intensive Care 2019; 9:121. [PMID: 31637537 PMCID: PMC6803605 DOI: 10.1186/s13613-019-0596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/10/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sébastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Matthieu Legrand
- Department of Anesthesiology, Critical Care and Burn Unit, St. Louis Hospital, UMR-S942, Inserm, University Paris 7 Denis Diderot, Paris, France
| | - Yael Langman
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | | | - Keitiane Kaefer
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium.
| |
Collapse
|