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Lehr AR, Rached-d’Astous S, Parker M, McIntyre L, Sampson M, Hamid J, Menon K. Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis. Syst Rev 2019; 8:195. [PMID: 31383009 PMCID: PMC6683512 DOI: 10.1186/s13643-019-1109-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isotonic crystalloid fluid bolus therapy is used in critically ill children to restore or maintain hemodynamic stability. However, the ideal choice of crystalloid remains to be determined. The most easily available and most frequently used crystalloid is 0.9% saline, an unbalanced crystalloid, that has been associated with hyperchloremic metabolic acidosis and acute kidney injury (AKI). Balanced fluids such as Ringer's lactate (RL) were developed to be closer to the composition of serum. However, they are more expensive and less readily available than 0.9% saline. Few trials have found RL to be associated with more favorable outcomes, but pediatric data is limited and inconsistent. The objective of the present systematic review is to review existing literature to determine the effect of balanced versus unbalanced fluid bolus therapy on metabolic acidosis in critically ill children. METHODS Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines, we will conduct a systematic review to retrieve all controlled trials and observational studies comparing balanced and unbalanced resuscitative fluids in critically ill children from age 28 days to 18 years old in any resuscitation settings. Search strategy was developed in collaboration with an experienced clinical research librarian. The primary outcome is the incidence and/or time to resolution of metabolic acidosis. Secondary outcomes included the incidence of hyperchloremia, AKI, duration of renal replacement therapy, vasopressors, mechanical ventilation, total volume of rehydration needed per day, extracorporeal membrane oxygenation, and length of stay and mortality. Study screening, inclusion, data extraction, and assessment of risk of bias will be performed independently by two authors. We intend to perform a meta-analysis with studies that are compatible on the basis of population and outcomes. DISCUSSION Isotonic crystalloid fluid bolus therapy is a ubiquitous treatment in resuscitation of critically ill pediatric patients and yet there is no clear recommendation to support the choice of balanced versus unbalanced fluid. The present review will summarize current available data in the literature and assess whether recommendations can be generated regarding the choice of crystalloids or otherwise identify knowledge gaps which will open the door to a large-scale randomized controlled trial (RCT).
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Affiliation(s)
- Anab Rebecca Lehr
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Soha Rached-d’Astous
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, 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
| | - Jemila Hamid
- Clinical Research Unit, 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, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
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Kuca T, Butler MB, Erdogan M, Green RS. A comparison of balanced and unbalanced crystalloid solutions in surgery patient outcomes. Anaesth Crit Care Pain Med 2016; 36:371-376. [PMID: 27856390 DOI: 10.1016/j.accpm.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate adverse patient outcomes associated with the choice of intravenous fluid administered during general anaesthesia. METHODS This study was a retrospective chart review of vascular surgery patients at a Canadian tertiary care hospital. Patients were separated into three groups: those who were intraoperatively administered normal saline (NS), balanced crystalloids, or a combination of both solutions. Multivariate analysis was performed to determine association between volume of each fluid type administered and adverse outcomes including in-hospital mortality, prolonged intensive care unit admission, vasopressor requirement, ventilator requirement, hemodialysis requirement, and a composite endpoint of any of these adverse events occurring. RESULTS Overall, 796 vascular surgery patients were included in the analysis. There were 425 patients who received balanced crystalloids, 158 patients who received NS, and 213 patients received both balanced crystalloids and NS. Groups were similar in age (P=0.06), but varied in gender (P<0.001) and overall health (ASA≥2; P=0.027). The most common adverse event was ventilator requirement (NS: 27.9%, balanced: 7.5%, both: 38.0%; P<0.001). Mortality was lowest in the group that received balanced fluids (NS: 12.0%, balanced: 5.9%, both: 10.8%; P=0.018). Patients who were administered NS or both fluids were more likely to reach the composite endpoint than patients receiving balanced crystalloid alone. CONCLUSION The administration of an unbalanced crystalloid solution was associated with poor patient outcomes in our study population.
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Affiliation(s)
- Tomas Kuca
- Department of critical care, Dalhousie university, room 377, Bethune building, 1276, South Park street, B3H 2Y9 Halifax, NS, Canada.
| | - Michael B Butler
- Department of critical care, department of mathematics and statistics, Dalhousie university, room 377, Bethune building, 1276, South Park street, B3H 2Y9 Halifax, Nova Scotia, Canada.
| | - Mete Erdogan
- Trauma Nova Scotia, Nova Scotia department of health and wellness, room 1-026B, Centennial building, 1276, South Park street, B3H 2Y9 Halifax, NS, Canada.
| | - Robert S Green
- Department of critical care, Dalhousie university, room 377, Bethune building, 1276, South Park street, B3H 2Y9 Halifax, NS, Canada.
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Reddy S, McGuinness S, Parke R, Young P. Choice of Fluid Therapy and Bleeding Risk After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1094-103. [DOI: 10.1053/j.jvca.2015.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Indexed: 02/07/2023]
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Perrault L, Makhija D, Beer I, Laplante S, Iannazzo S, Raghunathan K. Cost-effectiveness of Chloride-liberal versus Chloriderestrictive Intravenous Fluids among Patients Hospitalized in the United States. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2016; 4:90-102. [PMID: 34414248 PMCID: PMC8341618 DOI: 10.36469/9829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background: Patients developing acute kidney injury (AKI) during critical illness or major surgery are at risk for renal sequelae such as costly and invasive acute renal replacement therapy (RRT) and chronic dialysis (CD). Rates of renal injury may be reduced with use of chloride-restrictive intravenous (IV) resuscitation fluids instead of chloride-liberal fluids. Objectives: To compare the cost-effectiveness of chloride-restrictive versus chloride-liberal crystalloid fluids used during fluid resuscitation or for the maintenance of hydration among patients hospitalized in the US for critical illnesses or major surgery. Methods: Clinical outcomes and costs for a simulated patient cohort (starting age 60 years) receiving either chloride-restrictive or chloride-liberal crystalloids were estimated using a decision tree for the first 90-day period after IV fluid initiation followed by a Markov model over the remainder of the cohort lifespan. Outcomes modeled in the decision tree were AKI development, recovery from AKI, progression to acute RRT, progression to CD, and death. Health states included in the Markov model were dialysis free without prior AKI, dialysis-free following AKI, CD, and death. Estimates of clinical parameters were taken from a recent meta-analysis, other published studies, and the US Renal Data System. Direct healthcare costs (in 2015 USD) were included for IV fluids, RRT, and CD. US-normalized health-state utilities were used to calculate quality-adjusted life years (QALYs). Results: In the cohort of 100 patients, AKI was predicted to develop in the first 90 days in 36 patients receiving chloride-liberal crystalloids versus 22 receiving chloride-restrictive crystalloids. Higher costs of chloride-restrictive crystalloids were offset by savings from avoided renal adverse events. Chloride-liberal crystalloids were dominant over chloride-restrictive crystalloids, gaining 93.5 life-years and 81.4 QALYs while saving $298 576 over the cohort lifespan. One-way sensitivity analyses indicated results were most sensitive to the relative risk for AKI development and relatively insensitive to fluid cost. In probabilistic sensitivity analyses with 1000 iterations, chloride-restrictive crystalloids were dominant in 94.7% of iterations, with incremental cost-effectiveness ratios below $50 000/QALY in 99.6%. Conclusions: This analysis predicts improved patient survival and fewer renal complications with chloriderestrictive IV fluids, yielding net savings versus chloride-liberal fluids. Results require confirmation in adequately powered head-to-head randomized trials.
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Affiliation(s)
- Louise Perrault
- International Market Access Consulting, Inc., Zug, Switzerland
| | | | - Idal Beer
- Baxter Healthcare Corporation, Deerfield, IL, USA
| | | | | | - Karthik Raghunathan
- Duke University Medical Center, Division of Veterans Affairs, Durham, NC, USA
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Green RS, Butler MB, Hicks SD, Erdogan M. Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2016; 30:967-72. [PMID: 27222051 DOI: 10.1053/j.jvca.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients. DESIGN Retrospective case series. SETTING Single-center academic hospital. PARTICIPANTS The study included 1,395 adult vascular surgery patients with peripheral vascular disease. INTERVENTIONS Retrospective review of hospital databases. MEASUREMENTS AND MAIN RESULTS Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41). CONCLUSIONS Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.
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Affiliation(s)
- Robert S Green
- Departments of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada; Trauma Nova Scotia, Halifax, Nova Scotia, Canada.
| | - Michael B Butler
- Critical Care, Department of Mathematics and Statistics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shawn D Hicks
- Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mete Erdogan
- Trauma Nova Scotia, Halifax, Nova Scotia, Canada
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Hauffe T, Krüger B, Bettex D, Rudiger A. Shock Management for Cardio-surgical ICU Patients - The Golden Hours. Card Fail Rev 2015; 1:75-82. [PMID: 28785436 PMCID: PMC5490875 DOI: 10.15420/cfr.2015.1.2.75] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/22/2015] [Indexed: 12/14/2022] Open
Abstract
Postoperative shock following cardiac surgery is a serious condition with a high morbidity and mortality. There are four types of shock: cardiogenic, hypovolemic, obstructive and distributive and these can occur alone or in combination. Early identification of the underlying diseases and understanding of the mechanisms at play are key for successful management of shock. Prompt resuscitation measures are necessary to reverse the shock state and avoid permanent organ dysfunction or death. In this review, the authors focus on the management during the first 6 hours of shock (the 'golden hours'). They discuss how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery. The review incorporates the findings of recent trials on early goal-directed therapy and includes practical recommendations in areas in which the evidence is scare or controversial. While the review focuses on cardio-surgical patients, the suggested treatment algorithms might be usefully expanded to other critically ill patients with shock arising from other causes.
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Affiliation(s)
- Till Hauffe
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Bernard Krüger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Dominique Bettex
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Alain Rudiger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
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Santi M, Lava SAG, Camozzi P, Giannini O, Milani GP, Simonetti GD, Fossali EF, Bianchetti MG, Faré PB. The great fluid debate: saline or so-called "balanced" salt solutions? Ital J Pediatr 2015; 41:47. [PMID: 26108552 PMCID: PMC4479318 DOI: 10.1186/s13052-015-0154-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/16/2015] [Indexed: 11/10/2022] Open
Abstract
Background Intravenous fluids are commonly prescribed in childhood. 0.9 % saline is the most-used fluid in pediatrics as resuscitation or maintenance solution. Experimental studies and observations in adults suggest that 0.9 % saline is a poor candidate for fluid resuscitation. Although anesthesiologists, intensive care specialists, perioperative physicians and nephrologists have been the most active in this debate, this issue deserves some physiopathological considerations also among pediatricians. Results As compared with so-called “balanced” salt crystalloids such as lactated Ringer, administration of large volumes of 0.9 % saline has been associated with following deleterious effects: tendency to hyperchloremic metabolic acidosis (called dilution acidosis); acute kidney injury with reduced urine output and salt retention; damaged vascular permeability and stiffness, increase in proinflammatory mediators; detrimental effect on coagulation with tendency to blood loss; detrimental gastrointestinal perfusion and function; possible uneasiness at the bedside resulting in unnecessary administration of more fluids. Nevertheless, there is no firm evidence that these adverse effects are clinically relevant. Conclusions Intravenous fluid therapy is a medicine like insulin, chemotherapy or antibiotics. Prescribing fluids should fit the child’s history and condition, consider the right dose at the right rate as well as the electrolyte levels and other laboratory variables. It is unlikely that a single type of fluid will be suitable for all pediatric patients. “Balanced” salt crystalloids, although more expensive, should be preferred for volume resuscitation, maintenance and perioperatively. Lactated Ringer appears unsuitable for patients at risk for brain edema and for those with overt or latent chloride-deficiency. Finally, in pediatrics there is a need for new fluids to be developed on the basis of a better understanding of the physiology and to be tested in well-designed trials.
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Affiliation(s)
- Maristella Santi
- Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland
| | - Sebastiano A G Lava
- University Children's Hospital Berne and University of Berne, 3010 Berne, Switzerland
| | - Pietro Camozzi
- Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland
| | - Olivier Giannini
- Division of Internal Medicine and Nephrology, Ospedale Regionale, 6850 Mendrisio, Switzerland
| | - Gregorio P Milani
- Pediatric Emergency Department, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giacomo D Simonetti
- Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.,University Children's Hospital Berne and University of Berne, 3010 Berne, Switzerland
| | - Emilio F Fossali
- Pediatric Emergency Department, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mario G Bianchetti
- Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.
| | - Pietro B Faré
- Department of Internal Medicine, Ospedale San Giovanni, 6500 Bellinzona, Switzerland
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