New England Journal of Medicine· 2018Q1· Clinical trial
Balanced Crystalloids versus Saline in Critically Ill Adults
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Short summary
In critically ill adults, administering balanced crystalloids instead of saline for intravenous fluids led to a 1.1 percentage point reduction in major adverse kidney events within 30 days, a composite outcome including death, new renal-replacement therapy, or persistent renal dysfunction.
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Key points
- Balanced crystalloids reduced major adverse kidney events by 1.1% (14.3% vs 15.4%) in critically ill adults over 30 days.
- Major adverse kidney events included death, new renal-replacement therapy, or persistent renal dysfunction.
- The trial was a pragmatic, cluster-randomized, multiple-crossover study involving 15,802 adults across five ICUs.
- In-hospital mortality was slightly lower with balanced crystalloids (10.3% vs 11.1%), though not statistically significant (P=0.06).
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Abstract
BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS: Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60). CONCLUSIONS: Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779 .).
The authors' abstract, as published at the source. New England Journal of Medicine, 2018 · DOI ↗
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Field: Critical Care and Intensive Care Medicine
Critical Care and Intensive Care MedicineMedicine