Faculty Collaboration Database

Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med 2018 Mar 01;378(9):829-839

Date

02/28/2018

Pubmed ID

29485925

Pubmed Central ID

PMC5846085

DOI

10.1056/NEJMoa1711584

Scopus ID

2-s2.0-85042695561 (requires institutional sign-in at Scopus site)   832 Citations

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 .).

Author List

Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW, SMART Investigators and the Pragmatic Critical Care Research Group

Author

Jesse Ehrenfeld MD, MPH Sr Associate Dean, Director, Professor in the Advancing a Healthier Wisconsin Endowment department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adult
Aged
Critical Illness
Cross-Over Studies
Electrolytes
Emergency Service, Hospital
Female
Fluid Therapy
Humans
Infusions, Intravenous
Intensive Care Units
Isotonic Solutions
Kidney Diseases
Male
Middle Aged
Renal Replacement Therapy
Sodium Chloride