Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. (Colman)

Zampieri FG, et al. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016 Aug 5. [Epub ahead of print]

OBJECTIVES: To assess the impact of the percentage of fluid infused as Lactated Ringer (%LR) during the first 2 days of ICU admission in hospital mortality and occurrence of acute kidney injury.

DESIGN: Retrospective cohort.

SETTING: Analysis of a large public database (Multiparameter Intelligent Monitoring in Intensive Care-II).

PATIENTS: Adult patients with at least 2 days of ICU stay, admission creatinine lower than 5 mg/dL, and that received at least 500 mL of fluid in the first 48 hours.

INTERVENTIONS: None.

MEASUREMENT AND MAIN RESULTS: 10,249 patients were included in mortality analysis and 8,085 were included in the acute kidney injury analysis. For acute kidney injury analysis, we excluded patients achieving acute kidney injury criteria in the first 2 days of ICU stay. Acute kidney injury was defined as stage 2/3 Kidney Disease: Improving Global Outcomes creatinine criteria and was assessed from days 3-7. The effects of %LR in both outcomes were assessed through logistic regression controlling for confounders. Principal component analysis was applied to assess the effect of volume of each fluid type on mortality. Higher %LR was associated with lower mortality and less acute kidney injury. %LR effect increased with total volume of fluid infused. For patients in the fourth quartile of fluid volume (> 7 L), the odds ratio for mortality for %LR equal to 75% versus %LR equal to 25% was 0.50 (95% CI, 0.32-0.79; p < 0.001). Principal component analysis suggested that volume of Lactated Ringer and 0.9% saline infused had opposite effects in outcome, favoring Lactated Ringer.

CONCLUSIONS: Higher %LR was associated with reduced hospital mortality and with less acute kidney injury from days 3-7 after ICU admission. The association between %LR and mortality was influenced by the total volume of fluids infused.

Fluid resuscitation in septic shock the effect of increasing fluid balance on mortality. (Ruth)

Sadaka F, Juarez M, Naydenov S, O’Brien J. Fluid resuscitation in septic shock the effect of increasing fluid balance on mortality. J Intensive Care Med. 2013 Feb 27;29(4):213-217. [Epub ahead of print]

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PURPOSE: To determine whether progressively increasing fluid balance after initial fluid resuscitation for septic shock is associated with increased mortality.

METHODS: A retrospective review of the use of intravenous fluids in patients with septic shock in a large university affiliated hospital with 56 medical-surgical intensive care unit beds. We analyzed the data of 350 patients with septic shock who were managed according to the Surviving Sepsis Campaign guidelines. Based on net fluid balance at 24 hours, we examined the results of increase in positive fluid balance on the risk of in-hospital mortality. Patients were divided into 4 groups based on the amount of fluid balance by 24 hours, based on 6-L aliquots.

RESULTS: At 24 hours, the average fluid balance was +6.5 L. After correcting for age and sequential organ failure assessment score, a more positive fluid balance at 24 hours significantly increased the risk of in-hospital mortality. Using Cox proportional hazard analysis, excess 12-, 18-, and 24-L positive fluid balance had higher risk of mortality than those patients with a neutral to positive 6-L fluid balance (reference group). Adjusted hazard ratios, 1.519 (95% confidence interval [CI], 1.353-1.685), 1.740 (95% CI, 1.467-2.013), and 1.620 (95% CI, 1.197-2.043), respectively, P < .05.

CONCLUSION: In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality. Optimal survival occurred at neutral fluid balance and up to 6-L positive fluid balance at 24 hours after the development of septic shock.

 

Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis. (Stockwell)

Basnet S, Venepalli PK, Andoh J, Verhulst S, Koirala J. Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis. J Intensive Care Med. 2014 Jan-Feb;29(1):38-42.

Objective: This study aims to describe the effect of 0.9% saline (NS) versus 0.45% saline (half NS) when used during recovery phase of diabetic ketoacidosis (DKA) in children.

Methods: A retrospective analysis of all children (1-18 years old) with DKA admitted in the pediatric intensive care unit (PICU) from 2005 to 2009 was undertaken. The primary end point was effect on serum electrolytes and acidosis.

Results: Compared to 47 patients who received only NS (group A) throughout the recovery period and 33 patients who received NS but were switched to half NS (group B) at some point during recovery, 41 who received only half NS (group C) had a significant decrease in corrected serum sodium (P < .01). Hyperchloremia leading to nonanion gap acidosis was significantly greater in NS groups A and B than in half NS group C (P < .01). This led to increased duration of insulin infusion and length of stay in the PICU in the NS groups.

Conclusions: Hyperchloremia resulting in nonanion gap acidosis can occur and may prolong the duration of insulin infusion and length of PICU stay in patients receiving NS as post-bolus rehydration fluid. Alternatively, the use of half NS may result in a decrease in serum-corrected sodium. Providers need to be vigilant toward this while using higher or lower sodium chloride when managing children with DKA. Larger trials are required to study the clinical significance of the results of this study.

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