The Emergency Department is the land of fluid resuscitation. The most typical resuscitation fluid tends to be 0.9% Normal Saline. At simple face validity, this makes little sense as a volume expander – a poor mimic of basic physiology, and associated with an iatrogenic acidosis in large volumes. Questions abound regarding the risks of renal failure associated with excessive saline administration, as compared to a more balanced or buffered solution.
This SPLIT trial, performed in intensive care units across New Zealand and Australia, provides little additional insight. It is, happily, a lovely randomized, controlled, double-blind trial of fluid administration, comparing 0.9% NS with “buffered crystalloid”, also known as Plasma-Lyte. Various outcomes measured changes in renal function, need for renal replacement therapy, and in-hospital mortality.
No differences.
But, also, not terribly generalizable. Over 70% of these patients arrived to the ICU from the operating room, most of which was after elective surgery, most of which was cardiovascular. Only 15% arrived from the Emergency Department, and only 4% carried a diagnosis of sepsis. Patients also received only a median of 2 liters of fluid during their median of 1.5 days in the ICU.
It’s of mild interest to see no difference, but it does very little to further inform the sort of large-volume, rapid resuscitation routinely performed in the Emergency Department.
“Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial”
http://jama.jamanetwork.com/article.aspx?articleid=2454911
Also: for an excellent review of the “buffered crystalloid” solutions, visit PulmCrit.org.
Generalizable to ICU with a moderate volume of elective surgery. Never going to be generalizable to ED but presumably wasn't intended to be. Reads like a pilot for novel trial design more than the fluid comparison. Supposedly done very cheaply (minimal $ per patient) using routinely collected data & opt-out data consent (everyone received the Rx but able to opt out of their data being used). Also error above – NZ only, not Australia.
Ah yes – part of ANZICs, but took place at just four ICUs in NZ. Thanks for the correction.
I'm a little surprised these authors wondered if there would be a difference; perhaps they were just seeing costs rising from overuse of Plasma-Lyte?