Balanced Crystalloid vs. Saline, the Ride Never Ends

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Mad Jack

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Thread title fixed, link now goes to study. We just use "crystalloid" as shorthand for LR around here, didn't realize it wasn't a thing elsewhere.

LR is more balanced relatively speaking but still isn't plasmalyte (tm?). That is the study I'd like to see. Something I find intereating is that it took 15,000 patients to finally get the signal which I think speaks to the actual relative safety of saline actually. Like most critical care docs I use both saline and LR. Sometimes probably at random. I like to think I usually have a reason for a choice. I don't think NS is poison. I just don't know if this is enough to change my practice. Maybe. Everything being equal why not I guess. Again. I really would like to see a RTC plasmalyte trial. Would. Love love love it.
 
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There's a reason NS is the most common, its cheap and easiest to modify. The hyperchloremia can be a pain, but irrespective of that, it does the job. I'd be fine with an RCT, maybe NS versus LR versus Plasmalyte, but only if they did an associated cost analysis. Otherwise, the relative differences are going to infinitesimally small to not warrant a change in hospital practice.

As an aside, they need 14000 patients in their power calculation. Just thinking about that in and of itself, the number needed to treat is going to be very high, if there is a difference at all. I can't see any hospital changing its practice if this is not a cost-effective measure.
 
There's a reason NS is the most common, its cheap and easiest to modify. The hyperchloremia can be a pain, but irrespective of that, it does the job. I'd be fine with an RCT, maybe NS versus LR versus Plasmalyte, but only if they did an associated cost analysis. Otherwise, the relative differences are going to infinitesimally small to not warrant a change in hospital practice.

As an aside, they need 14000 patients in their power calculation. Just thinking about that in and of itself, the number needed to treat is going to be very high, if there is a difference at all. I can't see any hospital changing its practice if this is not a cost-effective measure.
From a cursory read, the NNT is about 100, but that 100 would save the hospital a few dialysis and extended stay cases per year secondary to AKI. With 5,000,000 patients requiring fluids in the ICU, these results have the potential to prevent 50,000 complications.
 
From a cursory read, the NNT is about 100, but that 100 would save the hospital a few dialysis and extended stay cases per year secondary to AKI. With 5,000,000 patients requiring fluids in the ICU, these results have the potential to prevent 50,000 complications.
Well, maybe, we'll see. But I'd still like to see cost analysis. Either way, what I suspect will happen, since they are doing this across multiple ICU with different physiologic complication rates and different comorbidities it that collectively it will be a wash, but specific post-hoc subsets will show minor benefits, maybe. Would these specific subsets change a way a hospital system purchases bulk quantities of IV fluids? I don't know, but that personally hasn't been my experience. The value of an intervention, not the outcome in isolation, is far more en vogue that I recall from the past.

Anyway, I'll be interested to see the results. I know a couple of the authors so if for nothing else, if it doesn't work... I can give them some crap for it.
 
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This was big news at Chest 2017. There were actually two trials across the spectrum of acuity from ED to ICU. What's posted here is only the study protocal. The MICU trial actually had a NNT of 83 (composite end-point). That's a higher proven benefit than anti-coagulation in ACS or a fair chunk of guideline-directed management for HF.

The median dose was around 1.5L by the way, which is peanuts compared to what some doctors pump into their patients. And let's not forget the garbage that is Surviving Sepsis. The point is: supraphysiological doses of chloride are nephrotoxic. I'm not sure how much more conclusive the evidence can get now with a proven mortality benifit in a well-designed RCT. I've argued this point before with other lines of evidence cited: Ordering IV fluids in the ER

I'm waiting for the sub-group analysis, but none of my patients are getting normal saline unless there's a very good reason, i.e. it's a considered decision rather than a flip of the coin.
 
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Well, maybe, we'll see. But I'd still like to see cost analysis. Either way, what I suspect will happen, since they are doing this across multiple ICU with different physiologic complication rates and different comorbidities it that collectively it will be a wash, but specific post-hoc subsets will show minor benefits, maybe. Would these specific subsets change a way a hospital system purchases bulk quantities of IV fluids? I don't know, but that personally hasn't been my experience. The value of an intervention, not the outcome in isolation, is far more en vogue that I recall from the past.

Anyway, I'll be interested to see the results. I know a couple of the authors so if for nothing else, if it doesn't work... I can give them some crap for it.
But if we can clearly demonstrate something enough for it to be considered standard of care and a hospital is not practicing the standard of care by not doing so...
 
But if we can clearly demonstrate something enough for it to be considered standard of care and a hospital is not practicing the standard of care by not doing so...

All HFrEF patients should probably be on a neprilysin-inhibitor, but alas... Chlortalidone and torsemide are two other examples that come to mind.
 
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But if we can clearly demonstrate something enough for it to be considered standard of care and a hospital is not practicing the standard of care by not doing so...
Well, these solutions have been around for decades and despite their rampant, yet unequal usage, outcome keep getting better globally. I find it hard to imagine that through the decades we’ve been picking the wrong solution. Maybe, but more likely we’ve just been giving too much of either solution. Anyway, we’ll see and with 14000 patients, hopefully that will satisfy people of the question.
 
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Anyway, I'll be interested to see the results. I know a couple of the authors so if for nothing else, if it doesn't work... I can give them some crap for it.

Anyway, we’ll see and with 14000 patients, hopefully that will satisfy people of the question.

But the results are in. Here's an abstract from one of them. Full results to be published shortly.

http://journal.chestnet.org/article/S0012-3692(17)32709-5/fulltext
 
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But the results are in. Here's an abstract from one of them. Full results to be published shortly.

http://journal.chestnet.org/article/S0012-3692(17)32709-5/fulltext
Okay, well they got a lot of patients, which is good, but the results are kinda of wash based on their statistics. In both outcome metrics, the CI reaches .99 and 1.01. That’s not an impressive statistical effect. Also, it appears the saline group got less fluid, were they relatively under resuscitated by comparison thus more AKI? Anywho, congrats to them for doing the study. I’ll have to ask the dude I know on the author list if it dramatically changed unit practice for him. In the US, NS is only slightly cheaper than LR. In the UK, NS is significantly cheaper, so this may up being regional preference rather than standard of care.

Edit: I don’t practice adult medicine so maybe someone can clarify this, but the two treatment arms received a median of about 1 liter of fluid. That’s it?! How is that possible? They must mean per day right? 1 liter is less than a 20 kg kid gets in a day. Maybe it’s a typo as there is another obvious typo in the abstract.
 
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Edit: I don’t practice adult medicine so maybe someone can clarify this, but the two treatment arms received a median of about 1 liter of fluid. That’s it?! How is that possible?

Because these trials were reallllllly well done, and the sub-group analysis will be pivotal. Entirely pragmatic to practice. Your friend deserves a pat on the back.

Also, that's not how you p-value! Besides, the CI was .80-1.01 for mortality, and less than 1 for MAKE30. Conclusive benefit. If you want to roll Bayesian, I think it's conclusive for both outcomes.
 
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Because this trial was reallllllly well done, and the sub-group analysis will be pivotal. Your friend deserves a pat on the back.

Also, that's not how you p-value! Besides, the CI was .80-1.01 for mortality, and less than 1 for MAKE30. Conclusive benefit. If you ever want to roll Bayesian, I think it's conclusive for both outcomes.
Hmm, how is giving adult critically ill patients only 1 liter of fluid a day really well done? I’m asking honestly because I don’t see how this is extrapolatable to common practice. I mean we give children more fluid. Is there some sort of calculation based on urine output plus insensible losses plus carrier fluids that equals that volume? Again, admitting my lack of experience in adult critical care medicine, for pediatrics, thus study doesn’t seem helpful. Maybe there is more information on the actual manuscript. I’ll have to suggest it when the final paper comes out and hear what the group says. We are an opinionated bunch...
 
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Hmm, how is giving adult critically ill patients only 1 liter of fluid a day really well done? I’m asking honestly because I don’t see how this is extrapolatable to common practice. I mean we give children more fluid. Is there some sort of calculation based on urine output plus insensible losses plus carrier fluids that equals that volume? Again, admitting my lack of experience in adult critical care medicine, for pediatrics, thus study doesn’t seem helpful. Maybe there is more information on the actual manuscript. I’ll have to suggest it when the final paper comes out and hear what the group says. We are an opinionated bunch...

It's because it's across the spectrum of acuity, and not everybody needs litres of fluids, like with non-infective COPD exacerbations requiring a little biPAP or decompensated HF. The point is, pending sub-group analysis, you can extrapolate this to argue that even a low dose of normal saline is toxic. The SALT trials, which includes ED, are next up. Exciting times for dweebs like me.

None of my patients get normal saline, even for mundane indications like maintenance, unless there's a good reason.
 
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It's because it's across the spectrum of acuity, and not everybody needs litres of fluids, like with COPD or decompensated. The point is, pending sub-group analysis, you can extrapolate this to argue that even a low dose of normal saline is toxic. The SALT trials, which includes ED, are next up. Exciting times for dweebs like me.

None of my patients get normal saline, even for mundane incubations like maintenance, unless there's a good reason.
Meh, we give kids saline all the time, even 3% infusions, but again kids are resilant. Like I said before, post hoc subgroup analysis is likely more informative than blanket statements of LR > NS for critically ill patients.

You do have to be careful with the calcium in LR as it can cause salt precipitation with additives in medications. It is actually contraindicated in infants and newborns exactly for this reason.
 
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You do have to be careful with the calcium in LR as it can cause precipitation with additives in medications.

Yeah, I avoid LR when I need to cocktail certain things, like a Mg + prochlorperazine migraine mix. Or otherwise fit and well young folks who just need a top-up in ED. But you see lots of people slammed with gent or whatever and a few litres of NS, and now that just seems dumb and sloppy practice.
 
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Something I find intereating is that it took 15,000 patients to finally get the signal which I think speaks to the actual relative safety of saline actually.

The N of the trial speaks to its quality and power, but a power calculation is more than just effect size. Besides, a NNT for MAKE30 of 83 is a decent effect size--I think practice-changing, even from a cost-analysis point of view (LR is about $5 a litre over here, peanuts compared to an extra few hospital days). This signal has been demonstrated many times before, but old habits die hard. (@SurfingDoctor, it wasn't that long ago we used to give hypotonic maintenance fluids to kids.)

Here was the study that caught my eye a few years ago from Melbourne with a similar conclusion. It's not about hyperchloraemic acidosis per se but chloride itself. @Nephro critical care, I'd be interested if you have any thoughts.

Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-72.

Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. - PubMed - NCBI
 
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The N of the trial speaks to its quality and power, but a power calculation is more than just effect size. Besides, a NNT for MAKE30 of 83 is a decent effect size--I think practice-changing, even from a cost-analysis point of view (LR is about $5 a litre over here, peanuts compared to an extra few hospital days). This signal has been demonstrated many times before, but old habits die hard. (@SurfingDoctor, it wasn't that long ago we used to give hypotonic maintenance fluids to kids.)

Here was the study that caught my eye a few years ago from Melbourne with a similar conclusion. It's not about hyperchloraemic acidosis per se but chloride itself. @Nephro critical care, I'd be interested if you have any thoughts.

Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-72.

Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. - PubMed - NCBI
Here's another study that compared LR to NS and also showed lower mortality and AKI with LR, but the effect became pronounced in patients who received >7L of fluids.

Lactated Ringer is Associated with reduced mortality and less acute kidney injury in critically ill patients: A Retrospective Cohort Analysis.
 
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The N of the trial speaks to its quality and power, but a power calculation is more than just effect size. Besides, a NNT for MAKE30 of 83 is a decent effect size--I think practice-changing, even from a cost-analysis point of view (LR is about $5 a litre over here, peanuts compared to an extra few hospital days). This signal has been demonstrated many times before, but old habits die hard. (@SurfingDoctor, it wasn't that long ago we used to give hypotonic maintenance fluids to kids.)

Here was the study that caught my eye a few years ago from Melbourne with a similar conclusion. It's not about hyperchloraemic acidosis per se but chloride itself. @Nephro critical care, I'd be interested if you have any thoughts.

Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-72.

Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. - PubMed - NCBI
We still do use hypotonic fluids maintenance fluids in children. I’m not sure I understand your comment.
 
The jury is still out but there are couple of points I have learned in the last 3-4 yrs that I didn’t know during my IM residency.
1. Default fluids should be LR in a large volume resuscitation > 3-4 L. Previously in IM residency the dogma was that LR causes hyperkalemia, it doesn’t. Too much NS causes a hypercholeremic acidosis and hypercholeremia causes renal injury. This may be because chloride causes renal vasoconstriction.
2. There is some data (SAFE trial) that in run of the mill septic shock patients albumin may be helpful/superior to saline both in increasing CVP and decreasing risk of AKI. There is a non significant mortality benefit with albumin in septic shock patients.
3. Albumin should not be used in trauma patients with possible brain injury as it increases mortality. I postulate this may be due to albumin leaking through blood brain barrier and increasing ICP.
4. Similarly post neurosurgery default fluids should be saline rather than LR. I would not give hypotonic fluids in any circumstances where I suspect cerebral edema as they will cause hyponatremia.
 
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The jury is still out but there are couple of points I have learned in the last 3-4 yrs that I didn’t know during my IM residency.
1. Default fluids should be LR in a large volume resuscitation > 3-4 L. Previously in IM residency the dogma was that LR causes hyperkalemia, it doesn’t. Too much NS causes a hypercholeremic acidosis and hypercholeremia causes renal injury. This may be because chloride causes renal vasoconstriction.
2. There is some data (SAFE trial) that in run of the mill septic shock patients albumin may be helpful/superior to saline both in increasing CVP and decreasing risk of AKI. There is a non significant mortality benefit with albumin in septic shock patients.
3. Albumin should not be used in trauma patients with possible brain injury as it increases mortality. I postulate this may be due to albumin leaking through blood brain barrier and increasing ICP.
4. Similarly post neurosurgery default fluids should be saline rather than LR. I would not give hypotonic fluids in any circumstances where I suspect cerebral edema as they will cause hyponatremia.
Where’s the evidence that “increasing CVP” is something you’re supposed to be doing. The albumin benefit in sepsis is only true within 24 hours last I heard, and I believe the rational has to do with glycocalyceal damage by endotoxin.
 
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Where’s the evidence that “increasing CVP” is something you’re supposed to be doing. The albumin benefit in sepsis is only true within 24 hours last I heard, and I believe the rational has to do with glycocalyceal damage by endotoxin.
I am not stating that ‘increasing CVP’ is necessarily beneficial. I am merely noting that in the SAFE trial it was noted that albumin was superior to saline in increasing CVP. In the SAFE trial albumin was associated with increased mortality in trauma patients with neurological injury.
In the ALBIOS study albumin was associated with improvement with HR/MAP, lower net fluid balances and a significant mortality benefit in the subgroup of patients with septic shock. Conversely in the subgroup of patients without septic shock it was associated with a non significant increase in mortality.
 
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We still do use hypotonic fluids maintenance fluids in children. I’m not sure I understand your comment.

Really? It's one of those old habits that I thought was dying out... I'd probably get the stank eye if I tried to give it here.

Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics. 2014;133(1):105-13.

Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis
 
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Really? It's one of those old habits that I thought was dying out... I'd probably get the stank eye if I tried to give it here.

Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics. 2014;133(1):105-13.

Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis
I’m well aware of the literature. People don’t use 1/4 NS, but D5 1/2 NS is still probably the most common maintenance fluid in pediatrics. Does it cause hyponatremia? Sure it can, though not commonly. Does it cause adverse effects? Like most things, it does if you don't put it in the proper pathophysiologic context and don't monitor what you are doing. I think I've seen 1 hyponatremic seizure in 10 years from an infant with bronchiolitis who was receiving 1/4 NS, which I don't personally use as a fluid and I think it is ridiculous that the Holladay/Segar method is even taught because it leads people to put infants on essentially free water. But 1/2 NS, I mean that is easily the most common pediatric fluid used. There are few trials to look at outcomes though. Those meta-analysis include 1/2 NS but also all the pointless more-hypotonic solutions available. I think that is not a very good comparison. These are the closest I've seen. Basically they show some hyponatremia, but with no adverse effects.
Intravenous Maintenance Fluids
A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia. - PubMed - NCBI
But as stated, NS causes hyperchloremic acidosis. So, I guess the argument then goes back to balanced crystalloids. I don't think the data exists, but in pediatrics, I think there would be no outcome difference between any LR vs NS vs 1/2 NS. Someone should do that study though.
 
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Finally got around to reading this paper in depth.

I'm not impressed with the data.

I know having a strong opinion on which IV fluid to use is like having a strong opinion on five guys vs shake shack.

The paper itself looks to be throwing bull**** without any significance against a statistical wall in enough ways and finding something you can finally get stuck there with a p-hacked 0.05
 
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Finally got around to reading this paper in depth.

I'm not impressed with the data.

I know having a strong opinion on which IV fluid to use is like having a strong opinion on five guys vs shake shack.

The paper itself looks to be throwing bull**** without any significance against a statistical wall in enough ways and finding something you can finally get stuck there with a p-hacked 0.05

SMART-SURG
SMART-MED
SALT-ED

All published this year.

No reason to give NS in 2018 barring a few specific indications. NNT around 97, which really adds up given how much fluid is prescribed. SALT-ED showed no mortality benefit but there was a significant difference in AKI.

Take-home message is that chloride is nephrotoxic and should be treated as such.

SMART-MED and SMART-SURG - Wiki Journal Club

NEJM-SALTED
 
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SMART-SURG
SMART-MED
SALT-ED

All published this year.

No reason to give NS in 2018 barring a few specific indications. NNT around 97, which really adds up given how much fluid is prescribed. SALT-ED showed no mortality benefit but there was a significant difference in AKI.

Take-home message is that chloride is nephrotoxic and should be treated as such.

SMART-MED and SMART-SURG - Wiki Journal Club

NEJM-SALTED

I'll have to look at those.

And there are reasons to give saline. It's not poison.
 
SMART-SURG
SMART-MED
SALT-ED

All published this year.

No reason to give NS in 2018 barring a few specific indications. NNT around 97, which really adds up given how much fluid is prescribed. SALT-ED showed no mortality benefit but there was a significant difference in AKI.

Take-home message is that chloride is nephrotoxic and should be treated as such.

SMART-MED and SMART-SURG - Wiki Journal Club

NEJM-SALTED

My commentary in unchanged. It looks like statistical crap thrown against a wall until something stuck. I'm still not impressed. All of the outcomes by themselves were not statistically significant. They had to get all lumped together for the statistical signal to show up.

All things being equal, I have no problems with more balanced salt solutions being used - a practice I think most of us in the ICU were doing anyway (*if* we thought the patient needed fluids, because most of us have been running patients "dry" for a few years now). I don't have a strong opinion based on this data. Shake shack vs Five guys . . . Five Guys has peanuts, so they win . . . I guess . . .
 
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MAKE-30 is a validated (and recommended by the ASN) outcome for AKI in clinical trials for clinically meaningful outcomes, which RIFLE criteria and "biomarkers" haven't been in previous trials. The criteria is a composite outcome yes but that in and of itself doesn't nullify the finding. And if you look carefully, the subgroup that benefitted the most was the group with sepsis, which makes it even more interesting as they would receive larger volumes of crystalloid traditionally. If LR and NS are the same cost at the end-user (which it is), and there was clinical equipose before, then now a large study with a NNT of 97 should push most units to use balanced solutions as the go to unless there was a specific indication otherwise. And, for what it's worth, TBI patients were excluded in this trial.
 
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And why would NS be chosen to prevent cerebral edema?
Is that the best choice?
Is there any evidence to support that of higher or even equal quality to what has been disparaged above?
Default to NS for goal sodium 145 is what neurosurgeons do.
HH
 
And why would NS be chosen to prevent cerebral edema?
Is that the best choice?
Is there any evidence to support that of higher or even equal quality to what has been disparaged above?
Default to NS for goal sodium 145 is what neurosurgeons do.
HH
You really need evidence to support that a fluid with osmolarity of 308 is better than one with osmolarity of 273, for ICP reduction, when every cc of cerebral edema matters?
 
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You really need evidence to support that a fluid with osmolarity of 308 is better than one with osmolarity of 273, for ICP reduction, when every cc of cerebral edema matters?
295 vs 308
And supplemented with "hypertonic" prn
 
Maybe for Plasmalyte. LR has 273.

As for hypertonic saline, how many ICUs actually use it?
Every ICU I've ever worked in. (Academics and the community)
Of corse, I see my anecdote as weak sauce...yet my original point still stands.
That said, I'm only advocating more questioning of NS for crystal heads - err, crystalloid-heads - like us.
If the average doc reached first for LR/Plasmalyte and demanded a reason for NS use (i.e. Heads), patients and medicine would be better off.
HH
 
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And why would NS be chosen to prevent cerebral edema?
Is that the best choice?
Is there any evidence to support that of higher or even equal quality to what has been disparaged above?
Default to NS for goal sodium 145 is what neurosurgeons do.
HH

Is there really good evidence for anything we do in the ICU . . . ???

Take a bong rip if you need one with that question because it really becomes a sophomore philosophy 201 afternoon discussion at this point.

You can give sick heads whatever you want, I'll keep using saline, when necessary, because that is what makes sense medically regardless of what the neurosurgeons say or do.

I think if any two neurosurgeons ever managed the same thing the same way hell would freeze over.

Can't always wait for the randomized double blind cross over that enlists everything important and nonconfounfing but doesn't keep out anything that would usually get the same treatment to do what looks like it's correct on first principles.

Any doctor that can be replaced with a bunch of RCTs and a few algorithms, should be.
 
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The er forum discussion on this topic is hilarious. Take home point was that everyone will keep getting ns because they don't want to get sued because of a Baxter package insert. Also evidence not good enough, we've been fooled before, and I've never seen anything bad happen etc etc.

I found this discussion to be much more nuanced and useful so thank you!
 
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heh heh

28bt76.jpg
 
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There's a reason NS is the most common, its cheap and easiest to modify. The hyperchloremia can be a pain, but irrespective of that, it does the job. I'd be fine with an RCT, maybe NS versus LR versus Plasmalyte, but only if they did an associated cost analysis. Otherwise, the relative differences are going to infinitesimally small to not warrant a change in hospital practice.

As an aside, they need 14000 patients in their power calculation. Just thinking about that in and of itself, the number needed to treat is going to be very high, if there is a difference at all. I can't see any hospital changing its practice if this is not a cost-effective measure.

Someone that does a lot of major vascular anesthesia here... I don't use NS and I bristle at the ER as they pour NS into my acutely occluded bilateral iliac or femoral artery occlusion patients from passing a weekend on the couch after an alcoholic binge and a fib mediated embolic events...to a certain extent, the acidemia of no lower extremity arterial flow for at least a day is sequestered. Once the surgeons open the arteries, all bets are off. Blood loss aside, these cases can get a lot of crystalloid. Why, if I had the choice, would I not give crystalloid with a pH of 7.4 as opposed to 6.5 (LR) or less (NS)? Anectodal to be sure, but take my word for it, managing acid/base balance in these circumstances is demonstrably easier with Plasmalyte/normosol
 
Someone that does a lot of major vascular anesthesia here... I don't use NS and I bristle at the ER as they pour NS into my acutely occluded bilateral iliac or femoral artery occlusion patients from passing a weekend on the couch after an alcoholic binge and a fib mediated embolic events...to a certain extent, the acidemia of no lower extremity arterial flow for at least a day is sequestered. Once the surgeons open the arteries, all bets are off. Blood loss aside, these cases can get a lot of crystalloid. Why, if I had the choice, would I not give crystalloid with a pH of 7.4 as opposed to 6.5 (LR) or less (NS)? Anectodal to be sure, but take my word for it, managing acid/base balance in these circumstances is demonstrably easier with Plasmalyte/normosol
Well we take care of many children with metabolic crises in pediatrics... kids who present with systemic pHs of 7.0... I’ve never seen the fluid type alter outcomes personally. But that is just my experience.
 
I'll have to look at those.

And there are reasons to give saline. It's not poison.
As someone who frequently describes his job as controlled polypharmacy, I have to disagree. Everything we give is poison. All of it. Every last drop is poison. At least that is how I view it.
 
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As someone who frequently describes his job as controlled polypharmacy, I have to disagree. Everything we give is poison. All of it. Every last drop is poison. At least that is how I view it.

That's a very "anesthesia way" of looking at things but I take your point to a point.

I think the context of my comment though was probably clear. While all things can be poisons in abundance (ZOMG WATER!!!!!) I was talking about things that are "harmful" at basically any dose. Sarin gas. Or cholera toxin. Black mamba venom. NS doesn't exist in the same categorically drawn box as those things.

How much more pedantic do we really want to make this discussion?? I think if we believe in ourselves and try really really hard we can go deeper.
 
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Does anyone know of any of the balanced solutions can safely be made into D10 versions? We just started stocking D5 plasmalyte but we were wondering if pharmacy could add more dextrose to make it D10 fit when we need it. Nothing on the package insert either way...
 
That's a very "anesthesia way" of looking at things but I take your point to a point.

I think the context of my comment though was probably clear. While all things can be poisons in abundance (ZOMG WATER!!!!!) I was talking about things that are "harmful" at basically any dose. Sarin gas. Or cholera toxin. Black mamba venom. NS doesn't exist in the same categorically drawn box as those things.

How much more pedantic do we really want to make this discussion?? I think if we believe in ourselves and try really really hard we can go deeper.

NNT 97. Greatest benefit in patients requiring high volume resuscitation. It's a dose-dependent effect. This has been demonstrated in a fair few "first principle" pathophysiological and retrospective studies. Then there was the SPLIT trial.

It's a settled question for me. Pursue a chloride-restrictive strategy in patient's at risk for adverse renal injury. And, generally speaking, if I had one fluid to choose, it would be a balanced solution. With a NNT of 97 and median fluid given of around a litre, I essentially save one patient a week from a MAKE-30 event.
 
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