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Balanced Crystalloid vs. Saline, the Ride Never Ends

Discussion in 'Critical Care' started by Mad Jack, Nov 10, 2017.

  1. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    Crap stats thrown against a wall. Something stuck with their lame p value.

    What was the number needed to treat? I missed it.

    Do what you want. You are clearly the superior human being to those who aren't overly impressed.
     
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  3. lymphocyte

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  4. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    Look. You have your rationale. I'm not even in here arguing for dumping saline into patients. I'm not Shake Shack or Five Guys. My point has been the data is not as robust as the Shake Shack fan bois want to make it out to be.

    The sanctimonious bible thumping of weak data is one of my big pet peeves with critical care culture.
     
  5. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Yep... you take Dextrose and put it into the bag... there's nothing special about D5, other than it is typically all that is needed in most situations.
     
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  6. Vigileo

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    Care to comment on what specifically you disagree with statistically? MAKE-30 is an accepted and patient-centric endpoint, so I'd be interested to see what you think. It's not the discovery of penicillin, but given clinical equipose on fluid choice, it does provide some guidance in terms of clinical practice. It doesn't or at least shouldn't result in not using physician judgment in treatment decisions. For full disclosure, I'm not associated with the study but do have a bias towards it.
     
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  7. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    I care little if some academics decided that MAKE-30 is an ok place to try and make statistical points.

    There was no difference between the two groups in all studies to the end points that matter when looked at specifically and individually. Which is what matters to me. Lumping it all together and then saying, "ah-ha!! signal!!" looks like the worst that EBM has to offer
     
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  8. nephrondoc

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    Some people will only get as far as they want and see only what they want to see. Then they make comments like " You can't even argue its the excess fluid that caused the adverse secondary outcomes. They lack that power. " " Show me the P<0.05" . " Normal saline is not poison".

    They also think on the lines of "Everyone is very stupid. Everyone. All of them. The whole world. All stupid. Forever."

    Reminds me of a quote:
    “Never argue with a fool, onlookers may not be able to tell the difference.” ― Mark Twain
     
  9. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    First, a disclaimer: I'm not sure where I really stand on this yet - I need to think about it a lot more it seems.

    On one hand, I totally get what you're saying, that it totally reeks of statistical manipulation and the worst of our current publication biases to find and report positive associations. And if our research apparatus is really trying to find scientific "truth", then knowing the actual associations/correlations for individual outcomes gets us a lot closer to that ideal...

    But, if you're a patient, wouldn't your default position be to avoid ANY adverse event? I think the argument can be readily made that such a simplification is beneficial for patients. Yes obviously avoiding death is a higher priority than avoiding persistent kidney dysfunction but if treatment A has a 10% chance of anything happening and treatment B as a 12% chance, you might reasonably prefer treatment A - especially if your physician was able to say that for the individual components there didn't seem to be an advantage.
     
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  10. Vigileo

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    Death, renal replacement therapy, and persistent renal dysfunction as endpoints aren't just "some academics deciding", but are endpoints that are all meaningful to patients and critical care docs, especially since mortality was the biggest driver in the composite. I think it's short sighted and curmudgeonly (?word) to just dismiss it. The study has also set the stage to try and look at the etiologies of possible renal dysfunction related to normal saline (is it chloride? is it the pH? something else?) as well as study other balanced crystalloids against each other. Studying the best way to do things we already do anway isn't a useless endeavor though admittedly not as sexy as Xigris or something else. I think BidRedBeta hits the head on the nail though with his last paragraph (and is augmenting my point about the study providing some guidance in the setting of clinical equipose).
     
  11. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    Those are only meaningful end points when they are actually statistically significantly different between the two groups. You can't lump them all together and pretend it is the same thing.
     
  12. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    The more I've thought about it, I've decided that I'm largely okay with the idea of composite endpoints, but like any methodology choices, it has to be an a priori decision in the study design, not something thrown together to salvage a study. A large part of this conclusion comes from my pediatrics background in which no study is ever large enough to actually garner any real confidence in it's apparent truth (N of 1 studies of parachutes notwithstanding). 500 subjects in a peds study gets categorized as "HUGE!" and the number of promising, important studies that have shut down due to inability to recruit patients is high, even moreso in the PCCM literature. With a baseline PICU mortality of about 3%, no one ever uses mortality as primary outcome, and yet when I've spoken to adult colleagues I've seen what I thought were good studies with important secondary outcomes get smashed to bits because the mortality didn't change. So I'm primed due to my training and my paradigm to look for alternative means of guiding clinical decision making.

    But in accepting a composite endpoint, it's clear that you have to really parse out the effects and your frame of reference, and to understand that it's not a scientific "truth". @jdh71 's use of the word "signal" is quite appropriate in this context. Highly recommend Nate Silver's book The Signal and the Noise if anyone wants some easily digestible statistics discussions.

    To be clear, endpoints such as all cause death and ventilator free days as primary endpoints could readily be argued are composite endpoints, so let's not pretend this is the first time data points have been lumped together.
     
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  13. TimesNewRoman

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    Tell that to a cardiologist....
     
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  14. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    Ok
     
  15. IMG-In-USA

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    According to evidence based critical care:

    The data presented above suggests that in almost all circumstances LR should be the f luid of choice for fluid resuscitation. There are however a few exceptions to this rule:

    Hyponatremic dehydration (0.9 % NaCl).

    Patients with acute cerebral insults at risk of cerebral edema (hypertonic solutions are preferable in these patients (0.9 % NaCl or hypertonic saline).

    0.9 % NaCl is considered the initial fluid of choice in patients with diabetic ketoacidosis before switching to 0.45 % NaCl [123, 124]. Most patients are switched at some point to one-half isotonic saline to replace the free water loss induced by the glucose osmotic diuresis. LR does not appear to have a role in the treatment of DKA [125].

    A solution of 1 l D5W with 2–3 amps of sodium bicarbonate; severe metabolic acidosis due to ethelylene glycol or severe metabolic acidosis due to loss of HCO3 (diarrhoea, renal tubular acidosis). This solution can also be considered in patients with renal failure and severe metabolic acidosis.

    I personally trust Dr. Marik's judgment.
     
    #64 IMG-In-USA, Apr 27, 2018
    Last edited: Apr 27, 2018
  16. Hamhock

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    What?!?
    The bolded in the quote above is what we must stop doing: propagating old-timer nonsense.
    Whenever such bold statements are made, the poster should be able to support them with at least logic, if not evidence.
    Perhaps [125] is such evidence, but without a real reference I have no idea what that means.
    CCM is a thinking-providers field...if we just continue to use abnormal saline without reason, without thought, or because some old guy with gray hair does it -- we might as well staff the ICU with IM or surgery generalists. (excuse the slightly provocative ending)
    That is what this entire thread is about!
    IMG-In-USA: are you just trolling?
    HH
     
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  17. IMG-In-USA

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    Van Zyl DG, Rheeder P, Delport E. Fluid management in diabetic-acidosis–Ringer’s lactate versus normal saline: a randomized controlled trial. QJM. 2012;105:337–43.
     
  18. economycian

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    All that study says is that there was no difference in resolution of dka between LR and NS (in 56 pts). It is quite a leap to go from this to saying LR has no role in the treatment of DKA.
     
  19. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    At least in Pediatric DKA, LR makes the acidemia correct faster, which gets them out of the ICU faster so we can free up beds and generate more billing without any complications. That is a win.
     
  20. anbuitachi

    anbuitachi ASA Member
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    at my institution, i believe ICUs mostly use NS still. In the OR though, standard is plasmalyte.

    Though I understand NS may be cheaper to produce, but my question is why 154 nacl? Who came up with 154??? Why not lower it a bit?? You can still have saline with just NaCl but just lower amts of Na and Cl.

    And I think if the patient is in the ICU, saving 1$ on a 1L of NS instead of plasmalyte shouldnt be a concern. That's like saving a EKG sticker

    Regarding #4. A neurosurgeon demanded in the OR we change our fluids from plasmalyte to NS, b/c his reasoning is plasmalyte causes brain to swell because plasmalyte causes hyponatremia despite me saying plasmalyte has a Na of 140 and osm of 294... I am not aware of any evidence supporting NS over plasmalyte in neurosurgery. Anyone know of any?


    Another question is how well done are these studies? I clearly didn't read it. But when i'm in the ICU, half of the patients IV fluid intake is not the maintenance fluid, NS or plasmalyte or LR or w/e you use. It's the fluid from meds!!! And I'm pretty sure those are not mixed in plasmalyte. If you have a study where a large % of plasmalyte group is actually not getting plasmalyte, that would lower its affect... i especially see this in the CCU/CTICU, where electrolyte repletions are frequent, are patients are often on many infusions. Antibiotics are also huge contributors of fluids
     
    #69 anbuitachi, Apr 28, 2018
    Last edited: Apr 28, 2018
  21. Trail Blazer

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    EM resident here, I have been silently following the thread. As a med student my fiance (now anesthesia resident) and I both were interested in the NS vs balanced crystalloid debate. We wrote a review on the subject (published in a crappy but pubmed searchable journal). There is an interesting article on the history of NS. The doi is 10.1016/j.clnu.2008.01.008. TL;DR it came from both dipping frog hearts in solution and seeing what made them beat the longest, and also from the freezing point of human plasma.

    I recently did a presentation on the SALT-ED and SMART trials and the history of the debate. I found it most interesting in SMART how they did find significance in MAKE-30 scores depending on disease state (specifically sepsis and previous RRT).

    I spoke with the person in charge of ordering fluids for our institution. For us, LR is cheaper than NS.

    Is there a significant difference? Maybe not. I still tend to go with balanced crystalloids as they just seem to make more sense.
     
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  22. anbuitachi

    anbuitachi ASA Member
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    Exactly, why dump something in that is so physiologically different into your body? Sure people are resilient and bit of junk probably wont make a difference but theres literally nothing physiologic about NS. NaCl too high, osmol too high, pH and everything else too low.
     
  23. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    I will say the one thing at no one else seemed to mention, the Ca++ in LR makes it incompatible with a lot of IV drug preparations. Now if you have tons of IVs, no big deal, but in pediatrics... we are usually lucky to have 2 and most patients only have 1, especially if they are tiny. Not saying LR isn't fine, I think it is... but there are other reason 0.9% NS is used frequently... it's compatible with everything.
     
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  24. lymphocyte

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    This argument makes no sense. We aren't in the business of naturopathy. Lots of interventions in medicine aren't physiological.
     
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  25. anbuitachi

    anbuitachi ASA Member
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    that logic makes no sense. should we use pure water then instead of saline? things aren't physiological cause there are reasons for it not to be. i dont see any for saline
     
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  26. lymphocyte

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    You can use free water to correct a free water deficit. There are plenty of reasons to use normal saline. Just not routinely.
     
  27. anbuitachi

    anbuitachi ASA Member
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    we usually dont give free water IV
     
  28. Psai

    Psai Snitches get zero vicryl
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    Which drugs are incompatible with LR?
     
  29. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Not a comprehensive list. You need would need Mircomedex.


    There is essentially nothing that is incompatible with NS
     
  30. Psai

    Psai Snitches get zero vicryl
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    That list is nonsense

    I have given many of those meds with LR on very frequent basis: decadron, fentanyl, ceftriaxone, heparin, txa, sodium bicarb

    I have had precipitation when I mixed decadron and zofran but that's because zofran is incompatible with many things

    I use LR instead of NS in every case except neurosurg or if I'm working with someone that doesn't understand esrd or blood transfusion
     
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  31. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Super. You know nurses won’t give them in the unit unless they are compatible or have verified with the pharmacist.
     
  32. anbuitachi

    anbuitachi ASA Member
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    Question is what data is it based on? The issue is not every incompatibility causes precipitation so you may not see it w eyes. I'm curious as to why fent can't mix w LR
     
  33. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    It says manufacturer testing. I don’t know any more than that. If there was a pharmacist here, I’m sure they would have better insight.
     
  34. Psai

    Psai Snitches get zero vicryl
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    Of course fent mixes with LR. In cardiac we push 20 cc of fent in LR on a daily basis.
     
  35. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    NS turned me into a newt
     
  36. 24GaugeEJ

    24GaugeEJ Small, but mighty; probably positional.
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    I got better.
     
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  37. NITRAS

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    Tell that to the nurses that decided not to give the fluids I ordered, (nor notify me) because they just had one twenty something gauge IV and the extended infusion antibiotics infuse most of the day.

    I suspect if they made a solution without calcium, lots of the incompatibility would go away.
     
  38. Psai

    Psai Snitches get zero vicryl
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    Your blood has calcium.
     
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  39. TimesNewRoman

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    Yes, I think the idea of comparable is nearly absurd. Particularly when the nurses say something isn’t comparable with blood. If it’s not company’s with blood, you shouldn’t be giving it.
     

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