RL or NS which is better in sepsis?
Crystalloids are used for resuscitation in sepsis and septic shock as it inexpensive and widely available. Commonly available IV fluids are NS & RL. Optimal fluid of choice has been point of debate and NS has used for decades as fluid of choice. Recent studies and evidences have raised concern of using NS due to hyperchloremic metabolic acidosis, renal vasoconstriction, AKI, increased cytokine secretion.
SALT-ED (2018) Trial is a single center, pragmatic, multiple crossover trial comparing balanced crystalloid (Lactated Ringers solution or Plasma-Lyte A) with saline among adullts who were treated with IV crystalloids in the ED and hospitalised outside ICU. A total of 13347 patients enrolled. Study found that hospital free days didn't differ between the balanced crystalloids and saline group (median, 25 days in each group). But study also showed that balanced cyrstalloid group has lower incidence of adverse kidney events within 30 days than saline (4.7% v/s 5.6%, p=0.01).
SMART Trial (2018) is pragmatic, cluster randomized, multiple crossover trial conducted in 5 ICU in a single academic centre, open label. Total of 15802 patients were randomised to receive either NS or balanced cyrstalloid. Study found among 7942 patients in the balanced group, 1139 (14.3%) had a major adverse kidney event compared to 1211 of 7860 patients (15.4%) saline group(p-0.04) . 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). Study concluded that 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.
SPLIT study (2015) is a double blind, cluster randomised, double crossover trial done on all patients admitted to ICU requiring crystalloid fluid therapy. 1152 patients recieved buffered crystalloid and 1110 patients recieved saline.Study found that in cyrstalloid group 9.6% developed AKI compared to 9.2% in saline group within 90 days of enrollement. Among the patients receiving crystalloid fluid therapy in the ICU, use of buffered crystalloid compared with saline didnot reduce the risk of AKI.
From these evidences SSG 2021suggest using balanced crystalloid instead of normal saline for resucitation.
BaSCIS Trial (2021) is a double blind,RCT conducted at 75 ICU in brazil. Study was done to determine the effect of a balanced solution v/s saline solution on 90 day survival in critically ill patients. Study concluded that among critically ill patients requiring fluid challenges, use of a balanced solution compared to 0.9% saline did not significantly reduce 90 day mortlaity.
Reference
1) 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. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018 Feb 27. PMID: 29485925; PMCID: PMC5846085.
2) Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27. PMID: 29485926; PMCID: PMC5846618.
3) Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, McGuinness S, Mehrtens J, Myburgh J, Psirides A, Reddy S, Bellomo R; SPLIT Investigators; ANZICS CTG. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA. 2015 Oct 27;314(16):1701-10. doi: 10.1001/jama.2015.12334. Erratum in: JAMA. 2015 Dec 15;314(23):2570. PMID: 26444692.
3) Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021
