Comparison of Balanced and Unbalanced Crystalloids As Resuscitation Fluid in Patients Treated for Cardiogenic Shock

Overview

Journal J Intensive Care

Publisher Biomed Central

Specialty Critical Care

Date 2023 Sep 6

PMID 37674211

Authors

Jonas Gmeiner

Bernhardt Bulach

Enzo Lusebrink

Leonhard Binzenhofer

Danny Kupka

Thomas Stocker

Kornelia Low

Ludwig Weckbach

Wolf-Stephan Rudi

Tobias Petzold

Stefan Kaab

Jorg Hausleiter

Christian Hagl

Steffen Massberg

Martin Orban

Clemens Scherer

Affiliations

Soon will be listed here.

Abstract

Background: The efficacy and safety of saline versus balanced crystalloid solutions in ICU-patients remains complicated by exceptionally heterogenous study population in past comparative studies. This study sought to compare saline and balanced crystalloids for fluid resuscitation in patients with cardiogenic shock with or without out-of-hospital cardiac arrest (OHCA).

Methods: We retrospectively analyzed 1032 propensity score matched patients with cardiogenic shock from the Munich University Hospital from 2010 to 2022. In 2018, default resuscitation fluid was changed from 0.9% saline to balanced crystalloids. The primary endpoint was defined as 30-day mortality rate.

Results: Patients in the saline group (n = 516) had a similar 30-day mortality rate as patients treated with balanced crystalloids (n = 516) (43.1% vs. 43.0%, p = 0.833), but a higher incidence of new onset renal replacement therapy (30.2% vs 22.7%, p = 0.007) and significantly higher doses of catecholamines. However, OHCA-patients with a lactate level higher than 7.4 mmol/L had a significantly lower 30-day mortality rate when treated with saline (58.6% vs. 79.3%, p = 0.013). In addition, use of balanced crystalloids was independently associated with a higher mortality in the multivariate cox regression analysis after OHCA (hazard ratio 1.43, confidence interval: 1.05-1.96, p = 0.024).

Conclusions: In patients with cardiogenic shock, use of balanced crystalloids was associated with a similar all-cause mortality at 30 days but a lower rate of new onset of renal replacement therapy. In the subgroup of patients after OHCA with severe shock, use of balanced crystalloids was associated with a higher mortality than saline.

Trial Registration: LMUshock registry (WHO International Clinical Trials Registry Platform Number DRKS00015860).

Citing Articles

Comparison of bicarbonate Ringer's solution with lactated Ringer's solution among postoperative outcomes in patients with laparoscopic right hemihepatectomy: a single-centre randomised controlled trial.

Song J, Liu Y, Li Y, Huang X, Zhang M, Liu X BMC Anesthesiol. 2024; 24(1):152.

PMID: 38649834 PMC: 11034129. DOI: 10.1186/s12871-024-02529-2.

References

Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R . A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004; 350(22):2247-56. DOI: 10.1056/NEJMoa040232. View

Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L . Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022; 386(9):815-826. DOI: 10.1056/NEJMoa2114464. View

von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J . Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007; 335(7624):806-8. PMC: 2034723. DOI: 10.1136/bmj.39335.541782.AD. View

Thiele H, Ohman E, de Waha-Thiele S, Zeymer U, Desch S . Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019; 40(32):2671-2683. DOI: 10.1093/eurheartj/ehz363. View

Thiele H, Akin I, Sandri M, de Waha-Thiele S, Meyer-Saraei R, Fuernau G . One-Year Outcomes after PCI Strategies in Cardiogenic Shock. N Engl J Med. 2018; 379(18):1699-1710. DOI: 10.1056/NEJMoa1808788. View

Yunos N, 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. DOI: 10.1001/jama.2012.13356. View

Yunos N, Kim I, Bellomo R, Bailey M, Ho L, Story D . The biochemical effects of restricting chloride-rich fluids in intensive care. Crit Care Med. 2011; 39(11):2419-24. DOI: 10.1097/CCM.0b013e31822571e5. View

Pfortmueller C, Funk G, Reiterer C, Schrott A, Zotti O, Kabon B . Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study. Br J Anaesth. 2018; 120(2):274-283. DOI: 10.1016/j.bja.2017.11.088. View

Perner A, Haase N, Guttormsen A, Tenhunen J, Klemenzson G, Aneman A . Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med. 2012; 367(2):124-34. DOI: 10.1056/NEJMoa1204242. View

10.

Semler M, Self W, Wanderer J, Ehrenfeld J, Wang L, Byrne D . Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018; 378(9):829-839. PMC: 5846085. DOI: 10.1056/NEJMoa1711584. View

11.

Myburgh J, Cooper D, Finfer S, Bellomo R, Norton R, Bishop N . Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007; 357(9):874-84. DOI: 10.1056/NEJMoa067514. View

12.

Ponikowski P, Voors A, Anker S, Bueno H, Cleland J, Coats A . 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special.... Eur Heart J. 2016; 37(27):2129-2200. DOI: 10.1093/eurheartj/ehw128. View

13.

Zampieri F, Machado F, Biondi R, Freitas F, Veiga V, Figueiredo R . Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021; . PMC: 8356144. DOI: 10.1001/jama.2021.11684. View

14.

Schrage B, Rubsamen N, Becher P, Roedl K, Soffker G, Schwarzl M . Neuron-specific-enolase as a predictor of the neurologic outcome after cardiopulmonary resuscitation in patients on ECMO. Resuscitation. 2019; 136:14-20. DOI: 10.1016/j.resuscitation.2019.01.011. View

15.

Kellum J . Abnormal saline and the history of intravenous fluids. Nat Rev Nephrol. 2018; 14(6):358-360. DOI: 10.1038/s41581-018-0008-4. View

16.

Thiele H, Zeymer U, Neumann F, Ferenc M, Olbrich H, Hausleiter J . Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012; 367(14):1287-96. DOI: 10.1056/NEJMoa1208410. View

17.

Kellum J, Song M, Venkataraman R . Effects of hyperchloremic acidosis on arterial pressure and circulating inflammatory molecules in experimental sepsis. Chest. 2004; 125(1):243-8. DOI: 10.1378/chest.125.1.243. View

18.

Hammond N, Zampieri F, Di Tanna G, Garside T, Adigbli D, Cavalcanti A . Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis. NEJM Evid. 2024; 1(2):EVIDoa2100010. DOI: 10.1056/EVIDoa2100010. View

19.

Myburgh J, Finfer S, Bellomo R, Billot L, Cass A, Gattas D . Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012; 367(20):1901-11. DOI: 10.1056/NEJMoa1209759. View

20.

Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C . 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; 314(16):1701-10. DOI: 10.1001/jama.2015.12334. View