Balanced Crystalloids versus Normal Saline as Intravenous Fluid Therapy among Critically Ill patients: A meta-analysis of randomized controlled trials

Introduction@#Recent studies on critically ill adults has shown that use of normal saline with its supraphysiologic chloride content has been associated with an increased incidence of hyperchloremic metabolic acidosis, acute kidney injury (AKI), renal replacement therapy (RRT), hypotension and death. The objective of this meta-analysis was to assess the clinical outcomes associated with the use of balanced crystalloids versus normal saline solution.@*Methods@#We searched PubMed/MEDLINE, Embase and Cochrane Library (CENTRAL) databases in accordance with PRISMA guidelines. Our inclusion criteria were the following: randomized controlled trials, adult critically ill patients, comparisons between patients receiving either balanced crystalloids (lactated ringer’s solution, plasma-lyte) or normal saline, and at least one endpoint that measure intensive care unit mortality, risk of AKI (defined as stage 2 or greater in the RIFLE criteria) and risk of RRT. Risk ratios (RRs) and confidence intervals (C.I) were calculated via Review Manager Version 5.3 using the fixed-effect modelling.@*Results@#A total of four randomized controlled trials, which were all assessed to be good quality and low risk of bias, with 19,105 patients were included. Use of balanced crystalloids showed a trend towards lower incidence of AKI (RR 0.94, 95% C.I [0.87-1.02], P=0.69), RRT use (RR 0.91, 95% C.I. [0.771.07], P=0.29) and ICU mortality (RR 0.91, 95% C.I. [0.82-1.01], P=0.95). There is no significant heterogeneity identified.@*Conclusion@#Use of balanced crystalloids as intravenous fluid therapy among critically ill patients demonstrated a trend toward lower incidence of AKI, RRT and ICU mortality, compared to normal saline solution.

Hidratación de mantenimiento en niños agudamente enfermos / Maintenance hydration in acutely ill children

Introducción: un aspecto crítico del cuidado de pacientes agudamente enfermos es la administración de líquidos intravenosos. Existe poco consenso sobre la tasa más apropiada de administración y la composición de los líquidos intravenosos. La práctica con respecto a los fluidos de mantenimiento varía ampliamente. Objetivo: describir la composición y las tasas de administración más apropiadas de los líquidos intravenosos. Método: se realizó una revisión en Medline/Pubmed, Elseiver y Scielo de los artículos publicados en el período comprendido entre 1953-2016. No hubo restricción de idioma. Los términos de búsqueda fueron: fluidos intravenosos, hiponatremia y niños. Desarrollo: los fluidos hipotónicos siguen siendo recomendados en pacientes agudamente enfermos, a pesar de la fuerte asociación entre su uso y el desarrollo de hiponatremia. La abrumadora evidencia prospectiva hasta la fecha, indica que las soluciones de mantenimiento isotónicas son más seguras que los fluidos hipotónicos en la protección de la hiponatremia moderada y severa. Consideraciones finales: es hora de que dejemos de usar fluidos hipotónicos en estados de enfermedad asociados con exceso de arginina vasopresina, y no existe razón para que esta práctica continúe. Esta información debe ser difundida por la Academia, pues los profesionales involucrados en el cuidado de niños enfermos necesitan ser informados y entrenados adecuadamente(AU)

Introduction: a critical aspect in the care of acutely ill patients is the administration of intravenous fluids. There is little consensus on the most appropriate administration rate and composition of intravenous fluids. The practice with respect to maintenance fluids widely varies. Objective: to describe the composition and the most appropriate administration rates of intravenous fluids. Method: a review of articles published in the period from 1953 to 2016 was made in Medline/Pubmed, Elseiver and Scielo. There was no language restriction. The search terms were: intravenous fluids, hyponatremia and children. Development: hypotonic fluids are still recommended in acutely ill patients, despite the strong association between their use and the development of hyponatremia. The overwhelming prospective evidence to date indicates that isotonic maintenance solutions are safer than hypotonic fluids in the protection of moderate and severe hyponatremia. Conclusions: it is time for us to stop using hypotonic fluids in disease states associated with an excess of arginine vasopressin, and there is no reason for this practice to continue. This information must be disseminated by the Academy, as the professionals involved in the care of sick children need to be informed and trained properly(AU)

Uso de soluciones intravenosas y su relación con la lesión renal aguda en la Unidad de Terapia Intensiva / Intravenous fluids and its relationship with acute kidney injury in the Intensive Care Unit / Uso de soluções intravenosas e sua relação com a lesão renal aguda na Unidade de Terapia Intensiva

Resumen: Introducción: La lesión renal aguda se define como una elevación de la creatinina superior a 0.3 mg/dL o una disminución en los flujos urinarios en las últimas seis horas en cualquier paciente. Métodos: Sostuvimos la hipótesis de que los pacientes admitidos en la Unidad de Terapia Intensiva (UTI) durante 2013 presentaban mayor incidencia de lesión renal aguda, puesto que eran reanimados con mayor cantidad de solución salina al 0.9% que los pacientes ingresados en la actualidad. Comparamos dos grupos de pacientes en dos periodos distintos (años 2013 y 2015). Se recabaron diariamente datos sobre el balance de líquidos (BL), criterios de lesión renal (LR) y tipo y cantidades de soluciones administradas. Resultados: Durante el periodo entre julio y agosto de 2013 se incluyó un total de 30 pacientes y durante el periodo comprendido entre julio y agosto de 2015 se incluyeron 36, obteniendo un tamaño de muestra de 66 pacientes (n = 66). No se encontró asociación estadísticamente significativa en cuanto al tipo y cantidad de solución cristaloide administrada con respecto a la presencia de lesión renal aguda (p = 0.8) y días de estancia en la UTI (p = 0.45). Se observó asociación estadísticamente significativa entre lesión renal y el uso de coloides como solución intravenosa (p = 0.01). Conclusiones: Actualmente se tiene una tendencia a utilizar más soluciones intravenosas balanceadas, la lesión renal aguda debe prevenirse en la UTI.

Abstract: Introduction: Acute Kidney Injury (AKI) is defined as an elevation of serum creatinine of 0.3 mg/dL and more, or as the presence of low urine output for less tan 0.3 mL/kg/hour for at least six hours. Methods: We had the hypothesis that the patients atmitted to the Intensive Care Unit (ICU) during 2013 used to have high incidence of AKI because they were resucitated with more saline 0.9% solution than patients today. We compare two groups of patients in different periods of time (years 2013 and 2015). We recorded every day different data like fluid balance (FB), cirteria of acute kidney injury (AKI) and type and quantity of intravenous fluids. Results: During the period of July-August 2013 we included 30 patients, and during the lapse of time of July-August 2015 we included 36 patients, for a total number of 66 patients (n = 66). There was no statistic association between the type or the quantity of cristalloid intravenous fluid administered with the incidence of AKI (p = 0.8) and the lenght of ICU stay (p = 0.45). We found only statistic significance between AKI and the use of colloids as an intravenous fluid (p = 0.01). Conclusions: Nowadays we have the trend of use more balance intravenous fluids, the acute kidney injury has to be forewarned and avoided in the ICU.

Resumo: A lesão renal aguda é definida como uma elevação da creatinina de 0.3 mg/dL ou uma diminuição do fluxo urinário nas últimas 6 horas em qualquer paciente. Métodos: Nossa hipótese foi que os pacientes admitidos na Unidade de Terapia Intensiva durante 2013 apresentaram uma maior incidência de lesão renal aguda, devido a que foram reanimados com maior quantidade de solução salina 0.9% que os pacientes admitidos atualmente. Comparou-se dois grupos de pacientes em dois períodos de tempo diferentes (2013 e 2015). Recoletamos diariamente os dados sobre o balance de líquidos (BL), critérios de lesão renal (LR), tipo e quantidades de soluções administradas. Resultados: Durante o período de Julho-Agosto de 2013, foram incluídos um total de 30 pacientes e durante o período compreendido entre Julho-Agosto de 2015 foram incluídos 36 pacientes, dando um tamanho de amostra de 66 pacientes (n = 66). Não encontramos uma associação estatisticamente significativo em quanto ao tipo e quantidade de solução cristalóide administrada, no que diz respeito a apresentação da lesão renal aguda (p = 0.8) e dias de permanência na UTI (p = 0.45). Encontramos uma associação estatisticamente significativa entre a lesão renal e o uso de colóides como solução intravenosa (p = 0.01). Conclusões: Atualmente existe uma tendência para utilizar soluções intravenosas mais equilibradas, devemos prevenir a lesão renal aguda na UTI.

Risks of Intravenous Fluid Therapy by First Year Residents – A Prospective Study.

Aims: Intravenous fluid prescriptions are common in hospitals and most are written by junior doctors. Despite the frequency in which clinicians prescribe IV fluids, the burden from mortality and morbidity related to IV fluids is huge with an estimate that 1 in 5 patients are harmed by inappropriately prescribed fluids. We wished to identify the deficiencies in foundation year 1 doctors’ (FY1s, first year of clinical practice after graduation) knowledge and practice of IV fluid prescribing and to identify barriers to good prescribing practice that they had encountered on the wards. FY1s are in their first year of internship after graduating from medical school and this UK experience may be mirrored across the world. Study Design: A prospective, mixed methods study was carried out, using questionnaires, educational interventions and post-interventional evaluation. Place and Duration of Study: Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescott Street, Liverpool, UK. The study took place over 2015. Methodology: A 53 point questionnaire was designed and used to sample data. An educational intervention was designed after a gap analysis and post-intervention sampling to assess the efficacy of the interventions was also carried out. Results: Significant deficiencies were revealed in the ability to prescribe maintenance fluids. 33% of doctors (n = 8) had not read any guidance about IV fluid prescribing. 42% (n = 10) of participants adhered to fluid prescribing guidance. 17% (n=4) doctors stated that they did not know the contents of fluid bags they prescribed. Only 25% (n = 6) of first year residents indicated that they adhered to weight based prescribing and 4% and 16% felt they at times prescribed too much sodium or water, or too little potassium, for maintenance. Most residents (92%, n=22) reported checking patient’s latest urea and electrolyte values prior to prescribing IV fluids and 54% (n=13) indicated that they reviewed the patient clinically prior to prescribing fluids, However, 67% (n = 16) reported not documenting IV fluid therapy and fluid status in the case notes. The analysis of the narrative data showed system barriers, such as nurses not weighing patent weight, as contributing to the deficiencies in prescribing correctly. The intervention was successful in reversing the deficiencies to a large extent. However cultural and system barriers were also identified. Conclusion: Cultural and system barriers are significant in any learning and need to be taken into account when designing healthcare improvements.

Mortality and Other Outcomes in Relation to First Hour Fluid Resuscitation Rate: A Systematic Review.

Objective: To determine the effect of different regimen of first hour fluid administration rates on mortality and severe consequences of impaired circulation in 2 to 60 months old children with impaired circulation. Design: Systematic review of randomized controlled trials. Data sources: Various databases including PubMed, Cochrane Library and EMBASE were searched. Results: We found only two relevant trials; one was excluded as there was no comparator arm. Only one study (The FEAST Trial) compared boluses with maintenance fluid alone in children with severe febrile illness and one or more signs of impaired perfusion. The 48-hour mortality was more in the bolus group (RR 1.45, 95% CI 1.13,1.86). The quality of evidence is rated as ‘moderate’. For the children who met the WHO criteria for shock (severely impaired circulation) (n=65 children), those receiving boluses had higher mortality (RR 2.40, 95% CI 0.84, 6.88); the quality of evidence was rated as ‘very low’. Conclusions: A single large randomized controlled trial conducted in low-resource settings indicates that administration of fluid bolus is associated with higher mortality in comparison to the maintenance fluids alone in children with severe febrile illness and one or more signs of impaired perfusion. The findings are not generalizable to contexts with different severity of and different causes of shock and in centers with better facilities. There is urgent need for research in different settings to determine the optimal rate of fluid resuscitation in the first hour in children presenting with impaired circulation, particularly with severely impaired circulation.

Safety and Efficacy of Isotonic (0.9%) vs. Hypotonic (0.18%) Saline as Maintenance Intravenous Fluids in Children: A Randomized Controlled Trial.

Objective: To compare the safety and efficacy of isotonic versus hypotonic maintenance fluid in children. Design: Randomized controlled trial. Setting: Tertiary-level teaching hospital. Participants: 60 children (age 0.5 to 12 years) who were admitted and anticipated to receive intravenous fluid for the next 48 hours. Intervention: Hypotonic fluid (Standard maintenance volume as 0.18% NaCl in 5% dextrose) or Isotonic fluid (60% Standard maintenance volume as 0.9% NaCl solution in 5% dextrose). Outcome measures: Primary: Incidence of hyponatremia. Secondary: Serum sodium, serum osmolality, blood sugar, blood urea, serum creatinine, serum potassium, serum chloride, pH, urine output, change in weight, morbidity and death. Results: At 24 hours, hyponatremia was noted in 7 (24%) patients in the isotonic and 16 (55%) in hypotonic group (P=0.031). At 48 hours, hyponatremia was noted in 4 (14%) and 13 (45%) patients in isotonic and hypotonic group, respectively (P=0.02). There was significant change in sodium levels in both isotonic (P=0.036) and hypotonic (P<0.001) intervention groups. The peak fall in mean serum sodium level was noted at 24 hours (-6.5, 95%CI: -3.5, -9.6 mEq/L; P<0.001) in hypotonic group. In isotonic group, there was significant increase between 24 and 48 hours (4.3, 95% CI: 0.1, 8.4 mEq/L; P=0.04). Conclusions: Reduced volume isotonic fluid results in fewer episodes of hyponatremia than hypotonic fluid in sick children during the first 48 hours of intravenous fluid therapy.

Hidratación parenteral / Parenteral rehydration

La Rehidratación oral es el método de elección para la deshidratación leve y moderada por diarrea. Sin embargo, en casos de shock hipovolémico, deshidratación grave, hiponatremia o hipernatremia severas, vómitos persistentes, íleo paralítico, en pacientes deshidratados con alteración de conciencia ó convulsiones y cuando ocurre deterioro o ausencia de mejoría clínica tras 8 horas de rehidratación oral, se debe indicar la hidratación endovenosa. Las indicaciones de la hidratación intravenosa varían dependiendo de la gravedad, del tipo (isonatrémica, hiponatrémica o hipernatrémica) y de los déficits de iones y ácido-básico asociados. Se realiza en 2 fases: la primera de emergencia para reponer la volemia si existe shock hipovolémico; y la segunda para reponer el déficit y suministrar las necesidades de mantenimiento de líquidos y electrolitos y las pérdidas concurrentes. Se calculan las necesidades basales de mantenimiento de líquidos y electrolitos por el método de Holliday-Segar y en caso de pacientes con peso mayor a 30 kg, se calculan de acuerdo a la superficie corporal del paciente. Los cálculos del déficit hídrico y de electrolitos se realizan siguiendo los esquemas y fórmulas específicas. Adicionalmente se tratan las complicaciones más frecuentes (acidosis metabólica e hipokalemia) en caso de existir indicaciones definidas. La hidratación del Recién Nacido deshidratado por diarrea es igual que en los lactantes, pero debe considerarse para el tratamiento, su particular balance hidroelectrolítico para evitar complicaciones. Para cada tipo de deshidratación (isonatrémica, hiponatrémica e hipernatrémica) se exponen ejemplos de cálculos para su tratamiento con hidratación endovenosa.

Oral rehydration is the method of choice for mild to moderate dehydration secondary to diarrhea. Intravenous hydration is indicated in hypovolemic shock, severe dehydration, severe hyponatremia or hypernatremia, persistent vomiting, paralytic ileus, in dehydrated patients with impaired consciousness or seizures, and when there is clinical deterioration or no improvement after 8 hours of oral rehydration. Intravenous hydration varies depending on the severity, type of dehydration (isonatrémic, hyponatremic or hypernatremic) and associated ion and acid-base deficits. It is performed in 2 phases: the first is the emergency phase to restore blood volume in cases of hypovolemic shock and the second phase to replenish deficits and to supply maintenance requirements and concurrent loss of fluid and electrolytes. Basal needs are calculated by the method of Holliday and Segar, and for patients weighing more than 30 kg. The patient's body surface is employed as the base for calculations. Fluid and electrolyte deficits are estimated according to specific schemes and formulas. Common complications of dehydration (metabolic acidosis and hypokalemia) should also be addressed with specific indications. Intravenous rehydration in the newborn with dehydration secondary to diarrhea is the same as in infants, but the particular electrolyte balance at this age should be considered in order to avoid complications. Examples of calculations for intravenous hydration for each type of dehydration (isonatrémic, hyponatremic and hypernatremic) are given.

Performance Characteristics of High Efficiency Fluid and Blood Warmer using Print Circuit Board Heater at Various Flow Rates / 대한마취과학회지

BACKGROUND: Currently available warming devices are often heavy and cumbersome, requiring development of more portable, user friendly, high efficiency fluid and blood warmer. The intravenous fluid heating capabilities of a new, heat-plate print circuit board (PCB) based warmer at various low flow rates were tested. METHODS: Model Joyother BM-1(R) was investigated for normal saline (0.9% NaCl) and colloid at various infusion rates (60-6000 ml/hr). Final temperatures were measured by electronic thermometer after passing through the warmer. Effective warming was defined as a fluid temperature > or = 32degrees C. Ambient temperature was maintained at 22-25degrees C. Degree of heating capability and temperature decrease were compared and correlated between different flow rates. RESULTS: The device warmed the room temperature crystalloid and colloid efficiently. Its warming capability was continuously improved as the flow rates increased in all tested flow rates, reaching maximum 41degrees C. After the warming, the temperature decrease showed high negative correlation with the flow rates. The extent of cooling was less in colloid. No overheating was noted at sudden brake. CONCLUSIONS: Joyother BM-1(R) heated crystalloid and colloid sufficiently and safely enough for clinical application (exit temperature > or = 35degrees C) at various flow rates. The warming capacity and the length of the intravenous tube infusion system determined the efficiency of the warmer. Further study is warranted for the efficiency of warming for the blood and its element changes.