Reply to Gueret et al. and to Hammond et al.
Year: 2020
Type: letter
Abstract: A recently published systematic review and meta-analysis attempted to clarify the impact of using balanced crystalloids in sepsis; however, including these new data with previously published controlled trials and observational studies improves on those efforts (2).When prior data are considered alongside the SMART post hoc analysis, the benefit on short-term mortality appears less certain, although potentially still impactful (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01)(1, 3-5) (Figure 1).We have greater confidence in the decreased odds of patients developing acute kidney injury (OR, 0.67; 95% CI, 0.49-0.92)but uncertainty regarding progression to receipt of renal replacement therapy (OR, 0.85; 95% CI, 0.71-1.03)when receiving balanced crystalloids (1, 4-6).Although two of the three individual outcomes did not show significance, there was a lower incidence of major adverse kidney events in 30 days with balanced crystalloids compared with saline (OR, 0.78; 95% CI, 0.65-0.94) in the two studies that evaluated this outcome (1,6).Differences in this composite outcome, which are not being driven by a particular intermediate clinical endpoint, are extremely encouraging for balanced crystalloid use.When financial costs are considered, the proposition of using a balanced crystalloid rather than saline becomes even more attractive.Although Plasma-Lyte 148 is almost three times more costly than saline, lactated Ringer's is available at approximately the same purchase price as saline.The majority of patients in most published studies who were prescribed a balanced crystalloid received lactated Ringer's (1, 4-6).Given the significant costs associated with poor clinical outcomes and adverse events during critical illness, using lactated Ringer's in critically ill patients with sepsis is likely to be a substantially cost-effective intervention in most scenarios.We hope that the fine work by Brown and colleagues will be considered favorably alongside other published evaluations of balanced crystalloids versus saline in critically ill adults (1).At this time, we believe providing fluid resuscitation with balanced crystalloids, particularly lactated Ringer's, to adult patients with sepsis is likely a more effective and cost-effective intervention than saline.
Authors: Ryan M. Brown, Li Wang, Jonathan D. Casey, Karen E. Jackson, Wesley H. Self, Todd W. Rice, Matthew W. Semler
Institution: Vanderbilt University Medical Center
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W3001468580