Dr. Knoeckle
Clinical question: Does the use of a balanced multi-electrolyte solution (BMES) for fluid resuscitation in adults admitted to an intensive-care unit (ICU) impact 90-day mortality?
Background: Recent evidence1 suggests that the use of saline, when compared to BMES, for resuscitation in critically ill patients leads to increased rates of acute kidney injury and three-day mortality, yet clinical uncertainty remains.
Study design: Double-blind, randomized, controlled trial
Setting: 53 ICUs in Australia and New Zealand
Synopsis: Between September 2017 and December 2020, 5,037 patients admitted to the participating ICUs with a clinical indication for fluid resuscitation were enrolled. The treating clinicians were blinded to fluids used. All other treatment decisions, including amount and rate of fluid, were at the discretion of the clinician. The baseline characteristics of the two groups were well-matched and included surgical patients.
Physiologic outcomes, such as serum chloride, trended lower in the BMES group in the first seven days. However, there was no significant difference in any of the clinical outcomes assessed, including the primary outcome of 90-day mortality and secondary outcomes of peak serum creatinine in the first seven days, the maximum increase in creatinine level during ICU stay, and receipt of new renal-replacement therapy.
Bottom line: Resuscitation with BMES (Plasmalyte-148) compared to saline in ICU patients did not reduce the risk of death or acute kidney injury in this large, multi-center study.
Citation: Finfer S, et al. Balanced multi-electrolyte solution versus saline in critically ill adults. N Engl J Med. 2022 Jan 18. doi: 10.1056/NEJMoa2114464. Epub ahead of print. PMID: 35041780.
Semler, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839.
Dr. Knoeckle is a hospitalist at Denver Health, Denver, and an assistant professor in the division of internal medicine, at the University of Colorado School of Medicine.