Skip to main navigation
Skip notifications
Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Search
No clear advantage to balanced crystalloids over saline; though 1 study suggests a mortality benefit in patients with sepsis
Clinical Question
As compared with normal saline, does the use of balanced crystalloids for fluid resuscitation in critically ill patients decrease mortality?
Bottom line
Data from a meta-analysis of 9 studies shows that using balanced crystalloids, such as lactated Ringer's solution, instead of normal saline for fluid resuscitation does not decrease mortality, reduce the incidence of acute kidney injury (AKI), or reduce the need for renal replacement therapy (RRT) in critically ill patients. However, in a subset of patients with sepsis from the SMART trial, the use of balanced crystalloids instead of saline resulted in fewer deaths over the short-term, with a number needed to treat of 20. Further studies are needed to confirm these findings, particularly in patients with sepsis. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Inpatient (ICU only)
Synopsis
These investigators searched MEDLINE, Cochrane Central, and EMBASE, as well as conference proceedings and reference lists of review articles, to find randomized controlled trials that compared the use of balanced crystalloids with normal saline for fluid resuscitation in critically ill adult patients. The primary outcome was mortality and the secondary outcomes were the incidence of AKI and the need for RRT. Two investigators independently selected studies, extracted data, and assessed the methodological quality of individual studies. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology and was assessed as moderate. Nine studies, including the SMART trial , were included in the meta-analysis. Six of the studies included patients admitted to an intensive care unit, 2 studies included patients with acute pancreatitis, and 1 study included trauma patients. No significant differences were detected between the balanced crystalloids groups and the normal saline groups with regard to mortality, incidence of AKI, or need for RRT. Using trial sequential analysis, the investigators determined that the evidence was not conclusive, and that further large trials are needed to confirm the data. Of note: In a recent secondary analysis of the SMART trial, patients admitted to a medical intensive care unit with sepsis had decreased 30-day in-hospital mortality with the use of balanced crystalloids instead of saline (26.3% vs 31.2%; odds ratio 0.74; 95% CI 0.59 - 0.93; P = .01).
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL