plasmalyte-a and Sepsis

We previously suggested that choosing balanced solutions over normal saline for fluid therapy might benefit patients. After all, administration of NaCl 0.9% invokes metabolic acidosis and hyperchloraemia which was linked to renal failure and mortality in retrospective studies. Two large randomized controlled clinical trials now confirm this signal. Both in intensive care patients and in the setting of emergency medicine, balanced solutions were shown to reduce the incidence of MAKE30, a composite end point of hospital mortality and indices of renal failure. In addition, predefined subgroup analysis revealed increased mortality for normal saline in intensive care patients with sepsis. Even though the effect size is small in both studies, this evidence against normal saline is hard to ignore, given the immense number of patients who receive NaCl 0.9% worldwide. Therefore, clinical medicine may shortly witness the quiet disappearance of normal saline.

Topics: Critical Care; Electrolytes; Fluid Therapy; Hospital Mortality; Humans; Randomized Controlled Trials as Topic; Retrospective Studies; Ringer's Lactate; Saline Solution; Sepsis

The choice of resuscitation fluid in patients with cirrhosis and sepsis-induced hypotension is unclear. 5% albumin was superior to normal saline in the FRISC study. We compared the efficacy and safety of 20% albumin, which has greater oncotic properties, to plasmalyte in reversing sepsis-induced hypotension.. Critically ill patients with cirrhosis underwent open-label randomization to receive either 20% albumin (0.5-1.0 g/kg over 3 hours; n = 50) or plasmalyte (30 ml/kg over 3 hours, n = 50). The primary endpoint of the study was the attainment of mean arterial pressure (MAP) above 65 mmHg at 3 hours.. Baseline characteristics were comparable in albumin and plasmalyte groups; arterial lactate (6.16±3.18 mmol/L vs. 6.38±4.77 mmol/L; p = 0.78), MAP (51.4±6.52 mmHg vs. 49.9±4.45 mmHg; p = 0.17) and SOFA score (10.8±2.96 vs. 11.1±4.2; p = 0.68), respectively. Most patients were alcoholics (39%) and had pneumonia (40%). In the intention-to-treat analysis, albumin was superior to plasmalyte in achieving the primary endpoint (62% vs. 22%; p <0.001). A faster decline in arterial lactate (p = 0.03), a reduced need for dialysis (48% vs. 62%; p = 0.16), and a longer time to initiation of dialysis (in hours) (68.13±47.79 vs. 99.7± 63.4; p = 0.06) were seen with albumin. However, the 28-day mortality rate was not different (58% vs. 62%, p = 0.57) and treatment had to be discontinued in 11 (22%) patients in the albumin group due to adverse effects compared to no discontinuations in the plasmalyte group.. In patients with cirrhosis and sepsis-induced hypotension, 20% albumin leads to a faster improvement in hemodynamics and lactate clearance than plasmalyte, while 28-day survival was similar. However, patients on 20% albumin need to be closely monitored as it was more often associated with pulmonary complications.. NCT02721238.. The current randomized-controlled trial performed in critically ill patients with cirrhosis and sepsis-induced hypotension highlights that 20% albumin restores arterial pressure more quickly but causes more pulmonary complications than plasmalyte. The impact on renal functions was also modest. These effects did not result in improvement in survival at 28 days. Plasmalyte is safer and well-tolerated and can be considered for volume resuscitation in patients with cirrhosis and sepsis-induced hypotension.

Topics: Albumins; Critical Illness; Electrolytes; Fluid Therapy; Humans; Hypotension, Controlled; Lactic Acid; Liver Cirrhosis; Sepsis; Shock, Septic

To compare the acute effects of 0.9% saline versus a balanced electrolyte solution on acute kidney injury in a rat model of sepsis.. Controlled laboratory experiment.. University laboratory.. Sixty adult, male Sprague-Dawley rats.. We induced sepsis by cecal ligation and puncture and randomized animals to receive fluid resuscitation with either 0.9% saline or Plasma-Lyte solution for 4 hours after 18 hours of cecal ligation and puncture (10 mL/kg in the first hour and 5 mL/kg in the next 3 hr). Blood and urine specimens were obtained from baseline, 18 hours after cecal ligation and puncture, immediately after 4 hours fluid resuscitation, and 24 hours later. We measured blood gas, plasma electrolytes, creatinine, interleukin-6, cystatin C, and neutrophil gelatinase-associated lipocalin concentrations. We also analyzed urine for cystatin C and neutrophil gelatinase-associated lipocalin. We used Risk, Injury, Failure, Loss and End-stage criteria for creatinine to assess severity of acute kidney injury. We observed all animals for survival up to 1 day after resuscitation. Surviving animals were killed for kidney histology. Finally, we carried out an identical study in 12 healthy animals.. Compared with Plasma-Lyte, 0.9% saline resuscitation resulted in significantly greater blood chloride concentrations (p < 0.05) and significantly decreased pH and base excess. Acute kidney injury severity measured by RIFLE criteria was increased with 0.9% saline compared with Plasma-Lyte resuscitation (p < 0.05), and these results were consistent with kidney histology and biomarkers of acute kidney injury. Twenty-four-hour survival favored Plasma-Lyte resuscitation (76.6% vs 53.3%; p = 0.03). Finally, in healthy animals, we found no differences between fluids and no evidence of acute kidney injury.. Volume resuscitation with Plasma-Lyte resulted in less acidosis and less kidney injury and improved short-term survival when compared with 0.9% saline in this experimental animal model of sepsis.

Topics: Acidosis; Acute Kidney Injury; Animals; Biomarkers; Blood Chemical Analysis; Disease Models, Animal; Electrolytes; Fluid Therapy; Hematologic Tests; Male; Rats; Rats, Sprague-Dawley; Resuscitation; Sepsis; Severity of Illness Index; Sodium Chloride; Urinalysis

Topics: Acute Kidney Injury; Animals; Electrolytes; Fluid Therapy; Male; Resuscitation; Sepsis; Sodium Chloride