Case 1 continued… the fluid debate

Thanks @RB_Cavalcanti, @canibagthat, and @rjggoldberg for being the first contributors in the #icurounds discussion.

Great points were raised – shouldn’t we address fluids before talking about pressors? What type of fluid?

Let’s take a look at some of the evidence behind fluid choice in resuscitation…

The SAFE trial looked at 4% albumin vs normal saline for intravascular fluid resuscitation in critically ill patients over the first 28 days of hospitalization. There was no difference in any endpoint, including mortality. When looking at the subset of patients with septic shock, there was also no difference in mortality.

The 2008 VISEP trial  was a two-by-two factorial trial looking at glycemic control and fluid resuscitation in patients with septic shock. 10% Pentastarch and modified Ringer’s lactate were used for fluid resuscitation. The trial was stopped early because of a trend towards increased 90 day mortality in patients receiving pentastarch.

Finally, in 2012 the 6S trial  resuscitated patients with septic shock with either hydroxyethyl starch or ringers acetate up to 33 ml/kg/day. At 28 days, mortality (51 vs 43%) and use of renal replacement therapy (22 vs 16%) was higher in the hydroxyethyl starch group.

That’s a fair amount of evidence suggesting that crystalloids are the best choice for fluid resuscitation. But which type? Normal saline? Ringer’s lactate?

The CHLORIDE trial looked at the use of high chloride solutions (0.9%  saline, 4% succinylated gelatin solution, or 4% albumin solution) vs “low” chloride solutions (Hartmann solution, Plasma-Lyte 148, or chloride poor 20% albumin). There was no difference in mortality, ICU length of stay, or need for long term renal replacement therapy. There was however a trend to higher rates of acute kidney injury and use of in-hospital renal replacement therapy in the high chloride group.

With all of that considered – should we consider a buffered, low-chloride, crystalloid solution (i.e. Ringer’s Lactate or Hartmann’s Solution) to be the ideal initial fluid for resuscitation in septic shock?

Please contribute your thoughts below, on twitter with the hashtag #icurounds, or on our Facebook page.

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