The use of balanced crystalloids versus saline in sepsis

Brown RM, et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019 Dec 15;200(12):1487-1495.

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Measurements and Main Results: Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio [aOR], 0.74; 95% confidence interval [CI], 0.59-0.93; P = 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 ± 12 vs. 19 ± 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 ± 12 vs. 19 ± 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group.

Conclusions: Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline.

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The balanced resuscitation approach

“Balanced resuscitation minimizes coagulopathy through permissive hypotension, restrictive crystalloid use, and high ratios of plasma and platelet to red blood cell transfusion.” (Cantle, 2017, p. 999)

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82.

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“Exsanguination, the predominant cause of death within the first 24 hours, was decreased in the 1:1:1 group (9.2%) vs the 1:1:2 group (14.6%) (difference, −5.4% [95% CI, −10.4% to −0.5%], P = .03); the median time to death due to exsanguination was 106 minutes interquartile range [IQR], 54 to 198 minutes) and 96 minutes (IQR, 43 to 194 minutes), respectively. From 24 hours through 30 days, the numbers of additional all-cause deaths were similar (32 for the 1:1:1 group vs 31 for the 1:1:2 group). Over 30 days, deaths due to exsanguination occurred in 10.7% of patients in the 1:1:1 group vs 14.7% in the 1:1:2 group, whereas deaths due to traumatic brain injury were 8.1% vs 10.3%, respectively. Additional causes of death were infrequent and are shown in Table 3. More patients achieved anatomic hemostasis in the 1:1:1 group (86.1% vs 78.1% in the 1:1:2 group, P = .006) with a median time of 105 minutes (IQR, 64 to 179 minutes) vs 100 minutes (IQR, 56 to 181 minutes), respectively (P = .44) in those who achieved anatomic hemostasis (Table 2).” (Holcomb, 2015, p. 475)

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Intraoperative cardiac arrest: Resuscitation and Management

One discussion this week included intraoperative cardiac arrest.

Reference: Moitra VK, et al. Cardiac arrest in the operating room: resuscitation and management for the anesthesiologist: part 1. Anesthesia & Analgesia. 2018 Mar;126(3):876-888. doi: 10.1213/ANE.0000000000002596.

Summary: Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure.

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