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The Case of the Balanced Solution - EM Nerd

Saline-based resuscitation strategies were first proposed as far back as 1831 during the Cholera Epidemic. In an article published in the Lancet in 1831, Dr. O’Shaughnessy suggests the use of injected salts into the venous system as a means of combating the dramatic dehydration seen in patients afflicted with this bacterial infection(1). Saline’s potential harms were first observed in post-surgical patients who after receiving large volumes of saline based resuscitation fluids during surgery were found to have a hyperchloremic acidosis (2). Though these changes appear transient and clinically trivial, it is theorized that when applied to the critically ill, the deleterious effects on renal blood flow may increase the rate of permanent renal impairment and even death. Unfortunately, no large prospective trials have demonstrated this hypothesis to be anything more than physiological reasoning. Small prospective trials have exhibited trivial trends in decreased renal blood flow, kidney function, and increased acidosis, though these perturbations were fleeting and of questionable clinical relevance (3, 4, 5, 6, 7). A larger retrospective study, bringing all the biases such trials are known to carry, demonstrated small improvements in mortality of ICU patients treated with a balanced fluid strategy, though it failed to demonstrate improvements in renal function (the theoretical model used to support balanced fluid administration) (8). In 2012 Yonus et al were the first to attempt to prospectively answer this question in an ICU population. Published in JAMA, on first glance the results seemed to vindicate those in support of the use of balanced fluids (9). Yet despite its superficial success, a closer look reveals this trial does little to demonstrate the deleterious effects of chloride-rich resuscitative strategies. In a recent publication in Intensive Care Medicine, Yonus et al re-examine this question in the hopes of once again demonstrating the benefits of balanced fluid strategies for the resuscitation of the critically ill (10).
over 6 years ago