Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults

Yunos NMBellomo RHegarty CStory DHo LBailey M

JAMA 2012

Does a chloride restrictive approach fluid replacement therapy reduce the risk of acute kidney injury in the critically ill patient?

A prospective, open label, before-and-after pilot study.

A control period of 6 months- patients were given fluids according to clinician preference with free use of chloride rich fluids.

6 month phase out period which included education and preparation of ITU staff.

6 month intervention period chloride rich fluids were only made available for specific conditions (hyponatreamia, traumatic brain injury, cerebral oedema). In place of chloride rich fluids were Hartmanns, Plasma-Lyte and a 20% albumin solution.

Primary end point

Increase in creatinine from baseline to peak ICU level and incidence of AKI.

Secondary end point

Need for RRT

Length of stay in ICU and hospital

Survival.

Main results.

760 patients in control period, 773 patients in intervention period.

There were no significant differences with regard to age, sex, baseline creatinine level, APACHE scores, SAPS II, comorbidities, diagnostic groups, and types of admission.

During the intervention period saline prescription decreased from 2411 litres to 52 litres and the administration of Hartmanns increased from 469 litres to 3205 litres.

The chloride-restrictive strategy was associated with a significantly lower increase in serum creatinine level during ICU stay of 14.8 µmol/L (95% CI, 9.8-19.9 µmol/L) during the intervention period vs 22.6 µmol/L (95% CI, 17.5-27.7 µmol/L) during the control period (P=.03; adjusted P=.007).

chloride fluids

The chloride-restrictive intravenous strategy intervention period was associated with a decrease in the incidence of injury and failure class of RIFLE-defined AKI.

It was further associated with a decrease in RRT use for 78 patients (10%; 95% CI, 8.1%-12%) during the control period vs 49 patients (6.3%; 95% CI, 4.6%- 8.1%) during the intervention period (P=.005).

Limmitations

As this was a bundle approach authors not able to say which component of the intervention(restricting chloride, using balanced solutions containing lactate, stopping a commercial 4% gelatin solution, using more 20% albumin and less 4%albumin, giving less sodium, delivering more potassium, or any combination of these)  might have been responsible for the changes.

Not a blinded randomised trial.

EMCRIT view

RESUS.ME opinion

Boring EM

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Originally posted 2014-07-08 10:57:01. Republished by Blog Post Promoter

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