HPE Human albumin handbook | Page 24

years , some evidence has shown that physiological saline is “ neither normal nor physiological ”, and its chloride ion concentration is as high as 154mmol / l , and far higher than the normal plasma level ( 94 – 111mmol / l ).
Some studies have shown that infusion of physiological saline can cause hyperchloraemic metabolic acidosis , thereby impairing kidney function . Early animal experiments revealed that hyperchloraemia can cause renal vasoconstriction , increase the response of renal blood vessels to vasoconstrictors , and reduce glomerular filtration rate . 22 A randomised , controlled , double-blind trial in healthy volunteers revealed that infusion of 2l of physiological saline decreased renal artery blood flow and renal cortical tissue perfusion . 23 Compared with clinical observations before and after , it was found that any chlorine transfusion strategy in critically ill adults increased the incidence of renal injury and the need for RRT . 24
Two large RCTs have compared the effects of physiological saline and balanced crystalloids . The SMART trial included 15,802 critically ill patients in intensive care , and confirmed that intravenous infusion of balanced crystalloid in critically ill adults can improve combined outcomes ( death , new RRT , or persistent renal dysfunction rate ) compared with physiological saline . 25 Subgroup analysis revealed that the advantage of balanced crystalloid over physiological saline was more obvious in patients with sepsis or septic shock . A second analysis of the patients with sepsis in the SMART trial confirmed that the use of balanced crystalloid was associated with lower 30-day hospital mortality compared with saline . 26 The results of SALT-ED in 13,347 noncritically ill patients admitted to the emergency department also confirmed that the use of balanced crystalloids led to a significant reduction in the incidence of major adverse renal events within 30 days . 27
Based on the above information , and in view of the equivalent prices of saline and balanced crystalloids , it seems reasonable to preferentially use balanced crystalloids instead of physiological saline for fluid resuscitation in critically ill patients unless the patient already has hypochloraemia that needs to be corrected .
Lactate-based or acetate-based buffered crystalloids ? The chloride ion content in balanced crystalloids is close to that in plasma . In order to achieve charge balance and pH neutrality , organic anions are generally added for buffering , such as bicarbonate , lactate or acetate , etc . The most widely used clinically are the lactate- or acetate-based buffered versions , such as lactated Ringer ’ s , Hartmann ’ s solution , and Plasmalyte , etc ( Table 1 ). In recent years , which is superior between the buffer containing lactate and that containing acetate has attracted attention . Both lactate and acetate that enter the body are metabolised to HCO 3- and play a buffering role . The conversion of lactate takes place in the liver , heart and brain , and takes 30 minutes to finally form HCO 3- ; the conversion of acetate to HCO 3- occurs in almost all organs and can be completed in only 15 minutes . 28 Other studies have shown that the strong ion difference of lactic acid Ringer ’ s solution is 28 , and that of acetic acid Ringer ’ s solution is 36 , and infusion of lactic acid Ringer ’ s solution results in a more obvious reduction in pH reduction . 29 In addition , experimental evidence shows that acetate has the advantage of increasing cardiac output , dilating coronary blood vessels , and increasing blood flow in the kidneys and gastrointestinal tract . 28
Although evidence from previous clinical studies seems to suggest that acetate-based buffered crystalloids might be advantageous , there are few relevant clinical studies . A recent randomised , controlled , double-blind study included patients undergoing scheduled heart valve surgery and compared resuscitation with two fluids during the perioperative period : 75 patients with Ringer ’ s acetate and 73 patients with Ringer ’ s lactate . 30 There was no difference in haemodynamic indexes , that is , acid – base balance parameters , etc . Therefore , whether acetate-based buffered crystalloids have more clinical advantages should be verified further .
References 1 Rhodes A et al . Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock : 2016 . Crit Care Med 2017 ; 45 ( 3 ): 486 – 52 . 2 Myburgh JA , Mythen MG . Resuscitation fluids . N Engl J Med 2013 ; 369 ( 13 ): 1243 – 51 . 3 Brown RM , Semler MW . Fluid management in sepsis . J Intensive Care Med 2019 May ; 34 ( 5 ): 364 – 73 . 4 Orbegozo Cortés D et al . Crystalloids versus colloids : exploring differences in fluid requirements by systematic review and meta-regression . Anesth Analg 2015 ; 120 ( 2 ): 389 – 402 . 5 Lewis SR et al . Colloids versus crystalloids for fluid resuscitation in critically ill people . Cochrane Database Syst Rev 2018 ; 8 ( 8 ): CD000567 . 6 Perner A et al . Expert statement for the management of hypovolemia in sepsis . Intensive Care Med 2018 ; 44 : 791 – 8 . 7 Vincent JL et al . Albumin administration in the acutely ill : what is new and where next ? Crit Care 2014 ; 18 ( 4 ): 231 . 8 Woodcock TE , Woodcock TM . Revised Starling equation
and the glycocalyx model of transvascular fluid exchange : an improved paradigm for prescribing intravenous fluid therapy . Br J Anaesth 2012 ; 108 ( 3 ): 384 – 94 . 9 Cochrane Injuries Group : Human albumin administration in critically ill patients : Systematic review of randomized controlled trials . BMJ 1998 ; 317:235 – 40 . 10 Finfer S et al . A comparison of albumin and saline for fluid resuscitation in the intensive care unit . N Engl J Med 2004 ; 350 ( 22 ): 2247 – 56 . 11 Caironi P et al . Albumin Replacement in Patients with Severe Sepsis or Septic Shock . N Engl J Med 2014 Apr 10 ; 370 ( 15 ): 1412 – 21 . 12 Xu JY et al . Comparison of the effects of albumin and crystalloid on mortality in adult patients with severe sepsis and septic shock : a meta-analysis of randomized clinical trials . Crit Care 2014 ; 18 ( 6 ): 702 . 13 Vincent JL , De Backer D , Wiedermann CJ . Fluid management in sepsis : The potential beneficial effects of albumin . J Crit Care 2016 Oct ; 35:161 – 7 . 14 Mårtensson J et al . Small
volume resuscitation with 20 % albumin in intensive care : physiological effects : The SWIPE randomised clinical trial . Intensive Care Med 2018 Nov ; 44 ( 11 ): 1797 – 806 . 15 Brunkhorst FM et al . Intensive insulin therapy and pentastarch resuscitation in severe sepsis . N Engl J Med 2008 ; 358 ( 2 ): 125 – 39 . 16 Guidet B et al . Assessment of hemody- namic efficacy and safety of 6 % hydroxyethylstarch 130 / 0.4 vs . 0.9 % NaCl fluid replacement in patients with severe sepsis : The CRYSTMAS study . Crit Care 2012 ; 16 ( 3 ): R94 . 17 Perner A et al . Hydroxyethyl Starch 130 / 0.42 versus ringer ’ s acetate in severe sepsis . N Engl J Med . 2012 ; 367 ( 2 ): 124 – 34 . 18 Myburgh JA et al . Hydroxyethyl starch or saline for fluid resuscitation in intensive care . N Engl J Med 2012 ; 367 ( 20 ): 1901 – 11 . 19 Zarychanski R et al . Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically Ill patients requiring volume resuscitation : a systematic review and metaanalysis . JAMA 2013 ; 309 ( 7 ): 678 – 888 . 20 Moeller C et al . How safe is
gelatin ? A systematic review and meta-analysis of gelatincontaining plasma expanders vs crystalloids and albumin . J Crit Care 2016 ; 35:75 – 83 . 21 Joannidis M et al . Prevention of acute kidney injury and protection of renal function in the intensive care unit : update 2017 : expert opinion of the working group on prevention , AKI section , European Society of Intensive Care Medicine . Intensive Care Med 2017 ; 43 ( 6 ): 730 – 49 . 22 Wilcox CS . Regulation of renal blood flow by plasma chloride . J Clin Invest 1983 ; 71 ( 3 ): 726 – 35 . 23 Chowdhury AH et al . A randomized , controlled , doubleblind crossover study on the effects of 2-L infusions of 0.9 % saline and plasma-lyte ® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers [ published correction appears in Ann Surg 2013 ; 258 ( 6 ): 1118 ]. Ann Surg 2012 ; 256 ( 1 ): 18 – 24 . 24 Yunos NM et al . Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults . JAMA 2012 ; 308 ( 15 ): 1566 – 72 . 25 Semler MW et al . Balanced
crystalloids versus saline in critically Ill adults . N Engl J Med 2018 ; 378 ( 9 ): 829 – 39 . 26 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 ; 200 ( 12 ): 1487 – 95 . 27 Self WH et al . Balanced crystalloids versus saline in noncritically Ill adults . N Engl J Med 2018 ; 378 ( 9 ): 819 – 28 . 28 Pfortmueller CA , Fleischmann E . Acetate-buffered crystalloid fluids : Current knowledge , a systematic review . J Crit Care 2016 ; 35:96 – 104 . 29 Pfortmueller CA et al . Serum chloride levels in critical illnessthe hidden story . Intensive Care Med Exp 2018 ; 6 ( 1 ): 10 . 30 Pfortmueller CA et al . Fluid management in patients undergoing cardiac surgery : effects of an acetateversus lactate-buffered balanced infusion solution on hemodynamic stability ( HEMACETAT ). Crit Care 20196 ; 23 ( 1 ): 159 .
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