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Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient. [ABSTRACT FROM AUTHOR]

Purpose: Fluid use could modulate the effect of balanced solutions (BS) on outcome of intensive care unit (ICU) patients. It is uncertain whether fluid use practices are driven more by patient features or local practices. It is also unclear whether a "dose–response" for the potential benefits of balanced solutions exists. Methods: The secondary analysis of the Balanced Solution in Intensive Care Study (BaSICS) compared 0.9% saline versus Plasma-Lyte 148® (BS) for fluid therapy in the ICU. The relative contribution of patient features and enrolling site (the random effect) on the volume of fluid used up to day 3 after admission was assessed using different methods, including a Bayesian regression, a frequentist mixed model, and a random forest, all adjusted for relevant patient confounders. Subsequently, a variety of methods were used to assess whether volume of fluid used modulated the effect of BS on 90-day mortality, including a traditional subgroup analysis for patients that remained alive and in the ICU up to 3 days, a Bayesian network accounting for competing risks, and an analysis based on site practices. Results: 10,505 patients were analyzed. Median fluid use in the BS arm and in the 0.9% saline arm were 2500 mL and 2488 mL, respectively. The random effect in the Bayesian regression explained 0.32 (95% credible intervals (CrI) 0.24–0.41) of all model variance (0.33, 95% credible intervals from 0.32–0.35). Frequentist and random forest models produced similar results. In the analysis including only patients alive and in the ICU at 3 days, there was a strong suggestion of interaction between fluid use and the effect of BS, driven mostly by a lower mortality with BS compared to 0.9% saline as fluid use increased for patients with sepsis. These results were consistent in the Bayesian network analysis and in an analysis based on site practices, where septic patients enrolled to BS at high fluid use sites had a lower mortality (absolute risk reduction of − 0.13 [95% credible interval − 0.27 to − 0.01]; 0.98 probability of benefit). Conclusion: Baseline patient characteristics collected in the BaSICS trial explain less of the variance of fluid use during the first 3 days than the enrolling site. Volume of fluid used and the effects of BS appear to interact, mostly in the sepsis subgroup where there was a strong association between fluid use after enrollment and the effect of BS on 90-day mortality. [ABSTRACT FROM AUTHOR]

Normal saline (N/S) and Ringer’s-Lactate (L/R), are administered in everyday clinical practice. Despite that, N/S increases the risk of sodium overload and hyperchloremic metabolic acidosis. In contrast, L/R has lower sodium content, significantly less chloride and contains lactates. In this study we compare the efficacy of L/R versus N/S administration in patients with prerenal acute kidney injury (AKI) and pre-established chronic kidney disease (CKD).

Intravenous fluid and electrolyte management in paediatrics requires an understanding of the indication for intravenous fluid therapy and the underlying pathophysiology in order to meet requirements and avoid adverse events. Careful consideration needs to be given to the rate as well as the composition of intravenous therapy, and children's ongoing needs should be reviewed regularly. Fluid therapy can be separated into maintenance fluids, replacement fluids that address electrolyte deficits and ongoing losses, and resuscitation fluids. We review the critical considerations when prescribing intravenous fluid for children and consider the challenges of non-osmotic secretion of anti-diuretic hormone (ADH), hyponatraemic encephalopathy and other electrolyte abnormalities. Fluid management in children with diabetic ketoacidosis is also reviewed. [ABSTRACT FROM AUTHOR]

Despite its known harmful effects, normal saline is still commonly used in the treatment of hypovolemia in polytrauma patients. Given the lack of pre-hospital research on this topic, the current study aims to assess the current practice of fluid administration during the pre-hospital phase of care and its effects on initial metabolic acid-base status in trauma patients. We extracted and completed data from patients recorded in the Lausanne University Hospital (CHUV) trauma registry between 2008 and 2019. Patients were selected according to their age, the availability of a blood gas analysis after arrival at the emergency room, data availability in the trauma registry, and the modality of arrival in the ED. The dominantly administered pre-hospital fluid was normal saline. No association between the type of fluid administered during the pre-hospital phase and the presence of hyperchloremic acidosis in the ED was observed. [ABSTRACT FROM AUTHOR]

Rationale: Optimal infusion rate for fluid challenges in critically ill patients is unknown. A large clinical trial comparing two different infusion rates yielded neutral results. Conditional average treatment effect (CATE) assessment may aid in tailoring therapy. Objectives: To estimate CATE in patients enrolled in the BaSICS trial and to assess the effects of receiving CATE model–recommended treatment in terms of hospital mortality. Methods: Post hoc analysis of the BaSICS trial assessing the effect of two infusion rates for the fluid challenge (fast, 999 ml/h, control group; vs. slow, 333 ml/h, intervention group) on hospital mortality. CATE was estimated as the difference in outcome for treatment arms in counterfactuals obtained from a Bayesian model trained in the first half of the trial adjusted for predictors hypothesized to interact with the intervention. The model recommended slow or fast infusion or made no recommendation in the second half. A threshold greater than 0.90 probability of benefit was considered. Results: A total of 10,465 patients were analyzed. The model was trained in 5,230 patients and tested in 5,235 patients. A recommendation could be made in the test set in 19% of patients (14% were recommended the control group and 5% the treatment group); for 81% of patients, no recommendation could be made. Slow infusion was more frequently recommended in cases of planned admissions in younger patients; fast infusion was recommended for older patients with sepsis. Slow infusion rate in the subgroup of patients in the test set in which slow infusion was recommended by the model was associated with an odds ratio of 0.58 (95% credible interval of 0.32–0.90; 0.99 posterior probability of benefit) for hospital mortality. Fast infusion in the subgroup in which the model recommended fast infusion was associated with an odds ratio of 0.72 (credible intervals from 0.54 to 0.91; probability of benefit >0.99). Conclusions: Estimation of CATEs from counterfactual probabilities in data from BaSICS provided additional information on trial data. Agreement between treatment recommendation and actual treatment was associated with lower hospital mortality. [ABSTRACT FROM AUTHOR]

Objective: To describe the effects of balanced solution use on the short-term outcomes of patients with traumatic brain injury enrolled in BaSICS trial. Methods: Patients were randomized to receive either 0.9% saline or balanced solution during their intensive care unit stay. The primary endpoint was 90-day mortality, and the secondary outcomes were days alive and free of intensive care unit stay at 28 days. The primary endpoint was assessed using Bayesian logistic regression. The secondary endpoint was assessed using a Bayesian zero-inflated beta binomial regression. Results: We included 483 patients (236 in the 0.9% saline arm and 247 in the balanced solution arm). A total of 338 patients (70%) with a Glasgow coma scale score = 12 were enrolled. The overall probability that balanced solutions were associated with higher 90-day mortality was 0.98 (OR 1.48; 95%CrI 1.04 - 2.09); this mortality increment was particularly noticeable in patients with a Glasgow coma scale score below 6 at enrollment (probability of harm of 0.99). Balanced solutions were associated with -1.64 days alive and free of intensive care unit at 28 days (95%CrI -3.32 - 0.00) with a probability of harm of 0.97. Conclusion: There was a high probability that balanced solutions were associated with high 90-day mortality and fewer days alive and free of intensive care units at 28 days. [ABSTRACT FROM AUTHOR]

Despite its known harmful effects, normal saline is still commonly used in the treatment of hypovolemia in polytrauma patients. Given the lack of pre-hospital research on this topic, the current study aims to assess the current practice of fluid administration during the pre-hospital phase of care and its effects on initial metabolic acid-base status in trauma patients. We extracted and completed data from patients recorded in the Lausanne University Hospital (CHUV) trauma registry between 2008 and 2019. Patients were selected according to their age, the availability of a blood gas analysis after arrival at the emergency room, data availability in the trauma registry, and the modality of arrival in the ED. The dominantly administered pre-hospital fluid was normal saline. No association between the type of fluid administered during the pre-hospital phase and the presence of hyperchloremic acidosis in the ED was observed.

The ideal fluid for intravenous maintenance fluid therapy (IV-MFT) in acutely and critically ill children is controversial, and evidence-based clinical practice guidelines are lacking and current prescribing practices remain unknown. We aimed to describe the current practices in prescribing IV-MFT in the context of acute and critically ill children with regard to the amount, tonicity, composition, use of balanced fluids, and prescribing strategies in various clinical contexts. A cross-sectional electronic 27-item survey was emailed in April–May 2021 to pediatric critical care physicians across European and Middle East countries. The survey instrument was developed by an expert multi-professional panel within the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). A total of 154 respondents from 35 European and Middle East countries participated (response rate 64%). Respondents were physicians in charge of acute or critically ill children. All respondents indicated they routinely use a predefined formula to prescribe the amount of IV-MFT and considered fluid balance monitoring very important in the management of acute and critically ill children. The use of balanced solution was preferred if there were altered serum sodium and chloride levels or metabolic acidosis. Just under half (42%, 65/153) of respondents believed balanced solutions should always be used. Respondents considered the use of isotonic IV solutions as important for acute and critically ill children. In terms of the indication and the composition of IV-MFT prescribed, responses were heterogeneous among centers. Almost 70% (107/154) respondents believed there was a gap between current practice and what they considered ideal IV-MFT due to a lack of guidelines and inadequate training of healthcare professionals. Conclusions: Our study showed considerable variability in clinical prescribing practice of IV-MFT in acute pediatric settings across Europe and the Middle East. There is an urgent need to develop evidence-based guidelines for IV-MFT prescription in acute and critically ill children. What is Known: • The administration of maintenance intravenous fluid therapy is a standard of care for a lot of hospitalized children • Maintenance intravenous fluid therapy prescriptions are often based on Holliday and Segar's historical guidelines even if this practice has been associated with several complications. What is New: • This study provided information on the prescribing practice regarding fluid restriction, fluid tonicity, and balance. • This study showed considerable variability in clinical prescribing practice of intravenous maintenance fluid therapy across Europe and the Middle East. [ABSTRACT FROM AUTHOR]

Rationale: The effects of balanced crystalloid versus saline on clinical outcomes for ICU patients may be modified by the type of fluid that patients received for initial resuscitation and by the type of admission. Objectives: To assess whether the results of a randomized controlled trial could be affected by fluid use before enrollment and admission type. Methods: Secondary post hoc analysis of the BaSICS (Balanced Solution in Intensive Care Study) trial, which compared a balanced solution (Plasma-Lyte 148) with 0.9% saline in the ICU. Patients were categorized according to fluid use in the 24 hours before enrollment in four groups (balanced solutions only, 0.9% saline only, a mix of both, and no fluid before enrollment) and according to admission type (planned, unplanned with sepsis, and unplanned without sepsis). The association between 90-day mortality and the randomization group was assessed using a hierarchical logistic Bayesian model. Measurements and Main Results: A total of 10,520 patients were included. There was a low probability that the balanced solution was associated with improved 90-day mortality in the whole trial population (odds ratio [OR], 0.95; 89% credible interval [CrI], 0.66-10.51; probability of benefit, 0.58); however, probability of benefit was high for patients who received only balanced solutions before enrollment (regardless of admission type, OR, 0.78; 89% CrI, 0.56-1.03; probability of benefit, 0.92), mostly because of a benefit in unplanned admissions due to sepsis (OR, 0.70; 89% CrI, 0.50-0.97; probability of benefit, 0.96) and planned admissions (OR, 0.79; 89% CrI, 0.65-0.97; probability of benefit, 0.97). Conclusions: There is a high probability that balanced solution use in the ICU reduces 90-day mortality in patients who exclusively received balanced fluids before trial enrollment. Clinical trial registered with www.clinicaltrials.gov (NCT02875873). [ABSTRACT FROM AUTHOR]

Abstract Background Intravenous fluid therapy represents the most common intervention critically ill patients are exposed to. Hyperchloremia and metabolic acidosis associated with 0.9% sodium chloride have been observed to lead to worse outcomes, including mortality. Balanced solutions, such as Plasma-Lyte 148 and Compound Sodium Lactate, represent potential alternatives but the evidence on optimal fluid choices in critically ill children remains scarce. This study aims to demonstrate whether balanced solutions, when used as intravenous fluid therapy, are able to reduce the incidence of a rise in serum chloride level compared to 0.9% sodium chloride in critically ill children. Methods This is a single-centre, open-label randomized controlled trial with parallel 1:1:1 assignment into three groups: 0.9% sodium chloride, Plasma-Lyte 148, and Compound Sodium Lactate solutions for intravenous fluid therapy. The intervention includes both maintenance and bolus fluid therapy. Children aged < 16 years admitted to intensive care and receiving intravenous fluid therapy during the first 4 h of admission are eligible. The primary outcome measure is a ≥ 5mmol/L increase in serum chloride level within 48 h post-randomization. The enrolment target is 480 patients. The main analyses will be intention-to-treat. Discussion This study tests three types of intravenous fluid therapy in order to compare the risk of hyperchloremia associated with normal saline versus balanced solutions. This pragmatic study is thereby assessing the most common intervention in paediatric critical care. This is a single-centre open-label study with no blinding at the level of delivery of the intervention. Certain paediatric intensive care unit (PICU) patient groups such as those admitted with a cardiac condition or following a traumatic brain injury are excluded from this study. Trial registration The study has received ethical approval (HREC/19/QCHQ/53177: 06/06/2019). It is registered in the Australian New Zealand Clinical Trials Registry ( ACTRN12619001244190 ) from 9th September 2019. Recruitment commenced on 12th November 2019. The primary results manuscript will be published in a peer-reviewed journal.

Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU).Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included.Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8–96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia

Background: Intravenous fluid therapy represents the most common intervention critically ill patients are exposed to. Hyperchloremia and metabolic acidosis associated with 0.9% sodium chloride have been observed to lead to worse outcomes, including mortality. Balanced solutions, such as Plasma-Lyte 148 and Compound Sodium Lactate, represent potential alternatives but the evidence on optimal fluid choices in critically ill children remains scarce. This study aims to demonstrate whether balanced solutions, when used as intravenous fluid therapy, are able to reduce the incidence of a rise in serum chloride level compared to 0.9% sodium chloride in critically ill children.Methods: This is a single-centre, open-label randomized controlled trial with parallel 1:1:1 assignment into three groups: 0.9% sodium chloride, Plasma-Lyte 148, and Compound Sodium Lactate solutions for intravenous fluid therapy. The intervention includes both maintenance and bolus fluid therapy. Children aged < 16 years admitted to intensive care and receiving intravenous fluid therapy during the first 4 h of admission are eligible. The primary outcome measure is a ≥ 5mmol/L increase in serum chloride level within 48 h post-randomization. The enrolment target is 480 patients. The main analyses will be intention-to-treat.Discussion: This study tests three types of intravenous fluid therapy in order to compare the risk of hyperchloremia associated with normal saline versus balanced solutions. This pragmatic study is thereby assessing the most common intervention in paediatric critical care. This is a single-centre open-label study with no blinding at the level of delivery of the intervention. Certain paediatric intensive care unit (PICU) patient groups such as those admitted with a cardiac condition or following a traumatic brain injury are excluded from this study.Trial Registration: The study has received ethical approval (HREC/19/QCHQ/53177: 06/06/2019). It is registered in the Australian New Zealand Clinical Trials Registry ( ACTRN12619001244190 ) from 9th September 2019. Recruitment commenced on 12th November 2019. The primary results manuscript will be published in a peer-reviewed journal. [ABSTRACT FROM AUTHOR]

Chloride, often overshadowed in electrolyte management, emerges as a crucial player in the physiological intricacies of critically ill patients. This comprehensive review explores the multifaceted aspects of chloride, ranging from its significance in cellular homeostasis to the consequences of dysregulation in critically ill patients. The pathophysiology of hyperchloremia and hypochloremia is dissected, highlighting their intricate impact on acid-base balance, renal function, and cardiovascular stability. Clinical assessment strategies, including laboratory measurements and integration with other electrolytes, lay the foundation for targeted interventions. Consequences of dysregulated chloride levels underscore the need for meticulous management, leading to an exploration of emerging therapies and interventions. Fluid resuscitation protocols, the choice between crystalloids and colloids, the role of balanced solutions, and individualized patient approaches comprise the core strategies in chloride management. Practical considerations, such as monitoring and surveillance, overcoming implementation challenges, and embracing a multidisciplinary approach, are pivotal in translating theoretical knowledge into effective clinical practice. As we envision the future, potential impacts on critical care guidelines prompt reflections on integrating novel therapies, individualized approaches, and continuous monitoring practices. In conclusion, this review synthesizes current knowledge, addresses practical considerations, and envisions future directions in chloride management for critically ill patients. By embracing a holistic understanding, clinicians can navigate the complexities of chloride balance, optimize patient outcomes, and contribute to the evolving landscape of critical care medicine., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Sagar et al.)

Intravenous fluid and electrolyte management in paediatrics requires an understanding of the indication for intravenous fluid therapy and the underlying pathophysiology in order to meet requirements and avoid adverse events. Careful consideration needs to be given to the rate as well as the composition of intravenous therapy, and children's ongoing need should be reviewed regularly. Fluid therapy can be separated into maintenance fluids, replacement fluids that address electrolyte deficits and ongoing losses, and resuscitation fluids. We review the critical considerations when prescribing intravenous fluid for children and consider the challenges of non-osmotic secretion of anti-diuretic hormone (ADH), hyponatraemic encephalopathy and other electrolyte abnormalities. Fluid management in children with diabetic ketoacidosis is also reviewed. [ABSTRACT FROM AUTHOR]

Early restoration of euvolemia is the initial step in the management of critically ill children and is important for preventing acute kidney injury(AKI). Isotonic crystalloids are the preferred solutions for fluid resuscitation. Repeated boluses of normal saline may lead to hyperchloremia, renal vasoconstriction and renal injury. Balanced solutions have a physiological advantage and there is evidence to suggest that resuscitation with balanced solutions may be associated with lower incidence of AKI. Synthetic colloids such as starches cause renal injury and should be avoided. Albumin can be used judiciously along with crystalloids to limit fluid overload. Fluid resuscitation alone prevents AKI only in 50% of the critically ill patients. Fluid overload as well as rapid fluid administration may adversely affect the kidney through injury to the glycocalyx. It may lead to intrarenal edema and a compartment-like syndrome compromising renal perfusion. Repeat fluid bolus should only be given when there is evidence of ongoing hypoperfusion and the bedside hemodynamic assessment suggests fluid responsiveness, provided the patient is not at high risk for fluid overload. Moderate fluid resuscitation combined with pressors may restore renal perfusion better than fluids alone. In established AKI, diuretics have a limited role. Timely institution of renal replacement therapy leads to optimum fluid management. Overzealous fluid removal should be avoided to prevent hypovolemia and recurrent renal injury.

Goal: to familiarize Russian anesthesiologists with the most recent data of the evidence-based medicine about peri-operative infusion therapy. The right choice of the infusion therapy strategy and tactics is a mandatory component of the successful management of the peri-operative period. The most significant changes have recently occurred specifically in this field. First the concept of restrictive tactics of infusion therapy emerged and won its popularity very fast. Then some reasonable doubts appeared about feasibility and safety of using HES solutions. Both affect basic principles of infusion therapy and the recent changes are to be considered from the position of the evidence-based medicine. British and German experts attended these issues and published the relevant guidelines in 2011 and 2016. Comparison and analysis of the implementation opportunities in Russia and recommendations make the subject of this publication. Conclusion: It is necessary to implement the international recommendations for peri-operative infusion therapy with adjustment to relevant Russian regulations in the anesthesiology and intensive care departments.

Objective: To report the statistical analysis plan (first version) for the Balanced Solutions versus Saline in Intensive Care Study (BaSICS). Methods: BaSICS is a multicenter factorial randomized controlled trial that will assess the effects of Plasma-Lyte 148 versus 0.9% saline as the fluid of choice in critically ill patients, as well as the effects of a slow (333mL/h) versus rapid (999mL/h) infusion speed during fluid challenges, on important patient outcomes. The fluid type will be blinded for investigators, patients and the analyses. No blinding will be possible for the infusion speed for the investigators, but all analyses will be kept blinded during the analysis procedure. Results: BaSICS will have 90-day mortality as its primary endpoint, which will be tested using mixed-effects Cox proportional hazard models, considering sites as a random variable (frailty models) adjusted for age, organ dysfunction and admission type. Important secondary endpoints include renal replacement therapy up to 90 days, acute renal failure, organ dysfunction at days 3 and 7, and mechanical ventilation-free days within 28 days. Conclusion: This manuscript provides details on the first version of the statistical analysis plan for the BaSICS trial and will guide the study's analysis when follow-up is finished. [ABSTRACT FROM AUTHOR]

The metabolic consequences in vivo of various balanced solutions are poorly known in critically ill patients. The main objective of this study was to describe the metabolic consequences of Plasmalyte versus Ringer lactate (RL) in critically ill burn patients, with a special focus on the plasma clearance of buffer anions (i.e., gluconate, acetate, and lactate). We conducted a randomized trial between August 2017 and October 2018 in a tertiary teaching hospital in Paris, France. Patients with burn total body surface area -30% were randomized to receive Plasmalyte or RL. The primary end point was the base excess 24 h after inclusion. The secondary end points were acetate, gluconate, and lactate plasma concentration, the strong ion difference (SID). Twenty-eight patients were randomized. Twenty- four hours after inclusion, plasma BE was not significantly different in the Plasmalyte and RL groups {-0.9 [95% confidence interval (95% CI): -1.8-0.9] vs. -2.1 [95% CI: -4.6-0.6] mmol/L, respectively, P = 0.26}. Plasma gluconate concentration was higher in the Plasmalyte group (P < 0.001), with a maximum level of 1.86 (95% CI: 0.98-4.0) mmol/L versus 0 (95% CI: 0-0.15) mmol/L. Plasma acetate and lactate were not significantly different. Ionized calcium level was lower in the Plasmalyte group (P = 0.002). Hemodynamics did not differ between groups. To conclude, the alkalinizing effect of Plasmalyte was less important than expected with no difference in base excess compared with RL, in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte led to significantly lower ionized calcium levels. [ABSTRACT FROM AUTHOR]

Objective This study aimed to investigate the impact of different types of intravenous fluids - normal saline (NS), lactated Ringer's solution (LR), and PlasmaLyte (PL) - on the acid-base balance and electrolyte concentration following kidney transplant, a common procedure for patients with end-stage renal disease (ESRD). Methodology A randomized controlled trial design was employed, wherein the primary parameters analyzed were postoperative pH and serum potassium levels. Postoperative concentrations of serum bicarbonate, sodium, chloride, and creatinine, as well as graft functionality, were assessed as secondary outcomes. These measurements were performed at the start and end of surgery, as well as 24 and 72 hours postoperatively. Results A total of 53 patients were included in the study and randomized into three cohorts: NS, LR, and PL, each of which showed comparability in terms of demographic and transplantation specifics. Notably, patients in the NS group exhibited a more significant decrease in pH (NS group: 7.285 ±0.098, LR group: 7.324 ±0.075, PL group: 7.7338 ±0.059) and bicarbonate levels (17.0 ±4.2, 20.9 ±2.8, 20.0 ±4.5) post 24 hours after the operation and displayed a similar pattern immediately after the surgery. However, there were no discernible differences in potassium (p=0.460), sodium (p=0.681), and chloride (p=0.321) levels across the groups. Furthermore, the study did not observe any significant differences in postoperative graft functionality. Conclusion The use of NS as the intraoperative fluid of choice led to lower pH and bicarbonate levels following kidney transplant, as compared to LR and PL. However, these results did not correlate with improvements in graft functionality., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Medeiros et al.)

Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm. [ABSTRACT FROM AUTHOR]

Intravenous maintenance fluids are life sustaining and form one of the cornerstones of paediatric in-patient management. Similar to other medical therapies fluids come with side effects and the potential for significant associated morbidity and mortality. An appreciation of their side effect profiles in the context of paediatric physiology, particularly during critical illness, is essential in order to minimise the risks. This article summarises the history of paediatric fluid prescribing practice, highlighting the associated iatrogenic risks and provides a strategy for safer practice. [ABSTRACT FROM AUTHOR]

Background: Current guidelines for the management of patients with severe sepsis and septic shock recommend crystalloids as the initial fluid solution of choice in the resuscitation of these patients. In recent years, there have been numerous studies published on the type of fluid used in the resuscitation of patients with sepsis. The primary goal of this article is to determine the preferred intravenous fluid for the resuscitation of patients with severe sepsis and septic shock.Methods: A MEDLINE literature review was completed to identify studies that investigated the type of resuscitation fluid in the management of patients with severe sepsis and septic shock. Articles included were those published in English between 2011 and 2016, enrolled human subjects, and limited to the following types: randomized controlled trial, prospective observational trial, retrospective cohort trial, and meta-analyses. All selected articles then underwent a structured review by the authors.Results: Nine thousand sixty-two articles were identified in the search. After use of predetermined criteria, 17 articles were selected for review. Eleven of these were original investigations and six were meta-analyses and systemic reviews.Conclusion: Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock. Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available. There is strong evidence that suggests semi-synthetic colloids decrease survival and should be avoided. The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain. [ABSTRACT FROM AUTHOR]

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Objective: Intravenous fluids are broadly categorized into colloids and crystalloids. The aim of this review is to present under a clinical point of view the characteristics of intravenous fluids that make them more or less appropriate either for maintaining hydration when enteral intake is contraindicated or for treating hypovolemia.Methods: We considered randomized trials and meta-analyses as well as narrative reviews evaluating the effects of colloids or crystalloids in patients with hypovolemia or as maintenance fluids published in the PubMed and Cochrane databases.Results: Clinical studies have not shown a greater clinical benefit of albumin solutions compared with crystalloid solutions. Furthermore, albumin and colloid solutions may impair renal function, while there is no evidence that the administration of colloids reduces the risk of death compared with resuscitation with crystalloids in patients with trauma, burns or following surgery. Among crystalloids, normal saline is associated with the development of hyperchloremia-induced impairment of kidney function and metabolic acidosis. On the other hand, the other commonly used crystalloid solution, the Ringer's Lactate, has certain indications and contraindications. These matters, along with the basic principles of the administration of potassium chloride and bicarbonate, are meticulously discussed in the review.Conclusions: Intravenous fluids should be dealt with as drugs, as they have specific clinical indications, contraindications and adverse effects. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of the percentage of fluid infused as Lactated Ringer (%LR) during the first 2 days of ICU admission in hospital mortality and occurrence of acute kidney injury.Design: Retrospective cohort.Setting: Analysis of a large public database (Multiparameter Intelligent Monitoring in Intensive Care-II).Patients: Adult patients with at least 2 days of ICU stay, admission creatinine lower than 5 mg/dL, and that received at least 500 mL of fluid in the first 48 hours.Interventions: None.Measurement and Main Results: 10,249 patients were included in mortality analysis and 8,085 were included in the acute kidney injury analysis. For acute kidney injury analysis, we excluded patients achieving acute kidney injury criteria in the first 2 days of ICU stay. Acute kidney injury was defined as stage 2/3 Kidney Disease: Improving Global Outcomes creatinine criteria and was assessed from days 3-7. The effects of %LR in both outcomes were assessed through logistic regression controlling for confounders. Principal component analysis was applied to assess the effect of volume of each fluid type on mortality. Higher %LR was associated with lower mortality and less acute kidney injury. %LR effect increased with total volume of fluid infused. For patients in the fourth quartile of fluid volume (> 7 L), the odds ratio for mortality for %LR equal to 75% versus %LR equal to 25% was 0.50 (95% CI, 0.32-0.79; p < 0.001). Principal component analysis suggested that volume of Lactated Ringer and 0.9% saline infused had opposite effects in outcome, favoring Lactated Ringer.Conclusions: Higher %LR was associated with reduced hospital mortality and with less acute kidney injury from days 3-7 after ICU admission. The association between %LR and mortality was influenced by the total volume of fluids infused. [ABSTRACT FROM AUTHOR]

Background: Abnormal chloride levels are commonly observed in critically ill patients, but their clinical relevance remains a matter of debate. We examined the association between abnormal chloremia and ICU and hospital mortality. To further refine findings and integrate them into the ongoing discussion on the detrimental effects of chloride-rich solutions, the impact of strong ion difference (SID) on the same end points was assessed. Methods: Retrospective cohort study in an academic tertiary intensive care unit on 8830 adult patients who stayed at least 24 h in the ICU was carried out. Patients admitted after elective cardiac surgery were treated as a separate subgroup ( n = 2350). Analyses were performed using multivariable logistic regression. All statistical models were extensively adjusted for confounders, including comorbidity, admission diagnosis, other electrolytes and acid-base parameters. Results: Severe hyperchloremia (>110 mmol/L), but not low (SID) was significantly associated with increased mortality in the ICU (odds ratio vs. normochloremia 1.81; 95 % CI 1.32-2.50; p < 0.001) and the hospital (odds ratio 1.49; 95 % CI 1.14-1.96; p = 0.003). Hyperchloremia and low (SID) were encountered in the majority of patients admitted after cardiac surgery (in 86.9 and 47.2 %, respectively), but were not negatively associated with mortality. Conclusions: In the ICU, hyperchloremia at admission was associated with negative outcome. On the other hand, decreased strong ion difference did not have an impact on mortality, precluding a simple extrapolation of these findings to the ongoing discussion on the detrimental effects of chloride-rich solutions. This notion is fueled by the finding that hyperchloremia after cardiac surgery, frequently encountered and probably fluid-induced, did not seem to be deleterious. [ABSTRACT FROM AUTHOR]

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Purpose: Recent data suggest that both elevated serum chloride levels and volume overload may be harmful during fluid resuscitation. The purpose of this study was to examine the relationship between the intravenous chloride load and in-hospital mortality among patients with systemic inflammatory response syndrome (SIRS), with and without adjustment for the crystalloid volume administered. Methods: We conducted a retrospective analysis of 109,836 patients ≥18 years old that met criteria for SIRS and received fluid resuscitation with crystalloids. We examined the association between changes in serum chloride concentration, the administered chloride load and fluid volume, and the 'volume-adjusted chloride load' and in-hospital mortality. Results: In general, increases in the serum chloride concentration were associated with increased mortality. Mortality was lowest (3.7 %) among patients with minimal increases in serum chloride concentration (0-10 mmol/L) and when the total administered chloride load was low (3.5 % among patients receiving 100-200 mmol; P < 0.05 versus patients receiving ≥500 mmol). After controlling for crystalloid fluid volume, mortality was lowest (2.6 %) when the volume-adjusted chloride load was 105-115 mmol/L. With adjustment for severity of illness, the odds of mortality increased (1.094, 95 % CI 1.062, 1.127) with increasing volume-adjusted chloride load (≥105 mmol/L). Conclusions: Among patients with SIRS, a fluid resuscitation strategy employing lower chloride loads was associated with lower in-hospital mortality. This association was independent of the total fluid volume administered and remained significant after adjustment for severity of illness, supporting the hypothesis that crystalloids with lower chloride content may be preferable for managing patients with SIRS. [ABSTRACT FROM AUTHOR]

Purpose: To reanalyze the results of the Balanced Solutions in Intensive Care Study (BaSICS) through hierarchical endpoint analysis with win ratio., Methods: All patients with full data in BaSICS trial were elected for the analysis. BaSICS compared balanced solutions (Plasma Lye 148) versus 0.9% saline in critically ill patients requiring fluid challenge. The win ratio was defined as a hierarchical endpoint of 90-day mortality, recepit of kidney replacement therapy, hospital length-of-stay (LOS), and intensive care unit (ICU) LOS. Both unstratified and stratified (by admission type: planned admission, unplanned admission with sepsis, and unplanned admission without sepsis) approaches were used. A subgroup analysis was performed in patients with traumatic brain injury., Results: A total of 10,490 patients were included in the analysis, resulting in 27,587,566 unique combinations for unstratified WR. Unstratified Win ratio was 1.02 (95% confidence interval 0.97; 1.07), which was similar to stratified WR. No stratum in the stratified analysis resulted in significant results. Subgroup analysis confirmed the possible harm of balanced solutions in traumatic brain injury patients (WR 0.80; 95% confidence interval 0.64; 0.99)., Conclusion: In this reanalysis of BaSICS, a win ratio analysis largely replicated the results of the main trial, yielding neutral results except for the subgroup of patients with traumatic brain injury where a signal of harm was found., Competing Interests: Declaration of Competing Interest FGZ has received grants for investigator-initiated trials from Bactiguard (Sweden), and Ionis Pharmaceuticals (USA), unrelated to the topic of this study. LCPA has received lecturing fees from Baxter®., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Administration of normal saline might increase circulating levels of pro-inflammatory cytokines and may cause variation of plasmatic electrolytic and hyperchloremic acidosis, which in turn can impair renal function. Hence the use of balanced solutions could influence the inflammatory cascade triggered by the surgical procedures, the plasmatic electrolyte concentration, the acid-base equilibrium, and the renal function. Methods: This is a double blind randomized trial. Forty patients undergoing major abdominal surgery (bowel cancer) were allocated in two groups, the balanced solution (BS) group in which the fluids administered were balanced solutions (colloids and crystalloids); and the unbalanced solution (UBS) group in which the fluids administered were unbalanced solutions (colloids and crystalloids). Measurements were performed after anaesthesia induction (T0), at the end of surgery (T1), within 2 h after surgery (T2) and 24 h after the beginning of surgery (T3). The following data were collected: 1) active matrix metalloproteinase 9 (MMP-9) and its tissue inhibitor (TIMP-1), IL-6, IL-8, IL-10; 2) blood gases variables; 3) electrolytes, albumin, total serum protein and the strong ion difference; 4) neutrophil gelatinase-associated lipocalin (NGAL) from urinary sample. Results: The BS group exhibited higher circulating level of IL-10 and TIMP-1 and lower level of active MMP-9. The UBS group experienced hypercloremia, hypocalcemia, hypomagnesemia, worse acid-base equilibrium and higher level of NGAL. Conclusions: The use of balanced solutions was responsible of less alteration of plasmatic electrolytes, acid-base equilibrium, kidney function and it might be associated with an early anti-inflammatory mechanisms triggering. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of this review is to draw up a statement on current knowledge available on the more recent hydroxyethyl starch (HES). Data sources: References were obtained from computerized bibliographic research (Medline®), recent review articles, the library of the service and personal files. Study selection: All categories of articles on this topic have been selected. Data extraction: Articles have been analysed for biophysics, pharmacology, toxicity, side effects, clinical effects and using prospect of HES. Data synthesis: The first HES was made available in the United States in 1970. The development of a new generation of HES restarted the discussion on clinical interest and the limits in the use of these macromolecules. This interest is also strengthened today by the recent data attached to plasma substitution in intensive care or perioperative resuscitation. The interest for crystalloids and colloids is still widely debated, and among the latter, the relative interest of the HES last generation compared to older ones. Recent HES development is in line with a decrease molecular weight, change rate molar substitution and to amend the glucose to hydroxyethyl report. The ultimate goal is to reduce the side effects of these molecules preventing their use. Side effects are dominated by haemostasis and renal dysfunction. The latest developments are the so-called HES “balanced” solutions. [ABSTRACT FROM AUTHOR]

Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU). Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included. Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8-96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia <130 mEq/L (aOR 9.75 95% CI 1.64-58.15; p = 0.01). Conclusions: Hyponatremia associated with the use of hypotonic maintenance solutions occurs in one out of four children in intensive care. The use of these solutions is associated with a longer hospital stay, and the main risk groups are post-operative patients and those who receive loop diuretics. Clinical studies are needed to determine which maintenance solutions have the greatest efficacy and safety in critically ill children., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Fernández-Sarmiento, Pérez, Echeverri, Jimenez, Joachim and Andrés-Jagua.)

Abstract: Perioperative fluid therapy remains a controversial topic despite much research. Here, we review the different types of fluids, what to use in different circumstances and some of the controversies associated with fluid use. Crystalloids are fluids with small water-soluble molecules that can easily cross semi-permeable membranes. Saline-based fluids stay mainly within the extracellular compartment. Glucose solutions provide free water that diffuses across all the fluid compartments of the body. Colloids are fluids with larger, more insoluble molecules that do not readily cross membranes. Gelatins, dextrans and hydroxyethyl starches are effective intravascular volume expanders but are associated with numerous complications including anaphylaxis, renal failure and coagulation changes. Balanced solutions have low chloride content to avoid producing hyperchloreamic acidosis with extensive fluid use. Maintenance requirements can be met by providing water, sodium and potassium. Replacement for third space and insensible losses should use a ‘balanced’ crystalloid. The type of fluid used for hypovolaemia resuscitation can be crystalloid or colloid, with neither proven to be better than the other. Goal-directed therapy has shown that giving surgical patients the optimal amount of fluid that they require, as guided by cardiac-output monitoring, is associated with better outcomes. [Copyright &y& Elsevier]

Objective: To summarize the evidence comparing various balanced crystalloid solutions., Data Sources: We searched MEDLINE, EMBASE, PUBMED, and CENTRAL databases., Study Selection: We included randomized controlled trials that directly compared the IV administration of one balanced crystalloid solution with another., Data Extraction and Analysis: We examined metabolic and patient-important outcomes and conducted meta-analysis using random effects model. For comparisons or outcomes with insufficient data to allow for pooling, we describe results narratively. We assessed risk of bias for individual trials using the Cochrane risk of bias tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology., Data Synthesis: We included 24 randomized controlled trials comparing Plasmalyte, Ringer's Lactate, Ringerfundin, Hartmann's solution, Ringer's Bicarbonate, Sterofundin, Kabilyte, Normosol, and novel balanced solutions. Of the included studies, 16 were performed in the perioperative setting, six in the ICU, one in the emergency department, and one in healthy volunteers. Administration of Plasmalyte resulted in a lower postinfusion serum chloride concentration (mean difference, 0.83 mmol/L lower; 95% CI, 0.03-1.64 mmol/L lower, low certainty), higher postinfusion base excess (mean difference, 0.65 mmol/L higher, 95% CI, 0.25-1.05 mmol/L higher, low certainty), and lower postinfusion serum lactate levels (mean difference, 0.46 mmol/L lower; 95% CI, 0.05-0.87 mmol/L lower, low certainty) compared with administration of any other balanced crystalloid. There were no important differences in postinfusion serum pH or potassium when comparing Plasmalyte with other balanced crystalloids. Data addressing other comparisons or examining the impact of different balanced crystalloids on patient-important outcomes were sparsely reported and too heterogeneous to allow for pooling., Conclusions: Administration of Plasmalyte results in lower serum concentrations of chloride and lactate, and higher base excess than other balanced crystalloids. The certainty of evidence is low and requires further study in large randomized controlled trials to inform the choice of balanced crystalloid in patients requiring volume replacement., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)