Should We Be Using Less Normal Saline

Yunos NM et al. The association between a chloride-liberal versus a chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012 Oct 17; 308:1566-72.

Objective
o Assess association of chloride-liberal versus chloride-restrictive IV fluid strategy in the critically ill

Design
o Prospective, open label, sequential pilot study in a university affiliated hospital in Melbourne, Australia
o 760 patients admitted to the ICU during the control period compared to 773 patients admitted consecutively
during the intervention period
o During control period, patients received the standard IV fluids, then a six month phase out period occurred
followed by an intervention period
o Chloride-liberal IV fluids: normal saline, 4% succinylated gelatin solution or 4% albumin solution
o Chloride-restrictive IV fluids: Lactated Ringer’s, Hartman’s solutions, Plasmalyte, and chloride poor 20% albumin

Outcome measures
o Primary
- Increase from baseline to peak creatinine levels in the ICU
- Actual incidence in AKI according to the RIFLE (risk injury failure loss end stage) classification

o Secondary
-The need for dialysis
- ICU and hospital stay

Results
o Control versus intervention
- Chloride administration decrease from 694 to 496 mmol/patient
- Mean serum creatinine increased while in the ICU (22.6 vs. 14.8 micromol/liter)
-AKI injury rate was 14% vs. 8.4
- Renal replacement or dialysis rate was 10% vs. 6.3%

o After adjusting for co-variance
- Association remained for AKI (OR 0.52)
- Use of renal replacement therapy OR 0.52
- No difference in length of hospital/ICU stay or need for renal replacement therapy after discharge

Conclusion
o Implementation of a chloride restrictive strategy in a tertiary ICU was associated with a significance decrease in AKI and use of renal replacement therapy
o First must know initial kidney function, and if risk of AKI, should consider chloride restrictive strategies
o May consider starting with lactate ringers to avoid hyperchloremic metabolic acidosis