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A6188 - Balanced Crystalloids Versus Saline for Adults with Sepsis or Septic Shock
Author Block: R. M. Brown1, J. P. Wanderer2, J. M. Ehrenfeld2, J. L. Stollings3, A. C. McKown1, L. Wang4, G. R. Bernard1, W. H. Self5, T. W. Rice1, M. W. Semler1, SALT Investigators, Pragmatic Critical Care Research Group; 1Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States, 2Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States, 3Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, United States, 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States, 5Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.
RATIONALE: Intravenous crystalloid resuscitation is a cornerstone of sepsis management. Whether balanced crystalloids or saline results in better outcomes in sepsis remains controversial. METHODS: We performed a pre-specified subgroup analysis of the isotonic Solution Administration Logical Testing (SALT) study, a prospective cluster-randomized, multiple-crossover trial among 974 patients admitted to a tertiary medical intensive care unit (ICU) from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A). We identified patients with a primary diagnosis at ICU admission of sepsis or septic shock. Among these patients, we compared the balanced crystalloid and saline groups with regard to the incidence of major adverse kidney events within 30 days (MAKE30), a composite of death, new renal replacement therapy (RRT), or persistent renal dysfunction. Secondary outcomes included 30 day in-hospital mortality, receipt of new RRT, stage II or greater acute kidney injury by KDIGO creatinine criteria, and vasopressor-free days. RESULTS: Among 260 patients with a primary diagnosis at ICU admission of sepsis or septic shock, those assigned to saline (n = 130) and balanced crystalloids (n = 130) were similar at baseline. Patients in the balanced crystalloid group received a median of 1229mL [IQR 310 - 3078] of balanced crystalloid and 85mL [0 - 1327] of saline, whereas patients in the saline group received 1408mL [608 - 3239] of saline and 0mL [0 - 10] of balanced crystalloids. The incidence of MAKE30 was lower in the balanced crystalloid group compared with the saline group (27.7% vs 40.8%; P = 0.026). In-hospital 30-day mortality (20.8% vs 25.4%; P = 0.377) and receipt of new RRT (3.1% vs 5.4%; P = 0.355) did not differ significantly between the balanced crystalloid and saline groups. The incidence of acute kidney injury was lower with balanced crystalloids compared to saline (28.5% vs 43.1%; P = 0.014). The median number of vasopressor-free days did not differ significantly between the balanced crystalloid and saline groups (28 days [IQR 12 - 28 days] vs 26 days [0 - 28 days]; P = 0.10). CONCLUSIONS: Among ICU patients with sepsis or septic shock, resuscitation with balanced crystalloids reduced the composite outcome of death, dialysis, or persistent renal dysfunction and decreased the incidence of acute kidney injury. Larger trials comparing balanced crystalloids to saline in patients with sepsis are needed to confirm these findings.