Balanced crystalloids versus saline in critically ill adults.
Open accessAbstract
BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS: Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60). CONCLUSIONS: Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779 .).
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In the SMART trial sepsis subgroup, balanced solutions were associated with lower 30-day mortality than normal saline.
“In the pre-specified subgroup of patients admitted with sepsis in all participating ICUs, 30-day mortality was lower in those receiving balanced solutions, compared to normal saline (OR 0.80; 95% CI 0.67−0.94).”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [334]
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- Authors
- Semler, M. W., Self, W. H., Wanderer, J. P., Ehrenfeld, J. M., Wang, L., Byrne, D. W., Stollings, J. L., Kumar, A. B., Hughes, C. G., Hernandez, A., Guillamondegui, O. D., May, A. K., Weavind, L., Casey, J. D., Siew, E. D., Shaw, A. D., Bernard, G. R., & Rice, T. W.
- Affiliations
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease...
- Vanderbilt University (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2018-03
- Volume
- 378
- Issue
- 9
- Pages
- 829-839
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC5846085
- OpenAlex
- W4241014756
- Semantic Scholar
- 550c6b6d37e9aed5646faede9465fc26f86b8c89
- Cited by
- 1,433
- References
- 38
- Citations by year
- 2026: 120 · 2025: 142 · 2024: 168 · 2023: 166 · 2022: 204 · 2021: 195 · 2020: 180 · 2019: 159 · 2018: 95 · 2015: 1
- FWCI
- 128.78
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Center for Advancing Translational Sciences (UL1 TR000445, UL1TR002243)
- Topics
- Health Sciences › Medicine › Nephrology › Acute Kidney Injury Research
- Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Keywords
- balanced crystalloids, saline, intravenous fluid therapy, critically ill adults, lactated Ringer's solution, Plasma-Lyte A, acute kidney injury, renal replacement therapy, persistent renal dysfunction, 30-day mortality, intensive care unit
- MeSH terms
- Ringer's Lactate, Adult, Aged, Electrolytes, Emergency Service, Hospital, Female, Fluid Therapy, Humans, Infusions, Intravenous, Intensive Care Units, Isotonic Solutions, Kidney Diseases, Male, Middle Aged, Sodium Chloride, Critical Illness, Renal Replacement Therapy, Cross-Over Studies
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