By Neal Biddick

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Synopsis: This study enrolled 13,347 adult patients receiving a minimum of 500 cc of intravenous fluid in the emergency department. Participants were randomized to receive either normal saline or balanced crystalloid fluid (lactated Ringer’s solution or Plasma-Lyte A). The study authors found no significant difference between the two groups in the primary outcome of hospital-free days (P = .41), or in several of the secondary outcomes including acute kidney injury stage 2 or higher (P = .14) and in-hospital mortality (P = .36). The balanced crystalloid fluid group did have a significantly lower incidence of a composite secondary outcome of major adverse kidney events (P = .01). However, given the primary and other secondary outcome findings, and concerns that composite outcomes lack patient centeredness, an accompanying editorial urged caution against changing clinical practice based on this finding.

Bottom line: There was no significant difference in hospital-free days for noncritically ill patients receiving IV fluids in the ED between those treated with saline and balanced crystalloid fluid.

Citation: Self WH et al. Balanced crystalloids versus saline in noncritically ill adults. N Eng J Med. 2018;378:819-28.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Synopsis: This study enrolled 13,347 adult patients receiving a minimum of 500 cc of intravenous fluid in the emergency department. Participants were randomized to receive either normal saline or balanced crystalloid fluid (lactated Ringer’s solution or Plasma-Lyte A). The study authors found no significant difference between the two groups in the primary outcome of hospital-free days (P = .41), or in several of the secondary outcomes including acute kidney injury stage 2 or higher (P = .14) and in-hospital mortality (P = .36). The balanced crystalloid fluid group did have a significantly lower incidence of a composite secondary outcome of major adverse kidney events (P = .01). However, given the primary and other secondary outcome findings, and concerns that composite outcomes lack patient centeredness, an accompanying editorial urged caution against changing clinical practice based on this finding.

Bottom line: There was no significant difference in hospital-free days for noncritically ill patients receiving IV fluids in the ED between those treated with saline and balanced crystalloid fluid.

Citation: Self WH et al. Balanced crystalloids versus saline in noncritically ill adults. N Eng J Med. 2018;378:819-28.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Synopsis: This study enrolled 13,347 adult patients receiving a minimum of 500 cc of intravenous fluid in the emergency department. Participants were randomized to receive either normal saline or balanced crystalloid fluid (lactated Ringer’s solution or Plasma-Lyte A). The study authors found no significant difference between the two groups in the primary outcome of hospital-free days (P = .41), or in several of the secondary outcomes including acute kidney injury stage 2 or higher (P = .14) and in-hospital mortality (P = .36). The balanced crystalloid fluid group did have a significantly lower incidence of a composite secondary outcome of major adverse kidney events (P = .01). However, given the primary and other secondary outcome findings, and concerns that composite outcomes lack patient centeredness, an accompanying editorial urged caution against changing clinical practice based on this finding.

Bottom line: There was no significant difference in hospital-free days for noncritically ill patients receiving IV fluids in the ED between those treated with saline and balanced crystalloid fluid.

Citation: Self WH et al. Balanced crystalloids versus saline in noncritically ill adults. N Eng J Med. 2018;378:819-28.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.