1. N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018
Feb 27.

Balanced Crystalloids versus Saline in Critically Ill Adults.

Semler MW(1), Self WH(1), Wanderer JP(1), Ehrenfeld JM(1), Wang L(1), Byrne
DW(1), Stollings JL(1), Kumar AB(1), Hughes CG(1), Hernandez A(1), Guillamondegui
OD(1), May AK(1), Weavind L(1), Casey JD(1), Siew ED(1), Shaw AD(1), Bernard
GR(1), Rice TW(1); SMART Investigators and the Pragmatic Critical Care Research
Group.

Collaborators: Brown RM, Noto MJ, Lindsell CJ, Domenico HJ, Costello WT, Gibson
J, Holcombe EW, Pretorius M, McCall AS, Atchison L, Dunlap DF, Felbinger M,
Hamblin SE, Knostman M, Rumbaugh KA, Sullivan M, Valenzuela JY, Young JB,
Mulherin DP, Hargrove FR, Strawbridge S.

Author information: 
(1)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 and Integrated Program for
Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center,
Nashville.

Comment in
    N Engl J Med. 2018 Mar 1;378(9):862-863.
    N Engl J Med. ;378(20):1949.
    N Engl J Med. ;378(20):1949.
    N Engl J Med. ;378(20):1950.
    N Engl J Med. 2018 May 17;378(20):1950.
    Med Klin Intensivmed Notfmed. 2018 Sep;113(6):490-493.

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 .).

DOI: 10.1056/NEJMoa1711584 
PMCID: PMC5846085
PMID: 29485925  [Indexed for MEDLINE]