Results of a new meta-analysis in shows that intravenous fluid (IV) therapy using balanced solutions rather than commonly used saline can reduce the risk of in-hospital death of critically ill patients by four percent.
Findings from the BEST-Living Study were presented today at the Critical Care Canada Forum (CCCF 2023) and simultaneously published in The Lancet Respiratory Medicine.
Prof Simon Finfer AO, an Intensive Care physician, Professorial Fellow at The George Institute for Global Health, and Adjunct Professor, UNSW Sydney - who was the senior author on the paper - said the results supported the important role of IV fluid choice in the treatment of intensive care patients.
“Our research shows that balanced fluids are a better treatment for most intensive care patients, and are associated with lower mortality rates than saline,” he said.
“While the positive effects were modest, this evidence can help clinicians make more informed choices about which intravenous fluids to use for their patients in critical care and increase the chance of most patients surviving their critical illness.”
Nearly all patients admitted to an intensive care unit will require intravenous fluids as part of their standard treatment. These fluids can be made up of saline (0.9 percent sodium chloride), or balanced crystalloids, which more closely match chemistry of human blood.
However, no individual trial of balanced solutions versus saline to date has reported a statistically significant effect on mortality.
To examine this more closely, an international group of researchers analysed data involving 34,685 patients across six clinical trials conducted in the USA, Australia, New Zealand and Brazil.
They found a four percent relative reduction in the odds of dying when patients were given balanced solutions. Among patients on balanced solutions, 16.8 percent died in hospital, versus 17.3 percent who received saline suggesting that one life is saved for every 250 patients treated.
Additionally, 5.6 percent of patients required renal replacement therapy (dialysis) in the balanced group, compared with 5.9 percent of patients assigned saline.
Naomi Hammond, Critical Care Program Head at The George Institute and Associate Professor, Faculty of Medicine, UNSW Sydney said there was an important caveat that in the small subset of patients with traumatic brain injury the risk of death was higher with balanced solutions (19.1 percent) versus saline (14.7 percent).
“While the results showed that overall, there is a high probability that use of balanced solutions compared with saline is associated with reduced in-hospital mortality and less need for renal replacement therapy - or dialysis - we saw that in patients with traumatic brain injury, balanced solutions probably increase mortality,” she said.
“However, balanced solutions are generally more expensive than saline and in settings where resources are limited and there is a greater disparity between the price of balanced and saline solutions, such a benefit may not be deemed cost-effective.”
The BEST-Living Study will be repeated annually to include new eligible trial data within its analysis. It was funded by the Hospital do Coracao (HCor) Research Institute and The George Institute for Global Health and conducted in partnership with Vanderbilt University Medical Centre, the Medical Research Institute of New Zealand, HCor and BRICNet (Brazilian Research in Intensive Care Network).
Journal
The Lancet Respiratory Medicine
Method of Research
Meta-analysis
Subject of Research
People
Article Title
Balanced crystalloids versus saline for critically ill patients (BEST-Living): a systematic review and individual patient data meta-analysis
Article Publication Date
30-Nov-2023
COI Statement
FGZ reports receiving consulting fees from Baxter (USA) and Bactiguard (Sweden), and grants, paid to his institution from Ionis Pharmaceuticals (USA), and receiving logistical support and donation of study materials from Baxter Hospitalar for the BaSICS trial. ABC reports receiving logistical support and donation of study materials from Baxter Hospitalar for the BaSICS trial. GLDT reports receiving consulting fees from Gilead paid to his then employer (The George Institute for Global Health) for work outside the scope of this paper. LPD reports receiving fees for statistical analysis from Nestlé and Endpoint Health, all unrelated to the scope of this study. NEH reports research funding and donation of study materials from Baxter Healthcare related to intravenous fluid therapy, research funding from Endpoint Health, and consulting fees from RevImmune unrelated to fluid therapy, all paid to her employer; and competitive research grants from the Australian National Health and Medical Research Council and Medical Research Future Fund. FRM reports receiving consulting fees from Baxter and receiving logistical support and donation of study materials from Baxter Hospitalar for the BaSICS trial. SM declares no competing interests. JM reports research funding and donation of study materials from Baxter Healthcare related to intravenous fluid therapy, paid to his employer; research funding from Endpoint Health unrelated to fluid therapy; and competitive research grants from the Australian National Health and Medical Research Council and Medical Research Future Fund. MR reports donation of study materials from Baxter Healthcare related to intravenous fluid therapy and competitive research grants from the Australian Medical Research Future Fund. BV reports donation of study materials from Baxter Healthcare related to intravenous fluid therapy, research funding from Endpoint Health unrelated to fluid therapy, and consulting fees from RevImmune unrelated to fluid therapy, all paid to his institution; and competitive research grants from the Australian National Health and Medical Research Council. TWR reports receiving consulting fees received from Cumberland Pharmaceuticals and Cytovale and fees for serving as a data safety and monitoring board member from Sanofi, all unrelated to the scope of this paper; and grants from the US National Institutes for Health, Centers for Disease Control, and Department of Defence, all paid to his institution. MWS reports receiving grants from the US National Institutes for Health and Department of Defence unrelated to the current work; and consulting fees and honoraria from Baxter Healthcare related to intravenous fluid therapy. PJY reports receiving competitive grants from the Health Research Council of New Zealand unrelated to this work; consulting fees from AM Pharma unrelated to this work; and consulting fees from Baxter Healthcare related to intravenous fluid therapy. SF reports competitive research grants from the Australian National Health and Medical Research Council, research funding and consulting fees from Baxter Healthcare related to intravenous fluid therapy, research funding and consulting fees from RevImmune unrelated to fluid therapy, and research funding from Endpoint Health unrelated to fluid therapy, all paid to his institution; and owning stock options in Sepsis Scout, unrelated to fluid therapy.