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Isha S, Satashia PH, Yarrarapu SNS, Govero AB, Harrison MF, Baig HZ, Guru P, Bhattacharyya A, Ball CT, Caples SM, Grek AA, Vizzini MR, Khan SA, Heise KJ, Sekiguchi H, Cantrell WL, Smith JD, Chaudhary S, Gnanapandithan K, Thompson KM, Graham CG, Cowdell JC, Murawska Baptista A, Libertin CR, Moreno Franco P, Sanghavi DK. A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis. Front Med (Lausanne) 2023; 10:1071741. [PMID: 37089586 PMCID: PMC10117883 DOI: 10.3389/fmed.2023.1071741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Background The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. Method We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Results Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. Conclusion In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Austin B. Govero
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael F. Harrison
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hassan Z. Baig
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Colleen T. Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, United States
| | - Sean M. Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ami A. Grek
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael R. Vizzini
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System Mankato, Mankato, MN, United States
| | - Katherine J. Heise
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hiroshi Sekiguchi
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, United States
| | - Warren L. Cantrell
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jeffrey D. Smith
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Charles G. Graham
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jed C. Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Claudia R. Libertin
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, United States
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Devang K. Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Devang K. Sanghavi,
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