Journal smart trial 09 08 18

Journal smart trial 09 08 18

• 1.
  Journal Club Balanced Crystalloidsversus Saline in Critically Ill Adults SMART Trial Matthew W. Semler, M.D., et al NEJM – March 1 , 2018 Anirudhya J Department of General medicine
• 2.
  Background • Both balancedcrystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. • Balanced crystalloids (Electrolyte composition closer to that of plasma) : Lactated Ringer’s solution and Plasma-Lyte A Saline : 0.9% Sodium chloride
• 3.
  Composition
• 4.
  • Location :Vanderbilt University Medical Center, Nashville • Pragmatic, unblinded, cluster-randomized, multiple- crossover trial conducted in five intensive care units. • Study period : Between June 1, 2015, and April 30, 2017. • Study population : All adults (Age : 18 years and above) admitted to a participating ICU. • Sample size : 15,802  7942 – Balanced crystalloids , 7860 - Saline Study design
• 5.
  • Primary outcome: • Major adverse kidney event within 30 days. • Death, New renal-replacement therapy, or persistent renal dysfunction (defined as a final inpatient creatinine value ≥200% of the baseline value) — at hospital discharge or 30 days after enrollment, whichever came first. Outcomes
• 6.
  • Patients whohad received renal replacement therapy before enrollment were ineligible to meet the criteria for new renal- replacement therapy or persistent renal dysfunction but could qualify for the primary outcome if they died in the hospital.
• 7.
  • Secondary clinicaloutcome : In-hospital death before ICU discharge or at 30 days or 60 days, as well as ICU-free days, ventilator-free days, vasopressor-free days, and days alive and free of renal-replacement therapy during the 28 days after enrollment. Outcomes
• 8.
  • Secondary renaloutcomes : New receipt of renal-replacement therapy, persistent renal dysfunction, AKI of stage 2 or higher, the highest creatinine level during the hospital stay, the change from baseline to the highest creatinine level, and the final creatinine level before hospital discharge.
• 10.
  Results Fewer patients inthe balanced-crystalloids group than in the saline group had a measured plasma chloride concentration greater than 110 mmol per liter (24.5%) or a plasma bicarbonate concentration less than 20 mmol per liter (35.2%)
• 11.
  Clinical outcomes
• 12.
  Secondary outcomes
• 13.
  Secondary renal outcomes
• 14.
  • The highchloride content of saline has been reported to cause hyperchloremia, acidosis, inflammation, renal vasoconstriction, AKI, hypotension, and death. • In the current trial, the use of balanced crystalloids rather than saline resulted in an absolute difference of 1.1 percentage points in favor of balanced crystalloids in the primary outcome. • This finding is consistent with the results of the SALT-ED trial conducted concurrently in non- critically ill adults. Discussion
• 15.
  • Use ofbalanced crystalloids rather than saline might prevent 1 patient among every 94 patients admitted to an ICU from the need for new renal-replacement therapy, from persistent renal dysfunction, or from death. • The difference in outcomes between balanced crystalloids and saline appeared to be greater for patients with sepsis and patients who received larger volumes of isotonic crystalloid. Discussion contd…
• 16.
  • Relative hypotonicityof balanced crystalloids could increase intracranial pressure in patients with brain injury. Thus, results can not be used to provide guidance as to whether balanced crystalloids should be used in patients with traumatic brain injury. • Conduct at a single academic center limits generalizability. • The outcomes of death and creatinine level were objective, but a clinician’s decision to initiate renal- replacement therapy may be susceptible to treatment bias. • The trial does not inform the choice between lactated Ringer’s solution and Plasma-Lyte A. Limitations
• 17.
  • Among criticallyill 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. Conclusion
• 18.
  Thank you