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Be SMART – Balanced Fluid for Sepsis

October 23, 2019

Written by Sam Parnell

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The use of balanced crystalloids for ICU patients with sepsis was associated with a lower 30-day in-hospital mortality (26.3% vs 31.2%, P=0.01) and a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%, aOR 0.78) compared to normal saline.  

Why does this matter?
Normal saline, the historical bastion of IV fluids, has supraphysiologic chloride concentration that may cause hyperchloremia, metabolic acidosis, renal vasoconstriction, hypotension, and altered immune function.  The recently published Isotonic Solutions and Major Adverse Renal Events Trial (SMART) compared balanced crystalloids to normal saline and found that balanced crystalloids decreased the composite outcome of death, new renal replacement therapy, or persistent renal dysfunction for critically ill adults. However, do patients with sepsis specifically benefit from balanced crystalloids?

Treating sepsis with a balanced approach…
This study was a secondary analysis of the 1,641 ICU patients with a diagnosis of sepsis from the original SMART trial. The use of balanced crystalloids was associated with a significantly lower 30-day in-hospital mortality (26.3% vs 31.2%, P=0.01). This corresponds to a 15.7% relative risk reduction and a 4.9% absolute risk reduction of death (NNT = 20) within 30 days. The effect on mortality was much more substantial for this subgroup of patients (i.e. sepsis) than the general ICU population in the SMART trial.

In addition, balanced crystalloids were associated with a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%, aOR 0.78), a greater number of vasopressor-free days (20 ± 12 vs 19 ± 13; aOR 1.25; 95% CI 1.02 – 1.54), and more renal replacement therapy-free days (20 ± 12 vs 19 ± 13; aOR 1.35 [1.08 – 1.69]) compared to the normal saline group.

This study has several limitations including being a subgroup analysis, unblinded, using ICD-10 codes for identifying patients with sepsis, and having all patients enrolled from a single academic center (even if Vanderbilt is great…not biased at all – LOL). However, with little downside and a possible reduction in mortality and adverse renal events, why not be SMART and just use balanced fluids for patients with sepsis?

Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019 Aug 27. doi: 10.1164/rccm.201903-0557OC. [Epub ahead of print]

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Reviewed by Thomas Davis

What are your thoughts?