A SMARTer Way to Give Fluid in Septic Patients

Written by Clay Smith

Spoon Feed
Starting balanced crystalloid fluid resuscitation vs normal saline early, while still in the ED as opposed to the ICU, appears to have mortality benefit among critically ill patients with sepsis.

Why does this matter?
SMART found that balanced crystalloid reduced major adverse kidney events, and the benefit appeared even greater in the subgroup with sepsis. For the first 7 months of the SMART study, the choice of IV fluid was not made until after the patient was in the ICU. But for the last 15 months of the study, the choice of fluid was made in the ED. Does an earlier start of balanced crystalloid in the ED impact mortality among critically ill septic patients?

A SMART fluid choice
This was a secondary analysis of SMART data comparing volume resuscitation with normal saline vs lactated Ringer’s or Plasmalyte (balanced crystalloid) among the subgroup of SMART patients with sepsis. For the 367 patients with the IV fluid choice after ICU arrival (late fluid), there was no mortality benefit with balanced fluid: 33.1% balanced vs. 32.9% saline; OR 1.14 (95%CI 0.70-1.88). However, when the fluid choice was started in the ED (early fluid) there was a mortality benefit with balanced fluid: 24.9% balanced vs. 30.6% saline; OR 0.68 (95%CI, 0.52-0.89). Bear in mind, this was not the primary outcome of the original study and only includes the subgroup of patients with sepsis admitted to the MICU. Nevertheless, it is interesting, noteworthy, and confirms my current practice.

Source
Effect of Early Balanced Crystalloids before ICU Admission on Sepsis Outcomes. Chest. 2020 Aug 31:S0012-3692(20)34295-1. doi: 10.1016/j.chest.2020.08.2068. Online ahead of print.

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