Saurabh Parasramka, MD

Clinical question: Does a balanced crystalloid solution lead to better outcomes than does normal saline when used in critically sick adults?

Background: Balanced crystalloids are considered more physiological, with a composition closer to plasma. Observational studies have shown lower rates of hyperchloremic acidosis, renal failure, and death with use of balanced crystalloids. In spite of this, normal saline has been the most commonly used fluid. Differences in effects on important patient-related outcomes of safety and efficacy between these two interventions remain unknown.

Study design: Pragmatic, unblinded, cluster-randomized, multiple-crossover trial.

Setting: Vanderbilt University Health Center, Nashville, Tenn.

Synopsis: This study comprised 15,802 adults with mean age of 58 admitted to ICU who were cluster randomized to receive either balanced crystalloid or normal saline. Primary outcome was a composite of death from any cause, renal replacement therapy, or persistent renal dysfunction at 30 days and was observed less frequently in the balanced crystalloid group (adjusted odds ratio, 0.90; 95% confidence interval, 0.82-0.99; P = .04).

Since the trial was cluster randomized, prognostic imbalance between the groups caused by confounding factors was a big risk. Results could not be generalized because the study was done in a university health center. Mean fluid amount received was modest in both groups. Questions still remain about the efficacy and safety of balanced fluids, and hospitalists should weigh their decisions in light of this new information.

Bottom line: Balanced crystalloid solution decreased 30-day composite outcome of death, renal replacement therapy, or persistent renal dysfunction.

Citation: Semler MW et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018 Mar 1;378(9):829-39.
 

Dr. Parasramka is an assistant professor in the division of hospital medicine at the University of Kentucky, Lexington.

Clinical question: Does a balanced crystalloid solution lead to better outcomes than does normal saline when used in critically sick adults?

Background: Balanced crystalloids are considered more physiological, with a composition closer to plasma. Observational studies have shown lower rates of hyperchloremic acidosis, renal failure, and death with use of balanced crystalloids. In spite of this, normal saline has been the most commonly used fluid. Differences in effects on important patient-related outcomes of safety and efficacy between these two interventions remain unknown.

Study design: Pragmatic, unblinded, cluster-randomized, multiple-crossover trial.

Setting: Vanderbilt University Health Center, Nashville, Tenn.

Synopsis: This study comprised 15,802 adults with mean age of 58 admitted to ICU who were cluster randomized to receive either balanced crystalloid or normal saline. Primary outcome was a composite of death from any cause, renal replacement therapy, or persistent renal dysfunction at 30 days and was observed less frequently in the balanced crystalloid group (adjusted odds ratio, 0.90; 95% confidence interval, 0.82-0.99; P = .04).

Since the trial was cluster randomized, prognostic imbalance between the groups caused by confounding factors was a big risk. Results could not be generalized because the study was done in a university health center. Mean fluid amount received was modest in both groups. Questions still remain about the efficacy and safety of balanced fluids, and hospitalists should weigh their decisions in light of this new information.

Bottom line: Balanced crystalloid solution decreased 30-day composite outcome of death, renal replacement therapy, or persistent renal dysfunction.

Citation: Semler MW et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018 Mar 1;378(9):829-39.
 

Dr. Parasramka is an assistant professor in the division of hospital medicine at the University of Kentucky, Lexington.

Clinical question: Does a balanced crystalloid solution lead to better outcomes than does normal saline when used in critically sick adults?

Background: Balanced crystalloids are considered more physiological, with a composition closer to plasma. Observational studies have shown lower rates of hyperchloremic acidosis, renal failure, and death with use of balanced crystalloids. In spite of this, normal saline has been the most commonly used fluid. Differences in effects on important patient-related outcomes of safety and efficacy between these two interventions remain unknown.

Study design: Pragmatic, unblinded, cluster-randomized, multiple-crossover trial.

Setting: Vanderbilt University Health Center, Nashville, Tenn.

Synopsis: This study comprised 15,802 adults with mean age of 58 admitted to ICU who were cluster randomized to receive either balanced crystalloid or normal saline. Primary outcome was a composite of death from any cause, renal replacement therapy, or persistent renal dysfunction at 30 days and was observed less frequently in the balanced crystalloid group (adjusted odds ratio, 0.90; 95% confidence interval, 0.82-0.99; P = .04).

Since the trial was cluster randomized, prognostic imbalance between the groups caused by confounding factors was a big risk. Results could not be generalized because the study was done in a university health center. Mean fluid amount received was modest in both groups. Questions still remain about the efficacy and safety of balanced fluids, and hospitalists should weigh their decisions in light of this new information.

Bottom line: Balanced crystalloid solution decreased 30-day composite outcome of death, renal replacement therapy, or persistent renal dysfunction.

Citation: Semler MW et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018 Mar 1;378(9):829-39.
 

Dr. Parasramka is an assistant professor in the division of hospital medicine at the University of Kentucky, Lexington.

We read the article by Monash et al.¹ published in the March 2017 issue with great interest. This randomized study showed a discrepancy between patients’ and residents’ satisfaction with standardized rounds; for example, residents reported less autonomy, efficiency, teaching, and longer time of rounds.

We agree that letting residents lead the rounds with minimal participation of an attending (only when needed) may improve resident satisfaction. Other factors, such as quality of teaching, positive comments to learners during bedside rounds (whenever appropriate), and a positive attending attitude, might be helpful.^2,3 We believe that the adaptation of such a model through the prism of residents’ benefit will lead to better satisfaction among trainees.

On the other hand, we note that the nature of the study might have exaggerated patient satisfaction when compared with real-world surveys.⁴ The survey appears to focus only on attending rounds and did not consider other factors like hospitality, pain control, etc. A low patient census and lack of double blinding are other potential factors.

In conclusion, we want to congratulate the authors for raising this important topic and showing positive patients’ satisfaction with standardized rounds on teaching services. Further research should focus on improving residents’ satisfaction without compromising patients’ experiences.

We read the article by Monash et al.¹ published in the March 2017 issue with great interest. This randomized study showed a discrepancy between patients’ and residents’ satisfaction with standardized rounds; for example, residents reported less autonomy, efficiency, teaching, and longer time of rounds.

We agree that letting residents lead the rounds with minimal participation of an attending (only when needed) may improve resident satisfaction. Other factors, such as quality of teaching, positive comments to learners during bedside rounds (whenever appropriate), and a positive attending attitude, might be helpful.^2,3 We believe that the adaptation of such a model through the prism of residents’ benefit will lead to better satisfaction among trainees.

On the other hand, we note that the nature of the study might have exaggerated patient satisfaction when compared with real-world surveys.⁴ The survey appears to focus only on attending rounds and did not consider other factors like hospitality, pain control, etc. A low patient census and lack of double blinding are other potential factors.

In conclusion, we want to congratulate the authors for raising this important topic and showing positive patients’ satisfaction with standardized rounds on teaching services. Further research should focus on improving residents’ satisfaction without compromising patients’ experiences.

We read the article by Monash et al.¹ published in the March 2017 issue with great interest. This randomized study showed a discrepancy between patients’ and residents’ satisfaction with standardized rounds; for example, residents reported less autonomy, efficiency, teaching, and longer time of rounds.

We agree that letting residents lead the rounds with minimal participation of an attending (only when needed) may improve resident satisfaction. Other factors, such as quality of teaching, positive comments to learners during bedside rounds (whenever appropriate), and a positive attending attitude, might be helpful.^2,3 We believe that the adaptation of such a model through the prism of residents’ benefit will lead to better satisfaction among trainees.

On the other hand, we note that the nature of the study might have exaggerated patient satisfaction when compared with real-world surveys.⁴ The survey appears to focus only on attending rounds and did not consider other factors like hospitality, pain control, etc. A low patient census and lack of double blinding are other potential factors.

In conclusion, we want to congratulate the authors for raising this important topic and showing positive patients’ satisfaction with standardized rounds on teaching services. Further research should focus on improving residents’ satisfaction without compromising patients’ experiences.