Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial

Brown RM, Wang L, Coston TD, et al. Am J Respir Crit Care Med. 2019 Aug 27. [CrossRef] [PubMed]

Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown. The authors compared the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis. Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical intensive care unit with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality, compared with 255 patients (31.2%) in the saline group (adjusted odds ratio, 0.74; 95% confidence interval, 0.59 - 0.93; P = 0.01) but the 60-day mortality did not significantly differ (aOR 0.80 [0.64 to 1.01]). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%; aOR 0.78; 95% CI 0.63 - 0.97) and a greater number of vasopressor-free days (20 ± 12 vs 19 ± 13; aOR 1.25; 95% CI 1.02 - 1.54) and renal replacement therapy-free days (20 ± 12 vs 19 ± 13; aOR 1.35 [1.08 - 1.69]), compared to the saline group. The authors conclude that amongst patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared to use of saline. The article is accompanied by a thoughtful editorial authored by Paul Young.