title: Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis*.
abstract: OBJECTIVE
  Isotonic saline is the most commonly used crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer's solution may be preferable. We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis.
  
  
  METHODS
  A retrospective cohort study of patients admitted with sepsis, not undergoing any surgical procedures, and treated in an ICU by hospital day 2. We used propensity score matching to control for confounding and compared the following outcomes after resuscitation with balanced versus with no-balanced fluids: in-hospital mortality, acute renal failure with and without dialysis, and hospital and ICU lengths of stay. We also estimated the dose-response relationship between receipt of increasing proportions of balanced fluids and in-hospital mortality.
  
  
  METHODS
  Three hundred sixty U.S. hospitals that were members of the Premier Healthcare alliance between November 2005 and December 2010.
  
  
  METHODS
  A total of 53,448 patients with sepsis, treated with vasopressors and crystalloids in an ICU by hospital day 2 including 3,396 (6.4%) that received balanced fluids.
  
  
  METHODS
  None.
  
  
  RESULTS
  Patients treated with balanced fluids were younger and less likely to have heart or chronic renal failure, but they were more likely to receive mechanical ventilation, invasive monitoring, colloids, steroids, and larger crystalloid volumes (median 7 vs 5 L). Among 6,730 patients in a propensity-matched cohort, receipt of balanced fluids was associated with lower in-hospital mortality (19.6% vs 22.8%; relative risk, 0.86; 95% CI, 0.78, 0.94). Mortality was progressively lower among patients receiving larger proportions of balanced fluids. There were no significant differences in the prevalence of acute renal failure (with and without dialysis) or in-hospital and ICU lengths of stay.
  
  
  CONCLUSIONS
  Among critically ill adults with sepsis, resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. If confirmed in randomized trials, this finding could have significant public health implications, as crystalloid resuscitation is nearly universal in sepsis.
authors.affiliation: 1Depawwrtment of Anesthesiology, Duke University Medical Center, Durham, NC. 2Durham VA Medical Center, Durham, NC. 3OptiStatim LLC, Longmeadow, MA. 4Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC. 5Department of Medicine, Baystate Medical Center, Springfield, MA. 6Department of Medicine, Duke University School of Medicine, Durham, NC. 7Center for Quality of Care Research and Department of Medicine, Baystate Medical Center and Tufts University School of Medicine, Springfield, MA.
authors.forename: Karthik
authors.initials: K
authors.lastname: Raghunathan
authors.forename: Andrew
authors.initials: A
authors.lastname: Shaw
authors.forename: Brian
authors.initials: B
authors.lastname: Nathanson
authors.forename: Til
authors.initials: T
authors.lastname: Stürmer
authors.forename: Alan
authors.initials: A
authors.lastname: Brookhart
authors.forename: Mihaela S
authors.initials: MS
authors.lastname: Stefan
authors.forename: Soko
authors.initials: S
authors.lastname: Setoguchi
authors.forename: Chris
authors.initials: C
authors.lastname: Beadles
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology; D000367:Age Factors; D015897:Comorbidity; D016638:Critical Illness / Q000628:therapy*; D000077324:Crystalloid Solutions; D004305:Dose-Response Relationship, Drug; D005440:Fluid Therapy / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D007552:Isotonic Solutions / Q000008:administration & dosage* / Q000627:therapeutic use; D007902:Length of Stay; D057216:Propensity Score; D015532:Rehydration Solutions / Q000627:therapeutic use; D012121:Respiration, Artificial; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D000077325:Ringer's Lactate; D018805:Sepsis / Q000453:epidemiology / Q000628:therapy*
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D015532:Rehydration Solutions; D000077325:Ringer's Lactate