title: Impact of intravenous fluid composition on outcomes in patients with systemic inflammatory response syndrome.
abstract: BACKGROUND
  Intravenous (IV) fluids may be associated with complications not often attributed to fluid type. Fluids with high chloride concentrations such as 0.9 % saline have been associated with adverse outcomes in surgery and critical care. Understanding the association between fluid type and outcomes in general hospitalized patients may inform selection of fluid type in clinical practice. We sought to determine if the type of IV fluid administered to patients with systemic inflammatory response syndrome (SIRS) is associated with outcome.
  
  
  METHODS
  This was a propensity-matched cohort study in hospitalized patients receiving at least 500 mL IV crystalloid within 48 hours of SIRS. Patient data was extracted from a large multi-hospital electronic health record database between January 1, 2009, and March 31, 2013. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay, readmission, and complications measured by ICD-9 coding and clinical definitions. Outcomes were adjusted for illness severity using the Acute Physiology Score. Of the 91,069 patients meeting inclusion criteria, 89,363 (98%) received 0.9% saline whereas 1706 (2%) received a calcium-free balanced solution as the primary fluid.
  
  
  RESULTS
  There were 3116 well-matched patients, 1558 in each cohort. In comparison with the calcium-free balanced cohort, the saline cohort experienced greater in-hospital mortality (3.27% vs. 1.03%, P <0.001), length of stay (4.87 vs. 4.38 days, P = 0.016), frequency of readmission at 60 (13.54 vs. 10.91, P = 0.025) and 90 days (16.56 vs. 12.58, P = 0.002) and frequency of cardiac, infectious, and coagulopathy complications (all P < 0.002). Outcomes were defined by administrative coding and clinically were internally consistent. Patients in the saline cohort received more chloride and had electrolyte abnormalities requiring replacement more frequently (P < 0.001). No differences were found in acute renal failure.
  
  
  CONCLUSIONS
  In this large electronic health record, the predominant use of 0.9% saline in patients with SIRS was associated with significantly greater morbidity and mortality compared with predominant use of balanced fluids. The signal is consistent with that reported previously in perioperative and critical care patients. Given the large population of hospitalized patients receiving IV fluids, these differences may confer treatment implications and warrant corroboration via large clinical trials.
  
  
  BACKGROUND
  NCT02083198 clinicaltrials.gov; March 5, 2014.
authors.affiliation: Dept of Anesthesiology, Vanderbilt University Medical Center, 1215 21st Avenue S., Suite 5160 MCE NT, Office 5163, Campus Box 8274, Nashville, TN, 37232-8274, USA. andrew.shaw@vanderbilt.edu.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Shaw
authors.affiliation: Former Employee Baxter Healthcare Corporation, 1 Baxter Parkway, Deerfield, IL, 60015, USA. cschermer@sbcglobal.net.
authors.forename: Carol R
authors.initials: CR
authors.lastname: Schermer
authors.affiliation: Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK. dileep.lobo@nottingham.ac.uk.
authors.forename: Dileep N
authors.initials: DN
authors.lastname: Lobo
authors.affiliation: Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA. sibyl.munson@bostonsp.com.
authors.forename: Sibyl H
authors.initials: SH
authors.lastname: Munson
authors.affiliation: Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA. victor.khangulov@bostonsp.com.
authors.forename: Victor
authors.initials: V
authors.lastname: Khangulov
authors.affiliation: Boston Strategic Partners, Inc., 4 Wellington Street, Boston, MA, 02118, USA. david.hayashida@bostonsp.com.
authors.forename: David K
authors.initials: DK
authors.lastname: Hayashida
authors.affiliation: Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA. kellumja@ccm.upmc.edu.
authors.forename: John A
authors.initials: JA
authors.lastname: Kellum
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007262:Infusions, Intravenous; D007552:Isotonic Solutions / Q000627:therapeutic use; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D018746:Systemic Inflammatory Response Syndrome / Q000628:therapy*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions