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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 249 - 253
Comparison Of Normal Saline and Multielectrolyte Solution in Critically Ill Patients
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1
Assistant Professor, department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar. India.
2
Professor& Head, department of Emergency Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar. India
3
Professor, department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar. India
4
Professor and head, department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar, India
Under a Creative Commons license
Open Access
Received
Nov. 25, 2024
Revised
Dec. 5, 2024
Accepted
Dec. 23, 2024
Published
Jan. 19, 2025
Abstract

Background: Fluid resuscitation is a critical component of care for critically ill patients, with the choice of resuscitation fluids significantly impacting patient outcomes. Normal Saline (NS) and Multielectrolyte Solution (MES) are widely used crystalloid fluids, but their comparative efficacy in terms of renal function, acid-base balance, and hemodynamic stability remains controversial. Objectives: This study aimed to compare NS and MES in critically ill patients undergoing major surgery, focusing on primary outcomes such as blood gas levels and hemodynamic stability, and secondary outcomes including renal function and chloride balance. Methods: This prospective cohort study, conducted in a tertiary care ICU, included 100 patients randomized into two groups: Group A (NS) and Group B (MES). Preoperative, intraoperative, and postoperative data were recorded, and the primary outcome was renal function assessed via serum creatinine levels. Secondary outcomes included arterial blood gas (ABG) pH, serum chloride, and hemodynamic parameters over 7 days. Results: Both groups had similar baseline characteristics, with a median treatment duration of 6.5 days. The MES group showed significantly higher arterial blood pH and lower serum chloride levels compared to the NS group, suggesting superior acid-base and chloride balance. Both groups demonstrated comparable improvements in renal function and hemodynamic stability. Serum creatinine, hemoglobin, lactate, and potassium levels did not differ significantly between groups. Conclusion: Both NS and MES are effective in managing critically ill patients, but MES offers advantages in maintaining acid-base stability and a balanced chloride profile. These findings suggest MES may be the preferred option in cases where acidosis or hyperchloremia is a concern. Further research is warranted to explore the long-term clinical implications of these differences.

Keywords
INTRODUCTION

Fluid resuscitation for hypovolaemia is a mainstay of the medical management of critically ill patients, whether as a result of trauma, burns, major surgery or sepsis. The selection and use of resuscitation fluids may affect the outcome of patients.1,2Although some studies have suggested that the timing of volume replacement deserves careful consideration, when it comes to selecting the resuscitation fluid, clinicians are faced with a range of options.3 At one level the choice is between a colloid or crystalloid solution. Colloids are widely used, having been recommended in a number of resuscitation guidelines and intensive care management algorithms.4

 

Crystalloids are low‐cost salt solutions (e.g. saline) with small molecules, which can move around easily when injected into the body.Colloids can be man‐made (e.g. starches, dextrans, or gelatins), or naturally occurring (e.g. albumin or fresh frozen plasma (FFP)), and have bigger molecules, so stay in the blood for longer before passing to other parts of the body. Colloids are more expensive than crystalloids.5

 

Saline is the most widely used and readily available liquid in clinical practice. Despite being referred to as “normal” saline, it contains a higher chloride concentration and lacks bicarbonate than the plasma.6Data suggests that intravenous saline may be associated with hyperchloremic metabolic acidosis, acute kidney injury, and death.7-10 Crystalloid solutions with electrolyte compositions closer to that of plasma (balanced crystalloids, such as lactated Ringer’s solution or Plasma-Lyte A) represent an increasingly used alternative to saline.11 Several observational studies and a before-and-after trial suggested that the use of balanced crystalloids is associated with lower rates of acute kidney injury, renal-replacement therapy, and death.12,13

 

The comparison of multiple electrolyte solution and normal saline in critically ill patients is still controversial. It is uncertain which is better at reducing mortality, need for blood transfusion or need for renal replacement therapy when given to critically ill people who need fluid replacement.Therefore, we planned to conduct this study to investigate the safety of multiple electrolyte solution and saline among critical ill patients. 

 

AIMS AND OBJECTIVES

The aim of this study is to compare normal saline with multiple balanced electrolyte solutions in critically ill patients undergoing exploratory laparotomy. The primary objectives are to evaluate blood gas levels and hemodynamic stability, while the secondary objectives include assessing organ dysfunction and morbidity by measuring serum creatinine, serum bilirubin, and the P/F ratio.

MATERIALS AND METHODS

This prospective cohort study was conducted in a tertiary care ICU in North India over a duration of 9 months, from July 2023 to March 2024, including data collection, organization, presentation, analysis, and interpretation. A total of 80 patients were enrolled and randomly assigned into two groups: Group A received fluid resuscitation with normal saline, and Group B received fluid resuscitation with a multiple electrolyte solution.

 

Inclusion criteria: Patients aged 18 years or older undergoing major surgery at our institution are eligible for inclusion. Major surgery is defined as any procedure lasting more than two hours, involving a surgical incision, and requiring at least one night of postoperative stay.

Exclusion criteria: Patients undergoing renal or liver transplantation, those classified as American Society of Anesthesiology Class 5, patients requiring a second operation, and individuals not willing to provide consent are excluded from the study.

 

Methodology-

The study was initiated after obtaining ethics committee approval and written informed consent from the patients. Preoperative data, including demographics, detailed medical history, preoperative biochemistry, and comorbidities, were recorded using a predesigned proforma. Intraoperative measurements such as the duration of surgery, surgical urgency, type of surgery, and volume of fluid administered were documented. The primary efficacy outcome was the proportion of patients with changes in renal function, assessed by creatinine concentration during their hospital stay. Other outcome measures, including length of hospital stay and adverse events, were also noted.

 

RESULTS

A total of 100 patients were randomized, with 50 assigned to the MES group and 50 to the saline group. Both groups had similar baseline characteristics. The average age of the patients was 57.9±11.5 years, with 40% being women, and the median APACHE II score was 18.5 in both groups. Of the total patients, 41.3% were admitted to the ICU directly from the operating room, the majority were on mechanical ventilation, and 45.3% had sepsis. Within 24 hours, both groups received comparable amounts and types of intravenous fluids.

 

The median treatment duration with the assigned trial fluid was 6.5 days (interquartile range: 3.0–10.0) for both groups. The median volume of trial fluid administered was 3.9 liters (interquartile range: 2.0–6.7) in the MES group and 3.7 liters (interquartile range: 2.0–6.3) in the saline group. Over the first 7 days, there were no significant differences between the groups in daily mean heart rate, mean arterial pressure, or mean central venous pressure. However, arterial blood pH was significantly higher and serum chloride levels significantly lower in the MES group compared to the saline group (Figs. 2 & 3). Serum creatinine levels (Fig. 1), as well as hemoglobin, lactate, and potassium levels, did not show significant differences between the groups.

 

Figure 2: Comparison of Serum Creatinine Levels Over 7 Days in Critical Patients Treated with NS) and MES

 

 

Figure 3: Comparison of Serum Chloride Levels Over 7 Days in Critical Patients Treated with NS & MES

Figure 4: Comparison of ABG-pH Levels Over 7 Days in Critical Patients Treated with NS & MES.

DISCUSSION

This study compared the effects of NS and MES in critically ill patients, focusing on fluid management, renal function, acid-base balance, and chloride levels. Both groups exhibited comparable baseline characteristics, including age, gender distribution, and illness severity, as reflected by the APACHE II scores. Over the median treatment duration of 6.5 days, both groups received similar fluid volumes and types, demonstrating effective fluid and renal management. However, MES showed notable advantages in maintaining acid-base balance and chloride levels.

 

Patients in the MES group had significantly higher arterial blood pH levels throughout the 7-day period, indicating better correction of acidosis compared to NS. This finding aligns with the SMART trial, which reported reduced metabolic acidosis and kidney-related complications with balanced crystalloids.14 Moreover, the MES group exhibited consistently lower serum chloride levels, suggesting that MES reduces the risk of hyperchloremia, a complication associated with saline use. This observation is consistent with results from the SPLIT trial, which highlighted hyperchloremia-related risks with saline,15and a meta-analysis by Raghunathan et al., which demonstrated reduced metabolic acidosis with balanced solutions.9

 

Renal function, measured by serum creatinine levels, improved similarly in both groups by the end of the study period, consistent with findings from the SALT-ED trial, which showed no significant differences in renal outcomes between balanced crystalloids and saline.16 However, the physiological benefits of MES in maintaining electrolyte and acid-base balance were more evident. Reviews by Myburgh and Mythen17 and Kellum and Lameire18 emphasize that hyperchloremia caused by saline can impair renal perfusion and exacerbate acidosis, further supporting the use of MES in critically ill patients.

 

These findings highlight the potential advantages of MES, particularly in preventing hyperchloremia and maintaining acid-base balance, which are critical for recovery in critically ill patients. Future studies are warranted to evaluate the long-term impact of these findings on morbidity and mortality.

CONCLUSION

In conclusion both NS and MES are effective in fluid management and supporting renal function in critically ill patients. However, MES demonstrates notable advantages, including superior correction of acidosis and maintaining a more stable chloride balance, making it a preferable option in situations where acid-base stability and chloride management are critical. While both solutions achieve comparable long-term outcomes, the enhanced acid-base and electrolyte balance observed with MES suggests its potential to improve patient care in critical settings. Further studies are warranted to explore the broader clinical implications of these findings.

REFERENCES
  1. Myburgh JA, Mythen MG. Resuscitation fluids. New Engl J Med. 2013;369(13):1243–51.
  2. Semler MW, Kellum JA. Balanced crystalloid solutions. Am J Respir Crit Care Med. 2019;199(8):952–60.
  3. Bickell WH, Wall MJ, Pepe PE, Martin R, Ginger VF, Allen MK, et al. Immediate versus delayed resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine 1994;331:1105‐9.
  4. Vermeulen LC, Ratko TA, Erstad BL, Brecher ME, Matuszewski KA. A paradigm for consensus. The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. Archives of Internal Medicine 1995;155(4):373‐9.
  5. Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;8(8):CD000567. 
  6. Reddy S, Weinberg L, Young P. Crystalloid fluid therapy. Crit Care. 2016 Mar 15;20:59. 
  7. Yunos NM, Kim IB, Bellomo R, Bailey M, Ho L, Story D, Gutteridge GA, Hart GK. The biochemical effects of restricting chloride-rich fluids in intensive care. Crit Care Med. 2011 Nov;39(11):2419-24.
  8. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. 2012;308:1566–72.
  1. Raghunathan K, Murray PT, Beattie WS, Lobo DN, Myburgh J, Sladen R, et al; ADQI XII Investigators Group. Choice of fluid in acute illness: what should be given? An international consensus. Br J Anaesth. 2014 Nov;113(5):772-83.
  1. Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014 Sep 2;161(5):347-55. 
  2. Hammond NE, Taylor C, Finfer S, Machado FR, An Y, Billot L, et al. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study. PLoS One. 2017 May 12;12(5):e0176292. 
  3. Shaw AD, Raghunathan K, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR. Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med. 2014 Dec;40(12):1897-905. 
  4. Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012 May;255(5):821-9. 
  5. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW; SMART Investigators and the Pragmatic Critical Care Research Group. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):829-839.
  6. Young P, Bailey M, Beasley R, et al. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the ICU: The SPLIT Randomized Clinical Trial. JAMA. 2015;314(16):1701-1710.
  7. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828.
  8. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243-1251.
  9. Kellum JA, Lameire N. Effects of hyperchloremia and acidosis on kidney function. Curr Opin Crit Care. 2018;24(6):462-468.
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