##plugins.themes.bootstrap3.article.main##

Huah Chiang Ooi Chun Chiat Yeoh Aik Howe Teo Abdul Muhaimin Noor Azhar Sherene Tan Ying Ying Thum Kwanhathai Darin Wong Sasi Kumar Sappanie

Abstract

Background: Balanced fluids are preferred in initial resuscitation of septic patients based on several recent studies. The Stewart’s concept on acid-base balance predicts that high strong ion difference (SID) fluid thus will increase the pH level. To date, the impact of high SID fluid in septic patient with metabolic acidosis remains uncertain. We conducted a single center, randomized, double-blind trial to compare the effect of High-SID fluid vs Hartmann’s solution on acid-base status in selected sepsis patients in the Emergency Department.

Method: Septic patient with hyperlactatemia and metabolic acidosis were randomized to receive either High-SID fluid or Hartmann’s solution during initial fluid resuscitation. The primary outcome measures the pH and bicarbonate levels difference pre- and post-resuscitation.

Results: 162 patients underwent randomization, 81 were assigned each to receive High-SID fluid or Hartmann’s solution. Both groups had similar baseline characteristics. High-SID group received 23.5ml/kg and the Hartmann’s group received 22.7ml/kg (p=0.360). High-SID fluid increased the mean(±SD) pH by 0.107(±0.09) vs Hartmann’s solution by 0.014(±0.12), p=<0.001. Mean bicarbonate level increased significantly in High-SID group compared to Hartmann’s (4.30±3.76 vs 1.25±3.33; p=<0.001). High-SID group had higher post resuscitation lactate clearance than Hartmann’s group (25.4±28.3% vs 12±34.1%;p=0.009). Shorter hospital stay was observed in high-SID group 8.04±5.96days vs Hartmann’s group 12.18±12.41days (p=0.048). Both groups showed no difference in incidence of pulmonary oedema, acute kidney injury and mortality.

Conclusion: Initial resuscitation using high SID fluid in selected septic patient improves pH and bicarbonate levels. The High-SID group had better post resuscitation lactate clearance and shorter hospital stay.

##plugins.themes.bootstrap3.article.details##

Keywords

Strong Ion Difference, Sepsis, Fluid Resuscitation, Hyperlactataemia, Metabolic Acidosis, Septic Shock, Acid-Base, Randomised Control Trial, Hartmann Solution, pH, Crystalloid

References
1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2): 580-637.
2. Alena Lira and Michael R Pinsky. Choices in fluid type and volume during resuscitation: impact on patient outcomes. Annals of Intensive Care 2014, 4:38
3. Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynaecologic surgery. Anesthesiology. 1999;90:1265–1270
4. Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology, 1999
May;90(5): 1265-70
5. Gunnerson K.J. Clinical review: the meaning of acid-base ab-normalities in the intensive care unit part I - epidemiology. Crit Care, 2005. 9(5): 508-16.
6. Raghunathan K, Murray PT, Beattie WS, et al. Choice of fluid in acute illness: what should be given? An international consensus British Journal of Anaesthesia 113 (5): 772–
83 (2014)
7. Stewart PA. Independent and dependent variables of acid–base control. Respir Physiol 1978; 33: 9–26.
8. Grocott MPW, Mythen MG, Gan TJ. Perioperative fluid management
9. Bilkovskia RN, Rivers EP, Matilda Horst H. Targeted resuscitation strategies after injury. CurrOpinCrit Care. 2004;10(6): 529-538.
10. Johan Groeneveld AB, Polderman KH. Fluid resuscitation: the good, the bad and the ugly. Crit Care Shock. 2005;8(3):52-54.
11. Hakan Hasman, Orhan Cinar, Ahmet Uzun, Erdem Cevik, Loni Jay, Bilgin Comert. A Randomized Clinical Trial Comparing the Effect of Rapidly Infused Crystalloids on Acid-Base Status in Dehydrated Patients in the Emergency Department. Int. J. Med. Sci. 2012; 9(1):59-64
12. Hae-Young Kim. Statistical notes for clinical researchers: assessing normal distribution using skewness and kurtosis.
(http://dx.doi.org/10.5395/rde.2013.38.1.52)
13. Finfer S, Bellomo R, Boyce N, et al. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 350;22 may 27, 2004
14. Annane D, Siami S, Jabeer S, et al. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013;310(17):1809-1817.
15. Aileen Clarke, Pam Rowe, Nick Black. Does a shorter length of hospital stay affect the outcome and costs of hysterectomy in southern England Journal of Epidemiology and Community Health 1996;50:545-550
16. Caplan G, Board N, Paten A, et al. Decreasing Lengths of stay: The cost to the community. Aust. N.Z. J. Surg. (1998) 68, 433-437
17. Ali A. El-Solh, Philippe Abou Jaoude, Jahan Porhomayon. Bicarbonate therapy in the treatment of septic shock: a second look. Intern Emerg Med (2010) 5:341–347
18. Filho RR, Rocha LL, Correa TD, et al. Blood Lactate levels Cutoff and mortality prediction in sepsis- Time for a reappraisal? A retrospective cohort study. Shock, Vol 46, No. 5, pp. 480-485, 2016
19. H S Kiran, G D Anil, K A Sudharshana Murthy, H Basavana Gowdappa. Severe Metabolic Acidosis in Critically Ill Patients and Its Impact on the Outcome; A Prospective Observational Study. International Journal of Scientific Study Nov 2015, Vol 3, Issue 8, 168-171
20. Jung B, Rimmele T, Le Goff C, et al. Severe metabolic or mixed acidemia on intensive care unit admission: incidence, prognosis and administration of buffer therapy. A prospective, multiple-center study. Crit Care 2011;15:R238.
21. Anders Perner, Nicolai Haase, Anne B. Guttormsen, et al. Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis. NEJM 2012, 367;2
22. Cooper DJ, Walley KR, Wiggs BR, et al: Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study. Ann Intern Med 1990; 112:492–498
23. Mathieu D, Neviere R, Billard V, et al: Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med 1991; 19:1352–1356
24. Lee SM, Kim SE, Kim EB, Jeong HJ, Son YK, An WS. Lactate Clearance and Vasopressor Seem to Be Predictors for Mortality in Severe Sepsis Patients with Lactic Acidosis Supplementing Sodium Bicarbonate: A Retrospective Analysis. PLoS ONE 10(12): e0145181.
25. Zhi Xun Fang, Yu Feng Li, Xiao Qing Zhou et al. Effects of resuscitation with crystalloid fluids on cardiac function in patients with severe sepsis. BMC Infectious Diseases 2008,
8:50
26. Uniacke MD, Venkat-Raman G, Hewitt J. Sodium Bicarbonate Use in Acute Kidney Injury. American Journal of Kidney Diseases. Volume 61, Issue 3 , 523
27. Hewitt J, Unaiacke M, Hansi NK, Venkat-Raman G, McCarthy K. Sodium bicarbonate supplements for treating acute kidney injury. Cochrane Database Syst Rev. 2012 Jun
13;(6)
28. Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit. JAMA. 2015;314(16):1701-1710
29. Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and Plasmalyte 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 2012; 256: 18–24. Erratum Ann Surg2012; 258: 369
30. 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. JAMA. 2012 Oct 17;308(15):1566-72
Section
EMAS Meeting 2018 Abtracts