Skip to main content

Advertisement

SpringerLink
Log in

Effect of a single small volume fluid bolus with balanced or un-balanced fluids on chloride and acid–base status: a prospective randomized pilot study (the FLURES-trial)

  • Original Article
  • Published:
Journal of Nephrology Aims and scope Submit manuscript

Abstract

Objective

To compare the short-term effects on acid base, electrolyte status and urine output of a single fluid bolus of saline to that of the balanced solution Plasmalyte® in critically ill patients.

Methods

Prospective, randomized, controlled trial. Adult patients (≥ 18 years) admitted to the ICU receiving a fluid bolus were randomized to receive 1 L of saline (NaCl 0.9%, Baxter) or a balanced fluid [Plasmalyte® (Baxter)]. Blood samples and urine output were collected just before (T0), just after (T1), 2 h after (T2) (only for urinary output) and three hours after termination of the fluid bolus (T4). The effect of fluid boluses on serum chloride, apparent strong ion difference, base excess, urinary output and blood pressure or vasopressor need were analyzed.

Main results

Patients who received a 1 L saline fluid bolus had a significant increase in serum chloride (1.60; 95% CI 1.10 to 2.10; P < 0.001) and short-term decrease in apparent strong ion difference (− 1.85; 95% CI − 2.71 to − 0.99; P < 0.001) and base excess (− 0.90; 95% CI − 1.31 to − 0.50; P < 0.001). We observed a 17% increase in patients developing hyperchloremia in the saline group (0.17; 95% CI 0.05 to 0.29; P = 0.005). No significant difference in urinary output, blood pressure or vasopressor need was observed in either group.

Conclusion

Even a single, small bolus of saline, administered to critically ill patients, causes a significant increase in chloride concentration and a decrease in apparent strong ion difference and base excess, and an increase in the number of patients developing hyperchloremia. No difference in effect on urinary output, blood pressure or vasopressor need was observed between the two groups.

EudraCT number

2014-001005-41; date of registration: 28/10/2014.

Local EC approval

EC project number 2014/038.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AG:

anion gap

AGadj :

anion gap adjusted

AKI:

acute kidney injury

BE:

base excess

BMI:

body mass index

CI:

confidence interval

EC:

ethical committee

GEE:

generalized estimating equations

ICU:

intensive care unit

IQR:

interquartile range

KRT:

kidney replacement therapy

MAP:

mean arterial pressure

SBE:

standard base excess

SIDa:

strong ion difference apparent

SIDe:

strong ion difference effective

SIG:

strong ion gap

VIS:

vasopressor-inotropic score

References

  1. Hammond NE, Taylor C, Saxena M et al (2015) Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med 41:1611–1619. https://doi.org/10.1007/s00134-015-3878-y

    Article  CAS  PubMed  Google Scholar 

  2. Glassford NJ, Mårtensson J, Eastwood GM et al (2016) Defining the characteristics and expectations of fluid bolus therapy: a worldwide perspective. J Crit Care 35:126–132. https://doi.org/10.1016/j.jcrc.2016.05.017

    Article  PubMed  Google Scholar 

  3. Wilcox CS (1983) Regulation of renal blood flow by plasma chloride. J Clin Invest 71:726–735

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Zhou F, Peng Z-Y, Bishop JV et al (2014) Effects of fluid resuscitation with 0.9% saline versus a balanced electrolyte solution on acute kidney injury in a rat model of sepsis*. Crit Care Med 42:e270-278. https://doi.org/10.1097/CCM.0000000000000145

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Chowdhury AH, Cox EF, Francis ST, Lobo DN (2012) A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 256:18–24. https://doi.org/10.1097/SLA.0b013e318256be72

    Article  PubMed  Google Scholar 

  6. Sadan O, Singbartl K, Kandiah PA et al (2017) Hyperchloremia is associated with acute kidney injury in patients with subarachnoid hemorrhage. Crit Care Med 45:1382–1388. https://doi.org/10.1097/CCM.0000000000002497

    Article  CAS  PubMed  Google Scholar 

  7. Krajewski ML, Raghunathan K, Paluszkiewicz SM et al (2015) Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg 102:24–36. https://doi.org/10.1002/bjs.9651

    Article  CAS  PubMed  Google Scholar 

  8. Yunos NM, Bellomo R, Glassford N et al (2015) Chloride-liberal vs. chloride-restrictive intravenous fluid administration and acute kidney injury: an extended analysis. Intensive Care Med 41:257–264. https://doi.org/10.1007/s00134-014-3593-0

    Article  CAS  PubMed  Google Scholar 

  9. Semler MW, Self WH, Wanderer JP et al (2018) Balanced crystalloids versus saline in critically ill adults. N Engl J Med 378:829–839. https://doi.org/10.1056/NEJMoa1711584

    Article  PubMed  PubMed Central  Google Scholar 

  10. Semler MW, Wanderer JP, Ehrenfeld JM et al (2017) Balanced crystalloids versus saline in the intensive care unit. The SALT randomized trial. Am J Respir Crit Care Med 195:1362–1372. https://doi.org/10.1164/rccm.201607-1345OC

    Article  PubMed  PubMed Central  Google Scholar 

  11. Zampieri FG, Machado FR, Biondi RS et al (2021) Effect of intravenous fluid treatment with a balanced solution vs 0.9% saline solution on mortality in critically ill patients: the BaSICS randomized clinical trial. JAMA 326:818–829. https://doi.org/10.1001/jama.2021.11684

    Article  CAS  Google Scholar 

  12. Finfer S, Micallef S, Hammond N et al (2022) Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med 386:815–826. https://doi.org/10.1056/NEJMoa2114464

    Article  CAS  PubMed  Google Scholar 

  13. Self WH, Semler MW, Wanderer JP et al (2018) Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med 378:819–828. https://doi.org/10.1056/NEJMoa1711586

    Article  PubMed  PubMed Central  Google Scholar 

  14. Young P, Bailey M, Beasley R et al (2015) Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial. JAMA 314:1701–1710. https://doi.org/10.1001/jama.2015.12334

    Article  CAS  PubMed  Google Scholar 

  15. Hammond NE, Zampieri FG, Di TGL et al (2022) Balanced crystalloids versus saline in critically ill adults—a systematic review with meta-analysis. NEJM Evid. https://doi.org/10.1056/EVIDoa2100010

    Article  PubMed  Google Scholar 

  16. Hoste EA, Maitland K, Brudney CS et al (2014) Four phases of intravenous fluid therapy: a conceptual model. BJA Br J Anaesth 113:740–747. https://doi.org/10.1093/bja/aeu300

    Article  PubMed  Google Scholar 

  17. Kellum JA, Kramer DJ, Pinsky MR (1995) Strong ion gap: a methodology for exploring unexplained anions. J Crit Care 10:51–55. https://doi.org/10.1016/0883-9441(95)90016-0

    Article  CAS  PubMed  Google Scholar 

  18. Neyra JA, Canepa-Escaro F, Li X et al (2015) Association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med 43:1938–1944. https://doi.org/10.1097/CCM.0000000000001161

    Article  PubMed  PubMed Central  Google Scholar 

  19. Gaies MG, Gurney JG, Yen AH et al (2010) Vasoactive–inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass*. Pediatr Crit Care Med 11:234–238. https://doi.org/10.1097/PCC.0b013e3181b806fc

    Article  PubMed  Google Scholar 

  20. Oliveira RAG, Mendes PV, Park M, Taniguchi LU (2019) Factors associated with renal Doppler resistive index in critically ill patients: a prospective cohort study. Ann Intensive Care 9:23. https://doi.org/10.1186/s13613-019-0500-4

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kim SY, Huh KH, Lee JR et al (2013) Comparison of the effects of normal saline versus Plasmalyte on acid-base balance during living donor kidney transplantation using the Stewart and base excess methods. Transplant Proc 45:2191–2196. https://doi.org/10.1016/j.transproceed.2013.02.124

    Article  CAS  PubMed  Google Scholar 

  22. Barhight MF, Brinton J, Stidham T et al (2018) Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med 44:2183–2191. https://doi.org/10.1007/s00134-018-5424-1

    Article  CAS  PubMed  Google Scholar 

  23. Commereuc M, Nevoret C, Radermacher P et al (2019) Hyperchloremia is not associated with AKI or death in septic shock patients: results of a post hoc analysis of the “HYPER2S” trial. Ann Intensive Care 9:95. https://doi.org/10.1186/s13613-019-0570-3

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Messina A, Bakker J, Chew M et al (2022) Pathophysiology of fluid administration in critically ill patients. Intensive Care Med Exp 10:46. https://doi.org/10.1186/s40635-022-00473-4

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

No funding.

Author information

Authors and Affiliations

  1. Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium

    M. Raes, M. Crivits, F. Viaene, M. Hemeryck, D. Benoit & E. Hoste

  2. Department of Anesthesiology, Brussels University Hospital, Brussels, Belgium

    M. Raes

  3. Department of Intensive Care, Brussels University Hospital, Brussels, Belgium

    M. Raes & J. Poelaert

  4. Division of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    J. A. Kellum

  5. Biostatistics Unit, University of Ghent, Ghent, Belgium

    R. Colman & S. Wallaert

  6. Department of Anesthesiology, AZ Alma, Eeklo, Belgium

    M. Crivits

  7. Department of Anesthesiology, AZ Sint-Lucas, Ghent, Belgium

    F. Viaene

  8. Department of Anesthesiology, AZ Sint-Elisabeth, Zottegem, Belgium

    M. Hemeryck

  9. Research Foundation-Flanders, Brussels, Belgium

    E. Hoste

Authors
  1. M. Raes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. A. Kellum
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Colman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. Wallaert
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Crivits
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. F. Viaene
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. Hemeryck
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. D. Benoit
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. J. Poelaert
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. E. Hoste
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MR, JK and EH analyzed and interpreted the data obtained for this study and wrote the main manuscript. RC and SW performed the statistical analyses. All authors read and approved the final manuscript.

Corresponding author

Correspondence to M. Raes.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval and consent to participate

The study design and informed consent forms were reviewed and approved by the local ethical committee of the University Hospital of Ghent, Belgium (EC project number 2014/038). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Before inclusion, written consent was obtained from the patient and/or legal representative.

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Raes, M., Kellum, J.A., Colman, R. et al. Effect of a single small volume fluid bolus with balanced or un-balanced fluids on chloride and acid–base status: a prospective randomized pilot study (the FLURES-trial). J Nephrol (2024). https://doi.org/10.1007/s40620-024-01912-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40620-024-01912-z

Keywords

Search

Navigation