Saline versus 5% dextrose in water as a drug diluent for critically ill patients: a retrospective cohort study
Tóm tắt
The choice of intravenous infusion products for critically ill patients has been studied extensively because it can affect prognosis. However, there has been little research on drug diluents in this context. The purpose of this study is to evaluate the impact of diluent choice (saline or 5% dextrose in water [D5W]) on electrolyte abnormalities, blood glucose control, incidence of acute kidney injury (AKI), and mortality. This before-after, two-group comparative, retrospective study enrolled adult patients who stayed for more than 48 h in a general intensive care unit from July 2015 to December 2018. We changed the default diluent for intermittent drug sets in our electronic ordering system from D5W to saline at the end of 2016. We included 844 patients: 365 in the D5W period and 479 in the saline period. Drug diluents accounted for 21.4% of the total infusion volume. The incidences of hypernatremia and hyperchloremia were significantly greater in the saline group compared to the D5W group (hypernatremia 27.3% vs. 14.6%, p < 0.001; hyperchloremia 36.9 % vs. 20.4%, p < 0.001). Multivariate analyses confirmed the similar effects (hypernatremia adjusted odds ratio (OR), 2.43; 95% confidence interval (CI), 1.54–3.82; hyperchloremia adjusted OR, 2.09; 95% CI, 1.31–3.34). There was no significant difference in the incidences of hyperglycemia, AKI, and mortality between the two groups. Changing the diluent default from D5W to saline had no effect on blood glucose control and increased the incidences of hypernatremia and hyperchloremia.
Tài liệu tham khảo
Egi M, Bellomo R, Stachowski E, et al. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology. 2006;105:244–52.
Cecconi M, Hochrieser H, Chew M, European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology, et al. Preoperative abnormalities in serum sodium concentrations are associated with higher in-hospital mortality in patients undergoing major surgery. Br J Anaesth. 2016;116:63–9.
Boniatti MM, Cardoso PR, Castilho RK, et al. Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study. J Crit Care. 2011;26:175–9.
Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308:1566–72.
Semler MW, Self WH, Wanderer JP, et al. SMART Investigators and the Pragmatic Critical Care Research Group: Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378:829–39.
Magee CA, Bastin MLT, Laine ME, et al. Insidious harm of medication diluents as a contributor to cumulative volume and hyperchloremia: a prospective, open-label, sequential period pilot study. Crit Care Med. 2018;46:1217–23.
Choo WP, Groeneveld AB, Driessen RH, et al. Normal saline to dilute parenteral drugs and to keep catheters open is a major and preventable source of hypernatremia acquired in the intensive care unit. J Crit Care. 2014;29:390–4.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1–138.
Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991;100:1619–36.
American Diabetes Association. Standards of Medical Care in Diabetes-2019 abridged for primary care providers. Clin Diabetes. 2019;37:11–34.
Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40:3251–76.
Oksanen T, Skrifvars MB, Varpula T, et al. Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med. 2007;33:2093–100.
Finfer S, Liu B, Chittock DR, et al. NICE-SUGAR Study Investigators: Hypoglycemia and risk of death in critically ill patients. N Engl J Med. 2012;367:1108–18.
Ni HB, Hu XX, Huang XF, et al. Risk factors and outcomes in patients with hypernatremia and sepsis. Am J Med Sci. 2016;351:601–5.
Neyra JA, Canepa-Escaro F, Li X, et al. Acute Kidney Injury in Critical Illness Study Group: Association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med. 2015;43:1938–44.
Siew ED, Ikizler TA, Matheny ME, et al. Estimating baseline kidney function in hospitalized patients with impaired kidney function. Clin J Am Soc Nephrol. 2012;7:712–9.
Matsuo S, Imai E, Horio M, Collaborators developing the Japanese equation for estimated GFR, et al. Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis. 2009;53:982–92.
Waite MD, Fuhrman SA, Badawi O, et al. Intensive care unit-acquired hypernatremia is an independent predictor of increased mortality and length of stay. J Crit Care. 2013;28:405–12.
Kanda Y. Investigation of the freely-available easy-to-use software “EZR” (Easy R) for medical statistics. Bone Marrow Transplant. 2013;48:452–8. https://doi.org/10.1038/bmt.2012.244 Advance online publication 3 December 2012.
Krajewski ML, Raghunathan K, Paluszkiewicz SM, et al. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg. 2015;102:24–36.
McCluskey SA, Karkouti K, Wijeysundera D, et al. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg. 2013;117:412–21.