This study explored fluid prescribing practices in intensive care – providing a picture of how fluid resuscitation is being managed internationally. They compared their data from 2014 with those of their previous study in 2007; they found that more crystalloids were being prescribed, particularly buffered salt solutions, while there were less colloids being given overall – semi-synthetic colloids had seen a large decrease, while albumin had seen a relative increase.
Fluid resuscitation is a common intervention in the intensive care unit (ICU) – with around a third of inpatients receiving intravenous fluid resuscitation each day. The authors of the current study conducted an investigation in 2007 to establish the fluid prescribing pattern of 391 ICUs across 25 countries. At that time, hydroxyethyl starch (HES) and ‘normal’ 0.9% saline solution were the most commonly administered colloid and crystalloid solutions respectively. Since that study, evidence has emerged demonstrating an increased risk of adverse events associated with some fluid types. The authors aimed to repeat their study and to contrast practice in 2014 with 2007 to determine what impact the pivotal evidence had generated.
The study followed a cross-sectional, prospective design; the participating departments were contacted with 10 potential dates. On their chosen date, there was a 24-hour period of data collection. Where there was a trend comparison between 2007 and 2014, only those departments participating in both studies were included. Patients over 16 years old who had at least one episode of fluid resuscitation were included; fluid resuscitation was classed as any bolus of fluid, any dose of colloid, or any infusion of crystalloid that was faster than 5 ml/kg/hour. Patient data were collected, as were data on which fluids were administered.
Participating departments included 426 ICUs from 27 countries worldwide. There were 6707 patients covered in that 24-hour period, during which 1456 received resuscitation fluid. There were a total of 2716 resuscitation events.
This saw significant geographical variation; crystalloid administration ranged from 50.8% to 95.4%, while colloid varied from 6.3% to 60.5%. The most widely used crystalloid fluids were buffered salt solutions, (58.0%; 1280/2208 crystalloid resuscitation events) followed by saline (40.6%; 897/2208 crystalloid resuscitation events).
When those units featuring in both 2007 and 2014 were reviewed, it was noted that the number receiving IV fluid resuscitation was similar, while patient characteristics were also similar. The proportion of patients receiving crystalloid increased significantly (45.5% in 2007, 74.3% in 2014; OR=2.98; 95% CI 2.02–4.40; p<0.001), and the overall number of episodes in which crystalloids were administered was higher in 2014 (42.7% in 2007, 72.3% in 2014; OR=3.75; 95% CI 2.95–4.77; p<0.001). The use of colloids also declined, the proportion of patients receiving colloid dropping from 74.0% in 2007 to 30.9% in 2014 (OR=0.27; 95% CI 0.22–0.35; p<0.001). The use of albumin as a proportion of administered colloid increased significantly (OR 8.86; 95% CI 5.87–13.70; p<0.001), while HES decreased significantly (OR=0.16; 95% CI 0.10–0.25; p<0.001). The biggest increase as a proportion of prescribed crystalloid was buffered salt solutions (OR=3.26; 95% CI 2.35–4.52; p<0.001), while saline use decreased significantly (OR=0.33; 95% CI 0.24–0.46; p<0.001).
The findings are consistent with the current literature – showing an increased use of buffered salt solutions, and crystalloid in general. Benefit from buffered salt solutions has largely been demonstrated through observational studies, while a randomised trial comparing buffered salt solutions with saline did not show any benefit relating to acute kidney injury, requirement for renal replacement therapy or in-hospital mortality – the study did only look at elective surgical patients admitted to ICU however. The decrease in use of semi-synthetic colloids is likely to be multifactorial, with the newer evidence base and pivotal randomised trials driving changes to licensing of these products. This has led to albumin becoming the predominant colloid – likely to be due to reduced HES usage, alongside evidence suggesting a benefit of albumin in severe sepsis. The authors mitigated selection bias for this study by only contrasting data from the same ICUs in 2014 as had provided data in 2007, and they prespecified the statistical analysis to avoid confounders. They did not account for availability of fluids, and some countries were under- or over-represented in the analysis.
This study provides a snapshot of changing practice, demonstrating the influence that newer evidence has had on the landscape of fluid prescription in intensive care.
Catch-up on the debate surrounding hydroxyethyl starch use as we take you on an interactive journey through its changing fortunes. Do you think current restrictions will be enough to change clinical practice?
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