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November 2015: Balanced Fluid Resuscitation in Sepsis

This month we welcome our EM colleagues from Naval Medical Portsmouth for a joint JC. About a week ago, I received an e-mail from one of our faculty (thanks MK!) who was attending ACEP. He stated that ‘balanced fluid resuscitation’ in sepsis was receiving a lot of attention and might be a good JC topic. I recalled seeing something in EP Monthly but otherwise missed the topic. A little research brought me to a brief ACEP point-counter-point as well as the excellent resident blog Everyday E(B)M at Wash U. A Pub-Med search led me to our included articles and a link to a recent meta-analysis not included. Two articles are retrospective so I have included an EBM read on how to properly assess articles based upon chart reviews. Finally, a brief essay in JAMA from John Ioannidis a true pioneer. Dr. Ioannidis in 2005, shook the medical community with what is still the most cited and downloaded article in the history of PLOS.  If you don’t know his work, The Atlantic did a great article a few years ago that is worth the read. He gives us a lot to think about. Should make for an interesting JC.  As always, free to tweet your perspective

P: In patients with evidence of sepsis requiring fluid resuscitation

I: Does the use of balanced fluid resuscitation

C: Compared to 0.9% normal saline alone

O: Improve patient centered outcomes (morbidity, mortality)

Tzavaras: Worster A, Hines Advanced statistics: understanding medical record review (MRR) studies. Acad Emerg Med. 2004 Feb;11(2):187-92.

Fellin: Young P et al. 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. 2015 Oct 27;314(16):1701-10

Jennings: Raghunathan et al. Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis. Crit Care Med. 2014 Jul;42(7):1585-91.

Navy : Raghunathan K et al. Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock. Anesthesiology. 2015 Sep 28.

Navy:  Yunos NM et al. 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. 

All: Ioannidis JP Is It Possible to Recognize a Major Scientific Discovery? JAMA. 2015 Sep 15