Chloride-Liberal versus Chloride-Restrictive Intravenous Fluid Administration and Acute Kidney Injury: An Extended Analysis
A comparison of chloride-liberal and chloride-restrictive intravenous fluid administration on acute kidney injury in adult intensive care unit patients
Austin Health
3,000 participants
Aug 18, 2007
Interventional
Conditions
Summary
Intravenous fluid therapy may influence outcomes in critically ill patients. Some of these outcomes have been linked to the contents of intravenous fluids, including colloid source and electrolyte compositions. The chloride content of intravenous fluids has recently emerged as an area of interest in terms of renal injury. For example, a double-blind randomized controlled trial in healthy volunteers showed significantly better renal cortical tissue perfusion following a 2L infusion of a low-chloride fluid (Plasma-Lyte-Registered Trade Mark) compared with a high-chloride fluid (0.9% saline) (Chowdhury et al 2012). Similar effects were seen with the administration of hydroxyethyl starch (HES) in a low chloride solution compared to HES in saline (Chowdhury et al 2014). These studies suggest that excess chloride administration may modulate renal perfusion in man. However, the clinical implications of reducing chloride administration remain poorly understood. We previously reported the findings of a before-and-after study of restrictive vs. liberal intravenous chloride administration in a tertiary intensive care unit (ICU). Although our study found a beneficial renal effect of restricting chloride administration, it was suggested that a Hawthorne effect induced by preparation and education for the before-and-after study may have accounted for the findings . Accordingly, to mitigate the impact of such a putative Hawthorne effect, we extended the control and the intervention periods of our study from 6 months to 1 year to include a longer control period and an intervention period when the most common prescribers (ICU residents and fellows) had not received any specific training and simply rotated through the ICU when only low chloride fluids were available. We hypothesize that extending the study period will not affect our earlier finding of decreased incidence of acute kidney injury with chloride-restrictive intravenous fluid strategy compared with chloride-liberal strategy.
Eligibility
Inclusion Criteria2
- All consecutive ICU admissions for the 1 year control period from 18 August 2007 through 17 August 2008.
- All consecutive ICU admissions for the 1 year intervention period from 18 February 2009 through 17 February 2010.
Exclusion Criteria1
- No exclusion criteria to this study because intravenous fluids were part of standard patient care in the ICU.
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Interventions
This is an extended analysis of an earlier study, Chloride High Level of Resuscitation Infusion Delivered Evaluation (CHLORIDE), registered with the ClinicalTrials.gov; NCT 00885404. The study was conducted in the 22-bed multidisciplinary ICU of the Austin Hospital, Heidelberg, Victoria. In the original prospective sequential study, the sequence consisted of a 6 month control period followed by a 6 month 'washout' period that included staff education and a 6 month intervention period. During the intervention period, ICU clinicians were not allowed to use chloride-rich fluids - 0.9% saline, Gelofusine, or Albumex 4 (4% albumin) - in their routine practice. In replacement, they were encouraged to use existing lower chloride fluids - Hartmann’s solution, Plasma-Lyte 148, and Albumex 20. However, chloride-rich fluids were allowed under exclusive and specific prescription by an ICU specialist for conditions which might be considered likely to benefit from their use (e.g., hyponatremia, cerebral edema, marked hypochloremic alkalosis). Adherence to the intervention was ensured through close coordination with the Pharmacy Unit. The Unit strictly supplied only low-chloride intravenous fluids during the intervention period. The only high chloride solution bags available in the ICU during this period were stored in an ICU specialist's room, released after specific prescriptions described above. For this study, the chloride-restrictive intravenous fluid intervention had been maintained in the same ICU for the subsequent 6 months, extending the intervention period to 1 year. We now have a longer intervention period when the most common prescribers (ICU residents and fellows) had not received any specific training and simply rotated through the ICU when only low chloride fluids were available.
Locations(1)
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ACTRN12614000866606