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Vol. 42. Num. 6.August - September 2018
Pages e13-e16Pages 327-396
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Vol. 42. Num. 6.August - September 2018
Pages e13-e16Pages 327-396
Letter to the Editor
DOI: 10.1016/j.medine.2018.05.009
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SMART: Is saline on the tightrope?
SMART: ¿está el suero salino en la cuerda floja?
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A. González-Castroa,
Corresponding author
e409@humv.es

Corresponding author.
, M. Ortiz-Lasaa, J. Bada Da Silvab
a Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
b Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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Dear Editor,
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Back in October 2015, the results from the SPLIT trial1 confirmed that the use of a balanced crystalloid solution as a resuscitation fluid in critically ill patients did not reduce the risk of developing acute renal failure compared to the use of a saline solution (SS). Contradicting important prior studies,2 those conclusions complicated a fundamental debate.

Two years later, October 2017, the results from the SMART trial were published: “Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial”.3

The SMART trial is a cluster-randomized, multiple-crossover trial that was conducted between July 1, 2015 and April 30, 2017 in 5 American ICUs of one single university hospital. Patients over 18, who had been admitted to 5 selected ICUs (medical, surgical, neurological, trauma, and cardiac), and who had been prescribed one IV crystalloid solution were included in the study. Same as the SPLIT trial, the SMART trial compared to use of a SS to a balanced crystalloid solution. The primary goal of the study was to determine the MAKE composite score (Major Adverse Kidney Events: intra-hospital death, renal replacement therapy, or renal dysfunction) within the first 30 days after the ICU admission (MAKE-30).4

The results presented, with 15,802 patients recruited, show that the outcome of MAKE-30 was present in 14.3% of patients from the group who received balanced SS compared to 15.4% of the patients from the second group (p=0.04), with a 0.91 adjusted odds ratio in favor of the balanced fluids (95% CI: 0.82–0.99). In this case, the difference between the arms was triggered by the hospital mortality rate (11.1 versus 10.3%; p=0.06).5

These findings, that are consistent with the different mortality rate seen in patients from the SPLIT trial (7.6 versus 8.6% in favor of the balanced solution), cannot be considered a casual finding.1,5

With the data presented from the SMART trial, the number of patients needed to treat (NNT) to save just one life would be 94. And even though this figure may be underestimated, it is really important to think about the impact that such a routine daily measure as picking up this or that resuscitation fluid can have on the costs and human lives here at our ICUs.

Also, balanced crystalloid solutions are more expensive. However, if we could use these fluids to avoid the occurrence of major adverse renal events, we would definitely find it cost-effective to use them, even if it wasn’t a short-term cost-effectiveness.

Conflict of interests

Dr. González-Castro, MD declares as a possible conflict of interest his job for Baxter.

This manuscript has received no funding whatsoever.

References
[1]
P. Young, M. Bailey, R. Beasley, S. Henderson, D. Mackle, C. McArthur, SPLIT Investigators; ANZICS CTG
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 (2015), pp. 1701-1710 http://dx.doi.org/10.1001/jama.2015.12334
[2]
N. Yunos, R. Bellomo, C. Hegarty, D. Story, L. Ho, M. Bailey
Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults
JAMA, 308 (2012), pp. 1566-1572 http://dx.doi.org/10.1001/jama.2012.13356
[3]
M.W. Semler, W.H. Self, L. Wang, D.W. Byrne, J.P. Wanderer, J.M. Ehrenfeld
Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial
[4]
M. Semler, W. Self, T. Rice
Balanced crystalloids vs saline for critically ill adults
Chest, 152 (2017), pp. A1120
[5]
A. González-Castro, Y. Peñasco, J.C. Rodríguez-Borregan, M. Ortiz-Lasa
The SPLIT trial: anything new in critical care fluid therapy?
Med Intensiva, 40 (2016), pp. 136-137 http://dx.doi.org/10.1016/j.medin.2015.12.005

Please cite this article as: González-Castro A, Ortiz-Lasa M, Bada Da Silva J. SMART: ¿está el suero salino en la cuerda floja? Med Intensiva. 2018;42:394–395.

Copyright © 2018. Elsevier España, S.L.U. and SEMICYUC
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