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In the first patient, pressure support is set at 18 and PEEP is set at 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, and by improving the interaction with the ventilator, the effort precedes the mechanical cycle (continuous line) with a respiratory frequency of 22<span class="elsevierStyleHsp" style=""></span>bmp to achieve a tidal volume of 0.450<span class="elsevierStyleHsp" style=""></span>l, with no signs of excessive respiratory effort and delta esophageal pressure (Δpes) values <5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. In the second case, pressure support is set at 25 and PEEP set at 6 keeping heart rate at 12<span class="elsevierStyleHsp" style=""></span>bmp and tidal volume at 0.783<span class="elsevierStyleHsp" style=""></span>l. In this second case, the patient's effort follows the beginning of the mechanical cycle and, possibly, the ventilator trigger is the change of pressure (or flow) caused by the heartbeat. The patient's effort (dotted line) reduces the phase of airway plateau pressure originating a new increase of inspiratory flow.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Ruiz Ferrón, J.M. Serrano Simón" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Ruiz Ferrón" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Serrano Simón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117301456" "doi" => "10.1016/j.medin.2017.04.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117301456?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718300936?idApp=WMIE" "url" => "/21735727/0000004200000006/v1_201807240414/S2173572718300936/v1_201807240414/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "SMART: Is saline on the tightrope?" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "394" "paginaFinal" => "395" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. González-Castro, M. Ortiz-Lasa, J. Bada Da Silva" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "González-Castro" "email" => array:1 [ 0 => "e409@humv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Ortiz-Lasa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Bada Da Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "SMART: ¿está el suero salino en la cuerda floja?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Back in October 2015, the results from the SPLIT trial<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> 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,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> those conclusions complicated a fundamental debate.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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”.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">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).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">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 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>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%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.06).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">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.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dr. González-Castro, MD declares as a possible conflict of interest his job for Baxter.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This manuscript has received no funding whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "SPLIT Investigators; ANZICS CTG" "etal" => true "autores" => array:6 [ 0 => "P. Young" 1 => "M. Bailey" 2 => "R. Beasley" 3 => "S. Henderson" 4 => "D. Mackle" 5 => "C. McArthur" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2015.12334" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2015" "volumen" => "314" "paginaInicial" => "1701" "paginaFinal" => "1710" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26444692" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Yunos" 1 => "R. Bellomo" 2 => "C. Hegarty" 3 => "D. Story" 4 => "L. Ho" 5 => "M. 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Ehrenfeld" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13063-017-1871-1" "Revista" => array:5 [ "tituloSerie" => "Trials" "fecha" => "2017" "volumen" => "18" "paginaInicial" => "129" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28302179" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Balanced crystalloids vs saline for critically ill adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Semler" 1 => "W. Self" 2 => "T. Rice" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Chest" "fecha" => "2017" "volumen" => "152" "paginaInicial" => "A1120" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The SPLIT trial: anything new in critical care fluid therapy?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. González-Castro" 1 => "Y. Peñasco" 2 => "J.C. Rodríguez-Borregan" 3 => "M. Ortiz-Lasa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2015.12.005" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2016" "volumen" => "40" "paginaInicial" => "136" "paginaFinal" => "137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26860216" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004200000006/v1_201807240414/S2173572718300997/v1_201807240414/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004200000006/v1_201807240414/S2173572718300997/v1_201807240414/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718300997?idApp=WMIE" ]
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