Shahed Omar University of WitwatersrandCHBAH What is balanced Baralyte 142 99 1431 36 49 0 27 0 296 SID NaKCl 40 0 28 27 50 52 ID: 1033951
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1. Is Balanced really the solution?Shahed OmarUniversity of Witwatersrand/CHBAH
2. What is balanced?Bara’lyte142991.43:13.64902.70296SID (Na+K-Cl)40 0 28 27 50 52
3. Balanced- depends on what you want3Carlesso et al (ICM 2010
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5. ConstantSID Na+ +K + -Cl- Total weak acid Alb-PaC02Keep PaC02 constantPerfect solutionReduction the SID - H+ =Reduction the Total weak acid- H+SID = 24No effect on pH
6. Balanced- depends on what you want6Carlesso et al (ICM 2010BICAR-ICU
7. Lancet 2018HypothesizedEarly NaHC03 infusion vs no NaHC03 would result the composite of fewer deaths (D28) and SOFA 1by D7
8. Inclusion (All)≥ 18yWithin 48h of ICU admissionpH≤ 7.2 and PaC02 ≤ 45SOFA ≥ 4 or Lac ≥ 2ExclusionResp Acidosis/ HC03 loss from GIT or kidneyCKD – 4KetoacidosisNaHC03 Rx or RRT within 24 of screening
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10. *
11. Control BicarbTotal Fluid 48h: 4550 4350Na mmol/l 130 194Cl 110 91K 4 3.3Est SID 24 100
12. So, what happened to pH?
13. You can guess what happened to Na
14. Chloride
15. What about PaC02 component?
16. Benefits of this strategy
17. *******
18. Sig p0.04620.01660.0142
19. So back to our question - what you want??Is this our target?
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22. What does the data indicate?
23. 2321 studies (6253 pt)15 RCT, 5 Observational and 1 controlled clinical trial2014
24. Mortality246 studies with mortality as an end point
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26. 26High Cl fluid:OtherMetabolic acidosis (RR 2.87)Greater serum Cl, More Blood T/FLonger MVHowever,
27. 2018Pragmatic, unblinded, Cluster randomized, multiple crossoverBal vs Saline, % ICU’s in one Center, >15 000 patientsOutcomes1 - MAKE 30 – Mortality/New RRT/Persistent renal dysfunction2 Outcomes and Prespecified subgroup analysis
28. Due to co-ordination with ED and OR – Received same fluid pre-ICU, hence the differences at ICU admission
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31. 7260Sepsis
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37. Duration of AKI was dependent on recovery sCr to within 25-50% of baseline sCr
38. Mehta S, Chauhan K, Patel A, Patel S, Pinotti R, Nadkarni GN, et al. The prognostic importance of duration of AKI: a systematic review and meta-analysis. BMC Nephrol [Internet]. 2018 Apr 19;19. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907696/
39. ConclusionDuration of AKI is independently associated with long-term mortality and may provide additional prognostic information over and above magnitude of serum creatinine alone. Thus, AKI duration can be considered as a prognostic factor for long-term mortality and other cardiovascular outcomes and can be used as an endpoint in intervention trials to prevent or treat AKI.Mehta S, Chauhan K, Patel A, Patel S, Pinotti R, Nadkarni GN, et al. The prognostic importance of duration of AKI: a systematic review and meta-analysis. BMC Nephrol [Internet]. 2018 Apr 19;19. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907696/
40. What about SPLITTotal87/1152 7.6%95/1110 8.6%1% absolute mortality reduction – obviously not significantYoung et al. JAMA 2015
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42. What does a change in Cl- do?42SID1.Na+ -Cl- 2. Alb-3. PaC02
43. SMART