Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study

Abstract

Background: In 2007, the Saline versus Albumin Fluid Evaluation-Translation of Research Into Practice Study (SAFE-TRIPS) reported that 0.9% sodium chloride (saline) and hydroxyethyl starch (HES) were the most commonly used resuscitation fluids in intensive care unit (ICU) patients. Evidence has emerged since 2007 that these fluids are associated with adverse patient-centred outcomes. Based on the published evidence since 2007, we sought to determine the current type of fluid resuscitation used in clinical practice and the predictors of fluid choice and determine whether these have changed between 2007 and 2014.

Methods: In 2014, an international, cross-sectional study was conducted (Fluid-TRIPS) to document current patterns of intravenous resuscitation fluid use and determine factors associated with fluid choice. We examined univariate and multivariate associations between patients and prescriber characteristics, geographical region and fluid type. Additionally, we report secular trends of resuscitation fluid use in a cohort of ICUs that participated in both the 2007 and 2014 studies. Regression analysis were conducted to determine changes in the administration of crystalloid or colloid between 2007 and 2014.

Findings: In 2014, a total of 426 ICUs in 27 countries participated. Over the 24 hour study day, 1456/6707 (21.7%) patients received resuscitation fluid during 2716 resuscitation episodes. Crystalloids were administered to 1227/1456 (84.3%) patients during 2208/2716 (81.3%) episodes and colloids to 394/1456 (27.1%) patients during 581/2716 (21.4%) episodes. In multivariate analyses, practice significantly varied between geographical regions. Additionally, patients with a traumatic brain injury were less likely to receive colloid when compared to patients with no trauma (adjusted OR 0.24; 95% CI 0.1 to 0.62; p = 0.003). Patients in the ICU for one or more days where more likely to receive colloid compared to patients in the ICU on their admission date (adjusted OR 1.75; 95% CI 1.27 to 2.41; p = <0.001). For secular trends in fluid resuscitation, 84 ICUs in 17 countries contributed data. In 2007, 527/1663 (31.7%) patients received fluid resuscitation during 1167 episodes compared to 491/1763 (27.9%) patients during 960 episodes in 2014. The use of crystalloids increased from 498/1167 (42.7%) in 2007 to 694/960 (72.3%) in 2014 (odds ratio (OR) 3.75, 95% confidence interval (CI) 2.95 to 4.77; p = <0.001), primarily due to a significant increase in the use of buffered salt solutions. The use of colloids decreased from 724/1167 (62.0%) in 2007 to 297/960 (30.9%) in 2014 (OR 0.29, 95% CI 0.19 to 0.43; p = <0.001), primarily due to a decrease in the use of HES, but an overall increase in the use of albumin.

Conclusions: Clinical practices of intravenous fluid resuscitation have changed between 2007 and 2014. Geographical location remains a strong predictor of the type of fluid administered for fluid resuscitation. Overall, there is a preferential use of crystalloids, specifically buffered salt solutions, over colloids. There is now an imperative to conduct a trial determining the safety and efficacy of these fluids on patient-centred outcomes.

Trial registration: Clinicaltrials.gov: Fluid-Translation of research into practice study (Fluid-TRIPS) NCT02002013.

Fig 1. Flow diagram of included ICUs and patients in 2007 and 2014.

+ Some ICUs that contributed data to both studies may have been defined as a single ICU in one study but as two ICUs in another study therefore the ‘paired’ ICU number not half of the total ICU number. These ICUs were combined into one ICU (as appropriate) to enable comparison of fluid use over time.

Fig 2. Proportion of all fluid resuscitation episodes of crystalloid and colloid in 2014 in 426 ICUs.

Proportions may not add to 100% as patients can be administered more than one type of fluid during resuscitation episodes. Denominator for crystalloid and colloid panel is all fluid resuscitation episodes (n = 2716); Denominator for crystalloid panel is for all crystalloid episodes (n = 2208); Denominator for colloid panel is for all colloid episodes (n = 581). BSS = Buffered Salt Solutions. HES = Hydroxyethyl Starch. Other = other crystalloids.

Fig 3. Proportion of all fluid resuscitation episodes given in 2007 and 2014 in 84 ICUs.

Denominator for crystalloid and colloid panel is all fluid resuscitation episodes (n = 1167 in 2007 and n = 960 in 2014); Denominator for crystalloid panel is for crystalloid episodes only (n = 498 in 2007 and n = 694 in 2014); Denominator for colloid panel is for all colloid episodes (n = 724 in 2007 and n = 297 in 2014). Proportions may not add to 100% as patients can be administered more than one type of fluid during resuscitation episodes. BSS = Buffered Salt Solutions. HES = Hydroxyethyl Starch. Other = other crystalloids.

Fig 4. Forest plots of change in use of crystalloid fluid resuscitation episodes between 2007 and 2014; overall and by pre-defined subgroup.

Unadjusted odds ratios and 95% Confidence Intervals (CI) presented.

Fig 5. Forest plots of crystalloid fluid resuscitation episodes between 2007 and 2014; overall and by region subgroup.

Unadjusted odds ratios and 95% Confidence Intervals (CI) presented.