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Brasil
Effect of Intravenous Fluid Treatment with a Balanced Solution vs. 0.9% Saline Solution on Mortality in Critically Ill Patients (BaSICS)
This team needs no introduction. The long and historic run of Brasil in soccer is well known: O'Rei (Pelé), the Maracaná, the jogo bonito (translated as "the beautiful game") (Audio 1)....all part of the Brasilian mythology in soccer.
However, it is the fact that Brasil holds more World Cups than every other nation on Earth that makes this team a serious competitor. For the NephroWorldCup it is no exception. Looking at all the conversations revolving around adequate fluids for resuscitation, it is no wonder that a nephrologist is needed to interpret the opposing views on IV fluids.
It turns out that fluids have their own fan base: a triad of those who prefer a) sodium chloride, b) balanced solutions (like lactated ringers), and c) neither (because they don't really see a difference. There is clearly much to be said and interpreted because supporters in each camp are vocal about their team. And so it is in this context Brasil presents it's team to win the NephroWorldCup: The BaSICS randomized trial.
Side note: what are balanced solutions anyway?
Here are some illustrative images of what makes a solution 'balanced'. Courtesy Dr. Thomas Langer and M. Velia Antonini
Audio 1: 🎵 Joga Bonito by Nike
Researchers on this team weren't joking when they designed BaSICS. This is a trial with a big impact: testing the hypothesis that a balanced crystalloid solution, compared with saline, decreases the 90-day all-cause mortality among critically ill patients. Designed as elegantly as the attack section of the Brasilian soccer team, BaSICS trial was a double-blind, factorial, randomized clinical trial that enrolled patients in 75 ICUs across Brasil (Figure 1). Patients were randomized in a 1:1 fashion to receive either a balanced solution (👥 = 5522) or saline (👥 = 5530).
Figure 1. In a 2 × 2 factorial design participants are randomly assigned to 1 of 4 groups: one group receives both treatments A and B (AB), one receives only treatment A (A0), one receives only treatment B (B0), and the remaining group receives neither treatment A nor treatment B (00) | Epidemiology and Psychiatric Sciences (2013), 22, 213–215
Figure 2. History of intravenous solutions | Presented at Kidney Week 2020 by Dr. Edward Siew
This may be a good point to step back and look at the history of this Brasilian squad...and in particular the balanced solution unit. Since the last NephroWorldCup (2018), the balanced solution group has gotten stronger. Balanced solutions aren't new...they've been around for a long, long...really long time (Figure 2 and Carousel 1).
In recent years trials like SALT-ED and SMART (Carousel 2) have shown the power of balanced solutions over saline: improved renal blood flow, reduction in AKI, and on and on.
So why do we need the BaSICS trial? Fans of the saline and indifferent groups aren't convinced by this data. Further studies, like SPLIT and a secondary analysis of SMART lend credence to these fans (Figures 3a and 3b).
Carousel 1: The benefits of balanced solutions | Presented at the 2019 International Fluid Academy and 2018 AKI-CRRT meeting | Courtesy Dr. Michelle Starr
Carousel 2: Outcomes of the SMART study | Presented at Kidney Week 2020
Figures 3a and 3b. Secondary analysis of SMART (left) and SPLIT (right) trials showing tepid efficacy of balanced solutions on MAKE and AKI, respectively | Presented at Kidney Week 2020 | Courtesy of Dr. Ernesto Lopez-Almaraz
Video 1: Buffered solutions and potassium balance in AKI | Courtesy Dr. Manu Malbrain
And now...onto the results. There was no difference between saline and balanced solutions on the 90-day mortality rates (adjusted HR 0.97 with 95% CI 0.90 - 1.05). This tight confidence interval can be as strong as any defense that Brasil may bring, although as a soccer team this is not uncharacteristic. About half of the patients admitted were surgical and both groups received an average of 1.5 L during the first day of enrollment. Of all the enrolled patients, 60% had hypotension and 44% required mechanical ventilation at the time of entry.
Is this a big red card for the controversies related fluid of choice? You be the judge. We know that fans in all three groups continue the discussion and defense of their favorite solution. More experienced and veteran players may say that when it comes to resuscitating a patient, any fluid is as good as another. And key opinion leaders, like Dr. Manu Malbrain, make strong arguments in favor of balanced solutions (Video 1).
💡 At game time a coach has to carefully select his/her strikers. Players like Ronaldinho, Rivaldo, Bebeto, Romario and Ronaldo have been top goal scorers for Brasil. Can this analogy be applied to fluid selection for hemodynamic improvement? Are those 'strikers' (fluids) equally effective? The debate continues, but we are certain that Brasil will create a lot of buzz during this NephroWorldCup.
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