In this episode I will:

1. Review an article about the choice of IV fluids in ICU patients

2. Answer a drug information question: “Have you seen dexmedetomidine drug fever?”

3. Share a free resource I use to stay updated with medical literature

Article

Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury (AKI) Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial

Lead author: Paul Young

Published in JAMA online October 7, 2015

Background

The question of which fluid to use for resuscitation has been debated for several decades. We’ve seen albumin and hetastarch fall out of favor due to adverse reactions. More recently concerns over hyperchloremic acidosis and kidney failure from normal saline have been expressed.

Purpose

To determine the effect of a buffered crystalloid (Plasma-Lyte 148) compared with saline on renal complications in patients admitted to the intensive care unit (ICU).

I wasn’t familiar with Plasma-Lyte so I had to look it up. Each 1000mL of Plasma-Lyte 148 Replacement IV Infusion has an ionic concentration of:

Sodium 140 mmol

Potassium 5 mmol

Magnesium 1.5 mmol

Chloride 98 mmol

Acetate 27 mmol

Gluconate 23 mmol

Methods

Double-blind, cluster randomized, double-crossover trial conducted in 4 ICUs in New Zealand from April 2014 through October 2014.

All ICU patients requiring crystalloid fluid therapy were eligible for inclusion.

Patients with AKI requiring renal replacement therapy (RRT) on ICU admission were excluded.

Participating ICUs were assigned a masked study fluid, either saline or a buffered crystalloid, for alternating 7-week treatment blocks.

The primary outcome was the proportion of patients with AKI. Secondary outcomes were incidence of RRT use and in-hospital mortality.

Results

In the buffered crystalloid group, 102 of 1067 patients (9.6%) developed AKI within 90 days after enrollment compared with 94 of 1025 patients (9.2%) in the saline group P = 0.77. In the buffered crystalloid group, RRT was used in 38 of 1152 patients (3.3%) compared with 38 of 1110 patients (3.4%) in the saline group P = 0.91. Overall, 87 of 1152 patients (7.6%) in the buffered crystalloid group and 95 of 1110 patients (8.6%) in the saline group died in the hospital P = 0.40.

Conclusion

The authors concluded the buffered crystalloid solution did not reduce the risk of AKI. An editorial which accompanied the article pointed out that the overall dose of IV fluid was low at about 2 liters. It is entirely possible that if sicker patients were treated with larger doses of the two IV fluids, a treatment effect might have been found.

Drug information question

Shout out to “Intensivist Anwar” for this question:

Q: Can dexmedetomidine cause fever?

A: Yes.

Here is the background information for the patient involved (age and/or gender may be altered from the actual case):

A 54 y/o male admitted to the ICU for delirium tremens was treated with benzodiazepines and dexmedetomidine. He developed temperatures of over 39C on hospital day 3. Past medical history was hypertension, dyslipidemia and GERD. Other medications were amlodipine, famotidine, folic acid, lorazepam, and heparin. There was no source suggestive of infection. WBC was 8.5 thousand.

A MeSH search on pubmed yielded one case report of drug fever from dexmedetimidine.

According to Lexi-comp the incidence of fever while on dexmedetomidine is 5-7%.

Dexmedetomidine was discontinued, and the patient’s fever began to resolve about 12 hours after, dropping to 38C. No other cause of the fever was identified (the team felt 39C was too high to attribute to delirium tremens).

Resource

I use a free app called pocket to help me stay updated with medical literature. It works on Android and iPhone. You can find it at getpocket.com. Pocket has a great text-to-speech feature and will read articles to you, turning any journal article into a podcast! I use it to store articles and webpages for later review when I commute or mow the lawn.

Shoutout to “Pharmacy Mary” & “Pharmacy Julie” who I recommended Pocket to over email. They both wrote me saying they tried it and found it useful for staying current with medical literature! For 7 more tips on how to stay up to date with medical literature listen to episode 7!

I’ve teamed up with Audible to offer you 2 free audiobooks. You can take advantage of this special offer at pharmacyjoe.com/book.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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