ABSTRACT
OBJECTIVE: We sought to compare resuscitation with 0.9% NaCl versus Plasma-Lyte A, a calcium-free balanced crystalloid solution, hypothesizing that Plasma-Lyte A would better correct the base deficit 24 hours after injury. BACKGROUND: Sodium chloride (0.9%) (0.9% NaCl), though often used for resuscitation of trauma patients, may exacerbate the metabolic acidosis that occurs with injury, and this acidosis may have detrimental clinical effects. METHODS: We conducted a randomized, double-blind, parallel-group trial (NCT01270854) of adult trauma patients requiring blood transfusion, intubation, or operation within 60 minutes of arrival at the University of California Davis Medical Center. Based on a computer-generated, blocked sequence, subjects received either 0.9% NaCl or Plasma-Lyte A for resuscitation during the first 24 hours after injury. The primary outcome was mean change in base excess from 0 to 24 hours. Secondary outcomes included 24-hour arterial pH, serum electrolytes, fluid balance, resource utilization, and in-hospital mortality. RESULTS: Of 46 evaluable subjects (among 65 randomized), 43% had penetrating injuries, injury severity score was 23 ± 16, 20% had admission systolic blood pressure less than 90 mm Hg, and 78% required an operation within 60 minutes of arrival. The baseline pH was 7.27 ± 0.11 and base excess -5.9 ± 5.0 mmol/L. The mean improvement in base excess from 0 to 24 hours was significantly greater with Plasma-Lyte A than with 0.9% NaCl {7.5 ± 4.7 vs 4.4 ± 3.9 mmol/L; difference: 3.1 [95% confidence interval (CI): 0.5-5.6]}. At 24 hours, arterial pH was greater [7.41 ± 0.06 vs 7.37 ± 0.07; difference: 0.05 (95% CI: 0.01-0.09)] and serum chloride was lower [104 ± 4 vs 111 ± 8 mEq/L; difference: -7 (95% CI: -10 to -3)] with Plasma-Lyte A than with 0.9% NaCl. Volumes of study fluid administered, 24-hour urine output, measures of resource utilization, and mortality did not significantly differ between the 2 arms. CONCLUSIONS: Compared with 0.9% NaCl, resuscitation of trauma patients with Plasma-Lyte A resulted in improved acid-base status and less hyperchloremia at 24 hours postinjury. Further studies are warranted to evaluate whether resuscitation with Plasma-Lyte A improves clinical outcomes.
Subject(s)
Acidosis/therapy , Electrolytes/therapeutic use , Fluid Therapy/methods , Plasma Substitutes/therapeutic use , Resuscitation/methods , Sodium Chloride/therapeutic use , Wounds and Injuries/therapy , Acidosis/etiology , Adult , Double-Blind Method , Female , Humans , Infusions, Intravenous , Isotonic Solutions , Linear Models , Male , Middle Aged , Pilot Projects , Treatment Outcome , Water-Electrolyte Imbalance/etiology , Water-Electrolyte Imbalance/therapy , Wounds and Injuries/complicationsABSTRACT
BACKGROUND: There are several methods of contrast administration when performing computed tomography (CT) scanning for suspected appendicitis. In this systematic review we evaluated the diagnostic performance of CT with and without contrast material. METHODS: Twenty-three reports were identified using a Medline search. RESULTS: The aggregated diagnostic performance characteristics of all modes of CT scanning were excellent with a range of sensitivity (83--97%), specificity (93--98%), positive predictive value (86--98%), negative predictive value (94--99%), and accuracy (92--97%). The diagnostic performance of CT without oral contrast was similar (sensitivity, 95% vs. 92% [not statistically significant]; negative predictive value, 96% for both protocols) or surprisingly better (specificity, 97% vs. 94%; positive predictive value, 97% vs. 89%; accuracy, 96% vs. 92%; P<.0001) than with oral contrast. CONCLUSIONS: Noncontrast CT techniques to diagnose appendicitis showed equivalent or better diagnostic performance compared with CT scanning with oral contrast. A prospective comparative trial of CT with and without oral contrast for appendicitis should be performed to assess the adequacy of this modality.
