Critical Illness: SMART MED and SMART Surg (Isotonic Solutions and Major Adverse Renal Events Trial in Medicine)2018

Question 1

SMART-MED/SURG Clinical Q

Answer 1

Among medical and surgical ICU patients, does the choice of fluid (normal saline versus a balanced crystalloid such as LR or Plasma-Lyte) impact rates of death, need for renal-replacement therapy, or persistent renal dysfunction?

Question 2

SMART-MED/SURG Bottom Line

Answer 2

Among medical and surgical ICU patients, balanced crystalloids such as LR or Plasma-Lyte reduce the rate of death, need for renal-replacement therapy, or persistent renal dysfunction, when compared to normal saline.

Question 3

SMART-MED/SURG Primary outcome

Answer 3

Composite of death, new renal-replacement therapy, or persistent renal dysfunction

Question 4

SMART-MED/SURG Inclusion Criteria

Answer 4

Admission to a participating adult ICU at Vanderbilt University Medical Center Eligible again if discharged and later readmitted to ICU

Question 5

SMART-MED/SURG Intervention

Answer 5

• ICUs were randomized to use either normal saline on even-numbered months and balanced crystalloids (LR or Plasma-Lyte A) on odd-numbered months, or vice versa.
• Group assignments were non-blinded. The choice of LR or Plasma-Lyte A in the balanced crystalloids group was at the discretion of the treating physician.
  
  • For patients with a relative contraindication to balanced crystalloid (eg, hyperkalemia or brain injury) or in whom clinicians felt saline was most appropriate, the treating physician was permitted to use saline.

Question 6

SMART-MED/SURG Criticism

Answer 6

• Concern about application to traumatic brain injury, where balanced crystalloid hypotonicity could adversely increase intracranial pressure
• Single-center study limits generalizability
• Non-blinded study
• No separate analysis of LR vs. Plasma-Lyte
• A Patients populations determined by hospital location, composite outcomes inherently not patient-centered and susceptible to confounding
  
  • However, the authors state that the NIDDK recommends the adverse renal event outcome used this trial as a patient-centered outcome.