***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: AIM We aim ed to determine whether using a balanced salt solution , Hartmann 's solution ( HS ) , in diabetic ketoacidosis ( DKA ) shortens the time to normalise acid-base status through the avoidance of hyperchloremic metabolic acidosis compared with 0.9 % normal saline ( NS ) . METHODS We conducted a double-blind , r and omised controlled trial comparing HS to NS as the initial intravenous fluid in children with DKA . Patients were stratified by severity ( pH < 7.1 ) and known or new diabetes .  Electrolytes , venous blood gases and glucose were measured every 2 h until intravenous fluids were ceased . The primary outcome was the time for the plasma bicarbonate to reach 15 mmol/L. Secondary outcomes included time to normalise pH ( 7.3 ) , time to receive subcutaneous ( SC ) insulin , change in sodium and insulin requirement . RESULTS A total of 77 children were enrolled . The groups were similar at baseline . There was no difference in the time to reach a bicarbonate of 15 mmol/L : geometric mean ( SD ) 8.6 ( 2.3 ) h for NS versus 6.2 ( 4.7 ) h for HS , ratio 1.4 ( 95 % confidence interval 0.8 - 2.5 ) , and no difference in time to normalise pH : NS 8.5 ( 2.3 ) h versus HS group 7.5 ( 1.8 ) h , ratio 1.1 ( 0.8 - 1.6 ) . Kaplan-Meier survival estimates showed shorter times for these end-points in the severe subgroup : log-rank test P = 0.0277 and 0.0024 , respectively . There was no difference in time to SC insulin , NS : 15.2 ( 2.4 ) h versus HS 14.3 ( 1.6 ) h , ratio 1.1 ( 0.8 - 1.5 ) . Patients treated with HS received significantly less total fluids/kg . CONCLUSIONS HS is an acceptable alternative to NS in DKA and may benefit those with severe DKA Background The use of hypertonic crystalloid solutions , including sodium chloride and bicarbonate , for treating severe sepsis has been much debated in previous investigations . We have investigated the effects of three crystalloid solutions on fluid resuscitation in severe sepsis patients with hypotension . Methods Ninety-four severe sepsis patients with hypotension were r and omly assigned to three groups . The patients received the following injections within 15 min at initial treatment : Ns group ( n = 32 ) , 5 ml/kg normal saline ; Hs group ( n = 30 ) , with 5 ml/kg 3.5 % sodium chloride ; and Sb group ( n = 32 ) , 5 ml/kg 5 % sodium bicarbonate .  Cardiac output ( CO ) , systolic blood pressure , mean arterial pressure ( MAP ) , body temperature , heart rate , respiratory rate and blood gases were measured . Results There were no differences among the three groups in CO , MAP , heart rate or respiratory rate during the 120 min trial or the 8 hour follow-up , and no significant differences in observed mortality rate after 28 days . However , improvement of MAP and CO started earlier in the Sb group than in the Ns and Hs groups . Sodium bicarbonate increased the base excess but did not alter blood pH , lactic acid or [HCO3]- values ; and neither 3.5 % hypertonic saline nor 5 % sodium bicarbonate altered the Na+ , K+ , Ca2 + or Cl- levels . Conclusion All three crystalloid solutions may be used for initial volume loading in severe sepsis , and sodium bicarbonate confers a limited benefit on humans with severe sepsis . Trial registration IS RCT N36748319 Objective : Isotonic saline is the most commonly used crystalloid in the ICU , but recent evidence suggests that balanced fluids like Lactated Ringer ’s solution may be preferable . We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis . Design : A retrospective cohort study of patients admitted with sepsis , not undergoing any surgical procedures , and treated in an ICU by hospital day 2 . We used propensity score matching to control for confounding and compared the following outcomes after resuscitation with balanced versus with no-balanced fluids :  in-hospital mortality , acute renal failure with and without dialysis , and hospital and ICU lengths of stay . We also estimated the dose-response relationship between receipt of increasing proportions of balanced fluids and in-hospital mortality . Setting : Three hundred sixty U.S. hospitals that were members of the Premier Healthcare alliance between November 2005 and December 2010 . Patients : A total of 53,448 patients with sepsis , treated with vasopressors and crystalloids in an ICU by hospital day 2 including 3,396 ( 6.4 % ) that received balanced fluids .  Interventions : None . Measurements and Main Results : Patients treated with balanced fluids were younger and less likely to have heart or chronic renal failure , but they were more likely to receive mechanical ventilation , invasive monitoring , colloids , steroids , and larger crystalloid volumes ( median 7 vs 5 L ) . Among 6,730 patients in a propensity-matched cohort , receipt of balanced fluids was associated with lower in-hospital mortality ( 19.6 % vs 22.8 % ; relative risk , 0.86 ; 95 % CI , 0.78 , 0.94 ) . Mortality was progressively lower among patients receiving larger proportions of balanced fluids . There were no significant differences in the prevalence of acute renal failure ( with and without dialysis ) or in-hospital and ICU lengths of stay . Conclusions : Among critically ill adults with sepsis , resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality . If confirmed in r and omized trials , this finding could have significant public health implication s , as crystalloid resuscitation is nearly universal in sepsis Community trials involve the assignment of intact social groups to study conditions and are becoming increasingly common in epidemiologic research . In both the design and analysis of these studies , whether cross-sectional or cohort , allowance must be made for the dependence of elements within intact groups if variances are to be properly estimated . In the design phase , the statistician needs estimates of the level of dependence likely to be encountered . In the analysis phase , external estimates of the level of dependence may be useful in preventing the erosion of power associated with small numbers of intact groups assigned to each condition . We report the intraclass correlation coefficients of the city-year component of variance as estimated in the Minnesota Heart Health Program for a variety of community survey variables and illustrate their use in both design and analysis . Of 23 variables assessed , all but two showed positive estimates of city-year intraclass correlations . In these data , estimates of intraclass correlation coefficients generally were in the range 0.002–0.012 BACKGROUND Comparative clinical effects of balanced crystalloids and saline are uncertain , particularly in noncritically ill patients cared for outside an intensive care unit ( ICU ) . METHODS We conducted a single‐center , pragmatic , multiple‐crossover trial comparing balanced crystalloids ( lactated Ringer 's solution or Plasma‐Lyte A ) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU . The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month , with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16‐month trial . The primary outcome was hospital‐free days ( days alive after discharge before day 28 ) . Secondary outcomes included major adverse kidney events within 30 days — a composite of death from any cause , new renal‐replacement therapy , or persistent renal dysfunction ( defined as an elevation of the creatinine level to ≥200 % of baseline ) — all censored at hospital discharge or 30 days , whichever occurred first . RESULTS A total of 13,347 patients were enrolled , with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3 % of the patients exclusively receiving the assigned crystalloid . The number of hospital‐free days did not differ between the balanced‐crystalloids and saline groups ( median , 25 days in each group ; adjusted odds ratio with balanced crystalloids , 0.98 ; 95 % confidence interval [ CI ] , 0.92 to 1.04 ; P=0.41 ) . Balanced crystalloids result ed in a lower incidence of major adverse kidney events within 30 days than saline ( 4.7 % vs. 5.6 % ; adjusted odds ratio , 0.82 ; 95 % CI , 0.70 to 0.95 ; P=0.01 ) . CONCLUSIONS Among noncritically ill adults treated with intravenous fluids in the emergency department , there was no difference in hospital‐free days between treatment with balanced crystalloids and treatment with saline . ( Funded by the V and erbilt Institute for Clinical and Translational Research and others ; SALT‐ED Clinical Trials.gov number , NCT02614040 . Background Normal saline ( NS ) is a common fluid of choice in neurosurgery and neuro-intensive care unit ( ICU ) , but it does not contain other electrolytes and has the potential to cause hyperchloremic metabolic acidosis with prolonged infusion . These problems may be reduced with the availability of balanced fluid ( BF ) , which becomes a more physiological isotonic solution with the presence of complete electrolyte content . This study aim ed to compare the changes in electrolytes and acid-base between NS and BF ( Sterofundin ® ISO ) therapy for post-operative severe traumatic brain injury ( TBI ) patients in neuro-ICU . Methods Sixty-six severe TBI patients who required emergency craniotomy or craniectomy and were planned for post-operative ventilation  were r and omised into NS ( n = 33 ) and BF therapy groups ( n = 33 ) . The calculation of maintenance fluid given was based on the Holliday-Segar method . The electrolytes and acid-base parameters were assessed at an 8 h interval for 24 h. The data were analysed using repeated measures ANOVA . Results The NS group showed a significant lower base excess ( -3.20 versus -1.35 , P = 0.049 ) , lower bicarbonate level ( 22.03 versus 23.48 mmol/L , P = 0.031 ) , and more hyperchloremia ( 115.12 versus 111.74 mmol/L , P < 0.001 ) and hypokalemia ( 3.36 versus 3.70 mmol/L , P < 0.001 ) than the BF group at 24 h of therapy . The BF group showed a significantly higher level of calcium ( 1.97 versus 1.79 mmol/L , P = 0.003 ) and magnesium ( 0.94 versus 0.80 mmol/L , P < 0.001 ) than the NS group at 24 h of fluid therapy . No significant differences were found in pH , pCO2 , lactate , and sodium level . Conclusion BF therapy showed better effects in maintaining higher electrolyte parameters and reducing the trend toward hyperchloremic metabolic acidosis than the NS therapy during prolonged fluid therapy for postoperative TBI patients BACKGROUND Normal saline ( NS ) is the most commonly used crystalloid solution worldwide but contains an excess of chloride and may cause metabolic acidosis and hyperchloraemia . Such abnormalities may be attenuated by the use of a balanced solution such as Plasma-Lyte 148 ( PL-148 ) . OBJECTIVE To assess the feasibility , safety and biochemical and physiological effects of resuscitation with NS versus PL-148 in critically ill patients . DESIGN , SETTING AND PARTICIPANTS An exploratory , multicentre , doubleblind , r and omised controlled trial involving patients aged ≥ 18 years who were prescribed crystalloid fluid resuscitation by the treating clinician between 16 July and 22 October 2015 , in three multidisciplinary intensive care units in Melbourne , Victoria , Australia . METHODS R and om allocation of NS or PL-148 was concealed , and all fluids were delivered in indistinguishable bags . INTERVENTION NS or PL-148 was administered for all fluid resuscitation and for all subsequent crystalloid fluid therapy until Day 4 of ICU admission . The treating intensivist determined the rate and frequency of fluid administration . MAIN OUTCOME MEASURES Primary outcome was daily base excess ( BE ) . Relevant secondary outcomes included the incidence of acute kidney injury ( AKI ) , change in serum creatinine and serum chloride levels , and mortality . RESULTS Seventy patients were recruited , with 34 in the NS group and 33 in the PL-148 group available for analysis . Baseline characteristics of study patients were well balanced ; the mean ages were 64 and 62 years , respectively , and nearly two-thirds of the patients in each group were men .  The median Acute Physiology and Chronic Health Evaluation III scores were 64 for the NS group ( interquartile range [ IQR ] , 48 - 73 ) and 55 for the PL-148 group ( IQR 
    Output:
    
We found no effect of buffered solutions on preventing in-hospital mortality compared to 0.9 % saline solutions in critically ill patients .
The certainty of evidence for this finding was high , indicating that further research would detect little or no difference in mortality .
The effects of buffered solutions and 0.9 % saline solutions on preventing acute kidney injury were similar in this setting .