***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: 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 BACKGROUND Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults , but it is not known which results in better clinical outcomes . METHODS In a pragmatic , cluster‐r and omized , multiple‐crossover trial conducted in five intensive care units at an academic center , we assigned 15,802 adults to receive saline ( 0.9 % sodium chloride ) or balanced crystalloids ( lactated Ringer 's solution or Plasma‐Lyte A ) according to the r and omization of the unit to which they were admitted . The primary outcome was a major adverse kidney event 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 Among the 7942 patients in the balanced‐crystalloids group , 1139 ( 14.3 % ) had a major adverse kidney event , as compared with 1211 of 7860 patients ( 15.4 % ) in the saline group ( marginal odds ratio , 0.91 ; 95 % confidence interval [ CI ] , 0.84 to 0.99 ; conditional odds ratio , 0.90 ; 95 % CI , 0.82 to 0.99 ; P=0.04 ) . In‐hospital mortality at 30 days was 10.3 % in the balanced‐crystalloids group and 11.1 % in the saline group ( P=0.06 ) . The incidence of new renal‐replacement therapy was 2.5 % and 2.9 % , respectively ( P=0.08 ) , and the incidence of persistent renal dysfunction was 6.4 % and 6.6 % , respectively ( P=0.60 ) . CONCLUSIONS Among critically ill adults , the use of balanced crystalloids for intravenous fluid administration result ed in a lower rate of the composite outcome of death from any cause , new renal‐replacement therapy , or persistent renal dysfunction than the use of saline . ( Funded by the V and erbilt Institute for Clinical and Translational Research and others ; SMART‐MED and SMART‐SURG Clinical Trials.gov numbers , NCT02444988 and NCT02547779 . 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 , 44 - 81 ) . After treatment , there was no significant difference in the worst ( most negative ) median BE between the NS and PL-148 groups ( -4 mEq/L [ IQR , -7 to -2 mEq/L ] v -3 mEq/L [ IQR , -7 to 2 mEq/L ] ; P = 0.42 ) . Chloride levels were significantly higher with NS therapy ( median , 111 mmol/L [ IQR , 108 - 116 mmol/L ] v 108 mmol/L [ IQR , 106 - 110 mmol/L ] ; P = 0.01 ) . There was no significant difference in the incidence of AKI ( P = 0.48 ) , peak creatinine levels ( P = 0.92 ) or ICU or hospital mortality between the two groups . CONCLUSIONS In our exploratory , double-blind , r and omised controlled trial , when compared with NS , PL-148 did not significantly increase BE values in critically ill patients requiring fluid resuscitation , but decreased peak chloride concentrations CONTEXT Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury ( AKI ) . OBJECTIVE To assess the association of a chloride-restrictive ( vs chloride-liberal ) intravenous fluid strategy with AKI in critically ill patients . DESIGN , SETTING , AND PATIENTS Prospect i ve , open-label , sequential period pilot study of 760 patients admitted consecutively to the intensive care unit ( ICU ) during the control period ( February 18 to August 17 , 2008 ) compared with 773 patients admitted consecutively during the intervention period ( February 18 to August 17 , 2009 ) at a university-affiliated hospital in Melbourne , Australia . INTERVENTIONS During the control period , patients received st and ard intravenous fluids . After a 6-month phase-out period ( August 18 , 2008 , to February 17 , 2009 ) , any use of chloride-rich intravenous fluids ( 0.9 % saline , 4 % succinylated gelatin solution , or 4 % albumin solution ) was restricted to attending specialist approval only during the intervention period ; patients instead received a lactated solution ( Hartmann solution ) , a balanced solution ( Plasma-Lyte 148 ) , and chloride-poor 20 % albumin . MAIN OUTCOME MEASURES The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk , injury , failure , loss , end-stage ( RIFLE ) classification . Secondary post hoc analysis outcomes included the need for renal replacement therapy ( RRT ) , length of stay in ICU and hospital , and survival .  RESULTS Chloride administration decreased by 144 504 mmol ( from 694 to 496 mmol/patient ) from the control period to the intervention period . Comparing the control period with the intervention period , the mean serum creatinine level increase while in the ICU was 22.6 μmol/L ( 95 % CI , 17.5 - 27.7 μmol/L ) vs 14.8 μmol/L ( 95 % CI , 9.8 - 19.9 μmol/L ) ( P = .03 ) , the incidence of injury and failure class of RIFLE-defined AKI was 14 % ( 95 % CI , 11%-16 % ; n = 105 ) vs 8.4 % ( 95 % CI , 6.4%-10 % ; n = 65 ) ( P < .001 ) , and the use of RRT was 10 % ( 95 % CI , 8.1%-12 % ; n = 78 ) vs 6.3 % ( 95 % CI , 4.6%-8.1 % ; n = 49 ) ( P = .005 ) . After adjustment for covariates , this association remained for incidence of injury and failure class of RIFLE-defined AKI ( odds ratio , 0.52 [ 95 % CI , 0.37 - 0.75 ] ; P < .001 ) and use of RRT ( odds ratio , 0.52 [ 95 % CI , 0.33 - 0.81 ] ; P = .004 ) . There were no differences in hospital mortality , hospital or ICU length of stay , or need for RRT after hospital discharge . CONCLUSION The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT . TRIAL REGISTRATION Clinical trials.gov Identifier : NCT00885404 Not enough fluid and too much fluid are both bad . That is the one great irrefutable truth in fluid management in anaesthesia and in the critically ill . For almost every other question in fluid therapy there is ‘ current opinion ’ . The big questions are when , where , which and why but of greater moment than all of these is ‘ how much ’ . The current drift towards the use of smaller volumes of fluid in major surgery suggests that the right amount at the right time is probably the way to go , so volume and timing are seemingly linked . This ties in neatly with the rediscovery of the notion that early fluid resuscitation in the emergency room is better than late and dovetails with the concept that adequate resuscitation , or optimisation , improves outcome in high risk surgery . New gadgets that help to achieve this end abound since the pulmonary artery catheter fell from grace . The recent discovery of hyperchloraemic acidosis as a new iatrogenic disease entity has focused attention on the importance of the fundamental constituents of the fluids that are given [ 1 ] . The meta-analytical cloud that the Cochrane collaboration placed over albumin was dissipated by the SAFE study only to be replaced by a different evidential cloud drifting over the world of starches [ 2 ] . This has reawakened interest in the potentially malevolent nature of synthetic molecules . As the dynamics of the questions and current answers change , it is easy to become confused . The publication of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients could therefore not be more timely [ 3 ] . The authors have asked a very large number of relevant questions , assessed a vast array of available information and measured it with an evidence -based score to produce recommendations bundled into guidelines . There are no less than 28 evidence -scored recommendations to assist in fluid management . This major work should be m and atory reading for anyone involved in fluid management for a range of reasons that will come clear . The recommendations , all 28 of them , each has an evidence level of between 1 and 5 , although some have several evidence levels for different parts of the same question . In brief ; level 1 is very good , 1a – a systematic review or 1b a r and omised control trial , while level 4 is a 
    Output:
    
Conclusion Balanced crystalloids and isotonic saline have no difference on various clinical outcomes including in-hospital mortality , AKI , overall ICU mortality , and new RRT .