***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: BACKGROUND Normal saline ( NS ) and lactated Ringer 's solution ( LR ) continue to be used interchangeably for the resuscitation of hemorrhagic shock in some institutions . We hypothesized that , aside from hyperchloremic acidosis , NS resuscitation would be similar to that of LR in a swine model of uncontrolled hemorrhage . METHODS Twenty swine weighing a mean of 37 kg underwent invasive line placement , midline celiotomy , and splenectomy .  After a 15-minute stabilization period , we recorded a baseline mean arterial pressure ( MAP ) and created a grade V liver injury . The animals bled freely for 30 minutes after which we measured blood loss . We blindly r and omized the swine to receive NS ( 10 animals ) versus LR ( 10 animals ) to achieve and maintain the baseline MAP for 90 minutes postinjury . Laboratory values were obtained at baseline and upon completion of the 2-hour study period . RESULTS Initial blood loss was 25 mL/kg in the NS group and 22 mL/kg in the LR group ( p = 0.54 ) . Animals required 256.3 + /- 145.4 mL/kg of fluid in the NS group as compared with 125.7 + /- 67.3 mL/kg in the LR group ( p = 0.04 ) . The urine output was higher in the NS group ( 46.6 + /- 39.5 mL/kg versus 18.9 + /- 12.9 mL/kg , p = 0.04 ) . Upon study completion , the NS group had a significant hyperchloremia ( 119 + /- 1.9 mEq/L versus 105 + /- 2.9 mEq/L , p < 0.01 ) with acidosis ( 7.28 + /- 0.12 versus 7.45 + /- 0.06 , p < 0.01 ) in comparison to the LR group . In addition , resuscitation with NS result ed in significantly lower fibrinogen levels ( 99 + /- 21 mg/dL versus 123 + /- 20 mg/dL , p = 0.02 ) . The serum lactate was 4.7 + /- 2.2 in the LR group and 1.7 + /- 1.7 in the NS swine ( p < 0.01 ) at the end of the study . CONCLUSIONS Resuscitation of uncontrolled hemorrhagic shock with NS requires significantly greater volume and is associated with greater urine output , hyperchloremic acidosis , and dilutional coagulopathy as compared with LR . Resuscitation with LR results in an elevation of the lactate level that is not associated with acidosis . Lactated Ringer 's solution is superior to NS for the resuscitation of uncontrolled hemorrhagic shock in swine 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 The safety and efficacy of hydroxyethyl starch ( HES ) for fluid resuscitation have not been fully evaluated , and adverse effects of HES on survival and renal function have been reported . METHODS We r and omly assigned 7000 patients who had been admitted to an intensive care unit ( ICU ) in a 1:1 ratio to receive either 6 % HES with a molecular weight of 130 kD and a molar substitution ratio of 0.4 ( 130/0.4 , Voluven ) in 0.9 % sodium chloride or 0.9 % sodium chloride ( saline ) for all fluid resuscitation until ICU discharge , death , or 90 days after r and omization . The primary outcome was death within 90 days . Secondary outcomes included acute kidney injury and failure and treatment with renal-replacement therapy . RESULTS A total of 597 of 3315 patients ( 18.0 % ) in the HES group and 566 of 3336 ( 17.0 % ) in the saline group died ( relative risk in the HES group , 1.06 ; 95 % confidence interval [ CI ] , 0.96 to 1.18 ; P=0.26 ) . There was no significant difference in mortality in six predefined subgroups . Renal-replacement therapy was used in 235 of 3352 patients ( 7.0 % ) in the HES group and 196 of 3375 ( 5.8 % ) in the saline group ( relative risk , 1.21 ; 95 % CI , 1.00 to 1.45 ; P=0.04 ) . In the HES and saline groups , renal injury occurred in 34.6 % and 38.0 % of patients , respectively ( P=0.005 ) , and renal failure occurred in 10.4 % and 9.2 % of patients , respectively ( P=0.12 ) . HES was associated with significantly more adverse events ( 5.3 % vs. 2.8 % , P<0.001 ) . CONCLUSIONS In patients in the ICU , there was no significant difference in 90-day mortality between patients resuscitated with 6 % HES ( 130/0.4 ) or saline . However , more patients who received resuscitation with HES were treated with renal-replacement therapy . ( Funded by the National Health and Medical Research Council of Australia and others ; CHEST Clinical Trials.gov number , NCT00935168 . ) BACKGROUND It remains uncertain whether the choice of resuscitation fluid for patients in intensive care units ( ICUs ) affects survival . We conducted a multicenter , r and omized , double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU . METHODS We r and omly assigned patients who had been admitted to the ICU to receive either 4 percent albumin or normal saline for intravascular-fluid resuscitation during the next 28 days . The primary outcome measure was death from any cause during the 28-day period after r and omization . RESULTS Of the 6997 patients who underwent r and omization , 3497 were assigned to receive albumin and 3500 to receive saline ;  the two groups had similar baseline characteristics . There were 726 deaths in the albumin group , as compared with 729 deaths in the saline group ( relative risk of death , 0.99 ; 95 percent confidence interval , 0.91 to 1.09 ; P=0.87 ) . The proportion of patients with new single-organ and multiple-organ failure was similar in the two groups ( P=0.85 ) . There were no significant differences between the groups in the mean ( + /-SD ) numbers of days spent in the ICU ( 6.5+/-6.6 in the albumin group and 6.2+/-6.2 in the saline group , P=0.44 ) , days spent in the hospital ( 15.3+/-9.6 and 15.6+/-9.6 , respectively ; P=0.30 ) , days of mechanical ventilation ( 4.5+/-6.1 and 4.3+/-5.7 , respectively ; P=0.74 ) , or days of renal-replacement therapy ( 0.5+/-2.3 and 0.4+/-2.0 , respectively ; P=0.41 ) . CONCLUSIONS In patients in the ICU , use of either 4 percent albumin or normal saline for fluid resuscitation results in similar outcomes at 28 days The high chloride content of 0.9 % saline leads to adverse pathophysiological effects in both animals and healthy human volunteers , changes not seen after balanced crystalloids . Small r and omized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients , but no clinical outcome benefit was demonstrable when compared with balanced crystalloids , perhaps due to a type II error . A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9 % saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids . Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy , and that  pathological hyperchloremia  may increase postoperative mortality . However , there are no large-scale r and omized trials comparing 0.9 % saline with balanced crystalloids . Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema .  Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia . Nevertheless , there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9 % saline , with perhaps better clinical outcome . Hence , we argue that chloride-rich crystalloids such as 0.9 % saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘ pre-renal ' acute kidney injury Metabolic acidosis and changes in serum osmolarity are consequences of 0.9 % normal saline ( NS ) solution administration . We sought to determine if these physiologic changes influence patient outcome . Patients undergoing aortic reconstructive surgery were enrolled and were r and omly assigned to receive lactated Ringer ’s ( LR ) solution ( n = 33 ) or NS ( n = 33 ) in a double-blinded fashion . Anesthetic and fluid management were st and ardized . Multiple measures of outcome were monitored . The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy ( 30 ± 62 mL in the NS group versus 4 ± 16 mL in the LR group ; mean ± sd ) , which was given if the base deficit was greater than −5 mEq/L. The NS patients also received a larger volume of platelet transfusion ( 478 ± 302 mL in the NS group versus 223 ± 24 mL in the LR group ; mean ± sd ) . When all blood products were summed , the NS group received significantly more blood products ( P = 0.02 ) . There were no differences in duration of mechanical ventilation , intensive care unit stay , hospital stay , and incidence of complications . When NS was used as the primary intraoperative solution , significantly more acidosis was seen on completion of surgery . This acidosis result ed in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products . These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration Study objective : To compare the effect of normal saline ( NS ) , lactated Ringer 's , and Plasmalyte on the acid-base status of dehydrated patients in the emergency department ( ED ) . Method : We conducted a prospect i ve , double-blind , r and omized trial of consecutive adult patients who presented to the emergency department with moderate-severe dehydration . Patients were r and omly allocated to blindly receive normal saline ( NS ) , lactated Ringer 's or Plasmalyte at 20 ml/kg/h for 2 hours . Outcome measures of the study were pH and changes in electrolytes , including serum potassium , sodium , chloride and bicarbonate levels at 0 , 60 , and 120 minutes in venous blood gas sample s. Results : Nin 
    Output:
    
Sensitivity analyses excluding heavily weighted studies result ed in non-statistically significant effects for acute kidney injury and mechanical ventilation time .
Conclusion A weak but significant association between higher chloride content fluids and unfavourable outcomes was found , but mortality was unaffected by chloride content