***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 
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    Input: 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 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 Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND The Saline versus Albumin Fluid Evaluation study suggested that patients with traumatic brain injury resuscitated with albumin had a higher mortality rate than those resuscitated with saline . We conducted a post hoc follow-up study of patients with traumatic brain injury who were enrolled in the study . METHODS For patients with traumatic brain injury ( i.e. , a history of trauma , evidence of head trauma on a computed tomographic [ CT ] scan , and a score of < or = 13 on the Glasgow Coma Scale [ GCS ] ) , we recorded baseline characteristics from case-report forms , clinical records , and CT scans and determined vital status and functional neurologic outcomes  24 months after r and omization . RESULTS We followed 460 patients , of whom 231 ( 50.2 % ) received albumin and 229 ( 49.8 % ) received saline .  The subgroup of patients with GCS scores of 3 to 8 were classified as having severe brain injury ( 160 [ 69.3 % ] in the albumin group and 158 [ 69.0 % ] in the saline group ) . Demographic characteristics and indexes of severity of brain injury were similar at baseline . At 24 months , 71 of 214 patients in the albumin group ( 33.2 % ) had died , as compared with 42 of 206 in the saline group ( 20.4 % ) ( relative risk , 1.63 ; 95 % confidence interval [ CI ] , 1.17 to 2.26 ; P=0.003 ) . Among patients with severe brain injury , 61 of 146 patients in the albumin group ( 41.8 % ) died , as compared with 32 of 144 in the saline group ( 22.2 % ) ( relative risk , 1.88 ; 95 % CI , 1.31 to 2.70 ; P<0.001 ) ; among patients with GCS scores of 9 to 12 , death occurred in 8 of 50 patients in the albumin group ( 16.0 % ) and 8 of 37 in the saline group ( 21.6 % ) ( relative risk , 0.74 ; 95 % CI , 0.31 to 1.79 ; P=0.50 ) . CONCLUSIONS In this post hoc study of critically ill patients with traumatic brain injury , fluid resuscitation with albumin was associated with higher mortality rates than was resuscitation with saline . ( Current Controlled Trials number , IS RCT N76588266 [ controlled-trials.com ] . ) OBJECTIVE To determine if Ringer 's lactate is superior to 0.9 % sodium chloride solution for resolution of acidosis in the management of diab 
    Output:
    
Conclusions Limited evidence supported statistical survival benefit with balanced crystalloid solutions , while it benefited in reducing organ support duration and fluctuations in serum electrolyte and base excess and was associated with decreased in-hospital mortality in sub population with sepsis and non-TBI .