Skip to content


  • Letter
  • Open Access

Abnormal saline: the unphysiological bag of brine

Critical Care201418:673

  • Published:


No abstract


  • Normal Saline
  • Balance Salt Solution
  • Resuscitative Fluid
  • Sodium Lactate
  • Endotoxic Shock

Duburcq and colleagues, in their article published in Critical Care, showed improved oxygenation, hemodynamic parameters, and microvascular reactivity in an experimental porcine endotoxic shock model with use of hypertonic sodium lactate 11.2% [1]. We applaud the authors for embarking on the arduous quest for the ideal resuscitative fluid, which has historically been fraught with shortcomings.

The control group in this experimental model was subjected to an infusion of 0.9% normal saline. Normal saline has become almost ubiquitous in patient care. More evidence is emerging that this so-called lifeblood, as unphysiological as it is, may be causing undue harm to our patients. A 0.9% normal saline infusion has been demonstrated to cause decreased renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers [2]. Abnormal saline was also associated with increased incidence of acute kidney injury and need for renal replacement therapy in a cohort of critically ill patients [3] and had a higher in-hospital mortality rate than more balanced salt solutions [4]. The significant chloride content of normal saline has been implicated in its adverse effect on acid–base status. It has become more evident that the use of balanced salt solutions may be associated with reduced mortality in the septic population [4],[5].

Given the mounting evidence against the use of normal saline, I believe it would be better served if, firstly, the normal saline arm is replaced with one with a balanced salt solution. Secondly, I suggest the experimental model should include a true control arm that did not receive any resuscitative fluids.


Authors’ Affiliations

Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA


  1. Duburcq T, Favory R, Mathieu D, Hubert T, Mangalaboyi J, Gmyr V, Quintane L, Maboudou P, Pattou F, Jourdain M: Hypertonic sodium lactate improves fluid balance and hemodynamics in porcine endotoxic shock. Crit Care. 2014, 18: 467-10.1186/s13054-014-0467-3.PubMedView ArticleGoogle Scholar
  2. Chowdhury AH, Cox EF, Francis ST, Lobo DN: A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012, 256: 18-24. 10.1097/SLA.0b013e318256be72.PubMedView ArticleGoogle Scholar
  3. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M: Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012, 308: 1566-1572. 10.1001/jama.2012.13356.PubMedView ArticleGoogle Scholar
  4. Raghunathan K, Shaw A, Nathanson B, Stürmer T, Brookhart A, Stefan MS, Setoguchi S, Beadles C, Lindenauer PK: Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis. Crit Care Med. 2014, 42: 1585-1591. 10.1097/CCM.0000000000000305.PubMedView ArticleGoogle Scholar
  5. Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, Mbuagbaw L, Szczeklik W, Alshamsi F, Altayyar S, Ip WC, Li G, Wang M, Wludarczyk A, Zhou Q, Guyatt GH, Cook DJ, Jaeschke R, Annane D: Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014, 161: 347-355. 10.7326/M14-0178.PubMedView ArticleGoogle Scholar


© Senussi.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.