Bicarbonated Ringer's Solution Versus Lactated Ringer's Solution in Patients With Septic Shock

Study Overview
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Brief Summary
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In this prospective randomized controlled trial, investigators aim to study the effects and safety of bicarbonated Ringer's solution in patients with septic shock compared with lactated ringer's solution, and provide evidence for current fluid resuscitation strategies for septic shock.

Detailed Description
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Although the latest guidelines recommend crystalloids as the first choice for the patients' fluid resuscitation, it still remains controversial that which crystalloid solution is the best choice. It is reported that balanced crystalloid can result in better outcomes than saline for critically ill patients. However, there are few studies conducted between different crystalloid solutions. Lactated ringer's solution is the longest-used crystalloid solution. Compared with lactated ringer's solution whose anion is lactate, the anion of bicarbonate ringer's solution is bicarbonate. And lactate needs to be metabolized into bicarbonate through the mitochondria of the liver before it can play an alkalization role. Therefore, in theory, bicarbonate ringer's solution does not need to rely on liver metabolism, the onset time to maintain acid-base balance is shorter, and it may be more suitable for patients with severe acidosis. In patients with septic shock, the incidence of moderate to severe metabolic is increased. Bicarbonate ringer's solution can directly supplement the concentration of bicarbonate, while lactated ringer's solution needs to take time and be metabolized in the liver. Thus, we hypothesize that bicarbonate ringer's solution is more effective for patients with shock and metabolic acidosis than lactated ringer's solution.

Official Title
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Fluid Resuscitation Management for Patients With Septic Shock: the Efficacy and Safety Comparison Between Bicarbonated Ringer's Solution and Lactated Ringer's Solution

Conditions
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Septic Shock, Fluid Resuscitation, Crystalloid Solution, Intensive Care Unit

Intervention / Treatment
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* Drug: Bicarbonated Ringer's solution
* Drug: Lactated Ringer's solution


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 1. At the age of 18 to 75; 2. Being treated in the ICU; 3. Diagnosed as septic shock according tho the definition of Sepsis 3.0 with fluid resuscitation requirement. Exclusion Criteria: 1. Severe hepatic failure; 2. Possible brain injury; 3. With absolute contraindications for central vena catheterization; 4. Ever participated in another clinical trial within 30 days prior enrollment; 5. Have corrected metabolic acidosis through alkaline drug application within 24 hours prior to enrollment; 6. Hypermagnesemia or hypothyroidism; 7. Pregnant of breast-feeding women; 8. Considered inevitable death; 9. Other situations where investigators think enrollment is not appropriate.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: bicarbonated ringer's solution<br>We apply bicarbonated ringer's solution as resuscitation fluid to patients with septic shock. | Drug: Bicarbonated Ringer's solution<br>* Method of administration: intravenous infusion; 500-1000ml each time; Speed of infusion: it is decided by the clinicians.<br>* Other names: Ringers Bicarbonate;|
| Experimental: lactated ringer's solution<br>We apply lactated ringer's solution as resuscitation fluid to patients with septic shock. | Drug: Lactated Ringer's solution<br>* Method of administration: intravenous infusion; 500-1000ml each time; Speed of infusion: it is decided by the clinicians.<br>* Other names: Ringers Lactate;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| the average doses of vasopressors | total doses of norepinephrine÷weight÷duration of usage | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs. About 24 hours. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| the PH value | the potencial of hydrogen of arterial blood | 0, 3 hours, 6 hours, 12 hours, 24 hours | 
| the BE value | the base excess of arterial blood | 0, 3 hours, 6 hours, 12 hours, 24 hours | 
| shock reversal time | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs. About 24 hours. | 
| total volume of fluids before hemodynamic stabilization | total volume of bicarbonated ringers/lactated ringers before hemodynamic stabilization | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs. About 24 hours. | 
| the change of serum lactate value at the 6th hour | serum lactate (6h) - serum lactate (0h) | 6 hours | 
| the proportion of patients whose serum lactate decreases 30% | the proportion of patients whose serum lactate decreases 30% | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs. About 24 hours. | 
| mortality from any cause | the rate of death from any cause within 28 days after enrollment | on the day28 after enrollment | 
| the rate of metabolic alkalosis | the percentage of metabolic alkalosis (PH>7.45 and HCO3>26mmol/L) | From the onset of shock to the first blood pressure stabilization (MAP≥65mmHg), or serum lactate <2.2mmol/l, or discontinuation of vasoactive drugs. About 24 hours. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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septic shock, fluid resuscitation, crystalloid solution, intensive care unit