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Major Complications, Mortality, and Resource Utilization After Open Abdominal Surgery: 0.9% Saline Compared to Plasma-Lyte

Shaw, Andrew D. MB, FRCA, FCCM*; Bagshaw, Sean M. MD; Goldstein, Stuart L. MD; Scherer, Lynette A. MD§; Duan, Michael MS; Schermer, Carol R. MD; Kellum, John A. MD#

doi: 10.1097/SLA.0b013e31825074f5

Objective: To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery.

Background: 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery.

Methods: An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models.

Results: For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66–0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline.

Conclusions: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

Supplemental Digital Content is Available in the Text.A 0.9% saline infusion predictably results in a hyperchloremic acidosis. Perioperative use of 0.9% saline in comparison to a calcium-free balanced crystalloid is associated with increased morbidity. Even after propensity scoring to decrease bias, 0.9% saline was associated with increased infections, rates of dialysis, and treatments for acidosis.

*Department of Anesthesiology, Duke University Medical Center, Durham, NC

Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada

Department of Pediatrics, Cincinnati Childrens Hospital, Cincinnati, OH

§Department of Surgery, UC Davis Medical Center, Sacramento, CA

Premier Inc, Philadelphia, PA

Baxter Healthcare, Deerfield, IL

#Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

Reprints: Andrew Shaw, MB, FRCA, FCCM, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27705. E-mail:

Disclosure: A.S., S.B., S.G., C.S., and J.K. attended a meeting to plan and design the study, the travel costs of which were met by Baxter. C.S. is an employee of Baxter.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2012 Lippincott Williams & Wilkins, Inc.