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Was the Intraaortic Balloon Pumping Under Venoarterial Extracorporeal Membrane Oxygenation Really Effective in Reducing the Mortality of Cardiogenic Patients?

To the Editor: We read with great interest the recent article published in a recent issue of Critical Care Medicine (June 17, 2016; online first) by Aso et al (1), Considering the hypothetical scenarios presented by Jo et al (1), all patients received a total infused volume below 7 L, which are below the theoretical cutoff for the eventual association between %LR and outcomes in our analysis (2). Therefore, if an association is to be found, it will likely be weak, if present at all. Nevertheless, we agree that receiving 4 L of a solution with a SID of zero would probably not be the most appropriate strategy, specially for a patient with heart failure and liver disease which are prone to retain water. We have examined this further and found that only 38 patients received more than 4 L of D5W during the first 48 hours while receiving less than 500 mL of either saline or lactated Ringer. Although we acknowledge that comorbidities may influence fluid type use, we do not believe that the attending physician would move from a isotonic crystalloid to an hypotonic glucose solution when aiming at fluid expansion and or maintenance, specially when water retention may play a role (3–5). We found no difference in the use of D5W in patients with and without cardiac failure (p = 0.106). Finally, we performed three simulations to predict mortality from a model that corrects for Simplified Acute Physiology Score (SAPS), total measured fluid volume and %NS, %LR, and %D5W. All are shown in the Figure 1. Total fluid received and SAPS were fixed at their median values. For the first simulation (black line), D5W was fixed at 50% and %LR