Association between the use of balanced fluids and outcomes in critically ill children: a before and after study

Abstract

Background Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU). Methods A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities. Results Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65–1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p = < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p = < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p = < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS. Conclusions Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed.

Endothelial and Glycocalyx Biomarkers in Children With Sepsis After One Bolus of Unbalanced or Balanced Crystalloids*

“…Steppan et al (26) found a significant elevation of syndecan-1 levels in adult patients with sepsis following abdominal surgery, which was correlated with increased plasma levels of inflammatory biomarkers. Barhight et al (9) found a before-versus-after study of a change in fluid protocol using various crystalloids, an association with greater frequency of hyperchloremia (15.5% vs 10.4%; p < 0.0001) with the use of UBFs. Fernández-Sarmiento et al (8) found a greater odds of acute kidney injury and the need for renal replacement therapy in children with sepsis in association with fluid resuscitation with UBFs.…”

“…These children with hyperchloremia also had a greater risk of acute kidney injury associated with endothelial glycocalyx alterations 6 hours after receiving UBFs (9/15 vs 6/15; OR, 1.7; 95% CI, 1.12-3.18). In this regard, the patients with acute kidney injury had a longer PICU stay than those without kidney injury (11 d [IQR,(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)] vs 8 d [5-14 d], respectively; p = 0.03). Likewise, we found that patients who received UBF boluses and had metabolic acidosis, hyperchloremia, and an elevated PBR at time 2 had a greater risk of developing acute kidney injury (11/16 vs 5/16; aOR, 4.39; 95% CI, 1.28-14.98; p = 0.01).…”

“…Fluid resuscitation with crystalloids is part of the bundle of basic interventions recommended in recent guidelines for sepsis management of children with hemodynamic instability (2–4). However, there are contradictory data on what type of solution should be used (i.e., balanced or unbalanced crystalloid solution) (5–9). A meta-analysis and systematic review of pediatric patients receiving fluid boluses found higher pH and bicarbonate 4–12 hours after balanced fluids (BFs) compared with unbalanced fluids (UBFs) (10).…”

Intravenous fluid therapy and hospital outcomes for vaso‐occlusive episodes in children, adolescents, and young adults with sickle cell disease

“…19 The average hourly IVF rate received by each patient was compared to their estimated weight-based maintenance IVF (mIVF) rate, calculated using the Holliday-Segar method ("4-2-1 rule"), 20 because this period aligns with the resuscitation and stabilization phase of care. 21 New oxygen requirement was defined as documented supplemental oxygen above baseline requirement. ACS was identified using established criteria of pulmonary infiltrate on chest x-ray along with fever or respiratory symptoms.…”

Fluid bolus therapy in pediatric sepsis: a narrative review

“…In all other situations, balanced crystalloids are suggested as first-line crystalloids, especially in pediatric sepsis [ 13 , 17 ]. They should be used with caution in cases of anuria, although hyperkaliemia does not contraindicate their use in critically ill children [ 52 ]. Indeed, balanced crystalloids do not generate higher kalemia, because their [K + ] content is rapidly diluted in the extracellular fluid and the [K + ] shifting out of cells induced by normal saline-related hyperchloremic metabolic acidosis is much greater [ 53 , 54 ].…”