Effect of Saline vs Gluconate/Acetate–Buffered Solution vs Lactate-Buffered Solution on Serum Chloride Among Children in the Pediatric Intensive Care Unit

Abstract

ImportanceMost children admitted to pediatric intensive care units (PICUs) receive intravenous fluids. A recent systematic review suggested mortality benefit in critically ill adults treated with balanced solutions compared with sodium chloride, 0.9% (saline). There is a lack of clinically directive data on optimal fluid choice in critically ill children.ObjectiveTo determine if balanced solutions decrease the rise of plasma chloride compared with saline, 0.9%, in critically ill children.Design, Setting, and ParticipantsThis single-center, 3-arm, open-label randomized clinical trial took place in a 36-bed PICU. Children younger than 16 years admitted to the PICU and considered to require intravenous fluid therapy by the treating clinician were eligible. Children were screened from November 2019 to April 2021.InterventionsEnrolled children were 1:1:1 allocated to gluconate/acetate–buffered solution, lactate-buffered solution, or saline as intravenous fluids.Main Outcomes and MeasuresThe primary outcome was an increase in serum chloride of 5 mEq/L or more within 48 hours from randomization. New-onset acute kidney injury, length of hospital and intensive care stay, and intensive care–free survival were secondary outcomes.ResultsA total of 516 patients with a median (IQR) age of 3.8 (1.0-10.4) years were randomized with 178, 171, and 167 allocated to gluconate/acetate–buffered solution, lactate-buffered solution, and saline, respectively. The serum chloride level increased 5 mEq/L or more in 37 patients (25.2%), 34 patients (23.9%), and 58 patients (40.0%) in the gluconate/acetate–buffered solution, lactate-buffered solution, and saline groups. The odds of a rise in plasma chloride 5 mEq/L or more was halved with the use of gluconate/acetate–buffered solution compared with saline (odds ratio, 0.50 [95% CI, 0.31-0.83]; P = .007) and with the use of lactate-buffered solution compared with saline (odds ratio, 0.47 [95% CI, 0.28-0.79]; P = .004). New-onset acute kidney injury was observed in 10 patients (6.1%), 6 patients (3.7%), and 5 patients (3.2%) in the gluconate/acetate–buffered solution, lactate-buffered solution, and saline groups, respectively.Conclusions and RelevanceBalanced solutions (gluconate/acetate–buffered solution and lactate-buffered solution) administered as intravenous fluid therapy reduced the incidence of rise in plasma chloride compared with saline in children in PICU.Trial Registrationanzctr.org.au Identifier: ACTRN12619001244190

A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO)

“…This finding is consistent with a systematic review and subsequent randomized trial in adult kidney transplant recipients, and a randomized trial in children on intensive care. 23 , 24 , 25 A recent randomized trial in deceased donor kidney transplant recipients found that Plasma-Lyte-148 reduced the incidence of delayed graft function compared with 0.9% sodium chloride; our study did not assess this outcome in children. 26 We observed no difference in transplant kidney function, graft survival, or patient survival between the Plasma-Lyte-148 and standard fluid groups, although the study was not powered for these outcomes.…”

Comparisons of Electrolyte Balance Efficacy of Two Gelatin-Balanced Crystalloid for Surgery Patients Under General Anesthesia: A Multi-Center, Prospective, Randomized, Single-Blind, Controlled Study

“…Massive infusion of SGI is inevitably accompanied by an infusion of large amount of chlorine, thus increasing the risk of hyperchloremic metabolic acidosis. 7 , 8 For SG-MESAI, sodium acetate solution, which contains potassium chloride, magnesium chloride, and sodium acetate, is used as the carrier instead of sodium chloride. Therefore, SG-MESAI can greatly reduce the risk of hyperchloremia after infusion while maintaining electrolyte-fluid and acid-base balance.…”

“…The subjects were excluded if they met any of the following exclusion criteria: (1) severe hypernatremia, hyperchloremia, and hypercalcemia before surgery, defined as serum sodium>152 mmol/L, serum calcium>12 mg/dL (>3.00 mmol/L), or serum chlorine>1.06 mmol/L. Assessment was made by combining laboratory tests with clinical manifestations, including sleepiness, coma, delirium, and insanity; 2) pulmonary edema, cerebral edema, intracranial hemorrhage, and heart failure; (3) liver and kidney function indicators more than twice the upper limit of the normal range; 4) having a history of organic brain diseases or cerebral hemorrhage, having organic heart diseases or wearing a cardiac stent, and having a history of mental illnesses and disturbance of consciousness; (5) abnormal results on coagulation function test and electrolyte test (abnormalities assessed by investigators as clinically significant); (6) having received dialysis treatment within one month before surgery; (7) having been judged as lacking the capacity to give informed consent; (8) having participated in other drug clinical trials in the past three months; (9) having a known allergy to the investigational drug and/or its ingredients (eg, gelatin plasma substitute, α-galactose); (10) having a history of hypothyroidism; (11) pregnancy, lactation, or preparing for pregnancy; (12) scheduled for neurosurgery; (13) any other conditions that disqualified the subjects for the present study, as judged by the investigator.…”

Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis

“…After reviewing the titles and abstracts, 1, 334 articles were excluded, and 59 studies were selected for the second screening after additionally excluding 64 duplicated studies. Finally, 13 full-text articles involving 38,798 patients were included in this meta-analysis [11,[22][23][24][25][26][27][28][29][30][31][32][33]. Of these studies, 10 were randomized controlled trials (RCTs), and 3 were cohort studies.…”