Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia?

Abstract

Our objective is to evaluate intravenous (IV) fluid prescription practice patterns in critically ill children in the first 72 hours of pediatric intensive care unit (PICU) admission and to evaluate the incidence and predictors of hyperchloremic metabolic acidemia (HCMA) and the association between HCMA and adverse outcomes. This retrospective cohort study was conducted in two tertiary-care Canadian PICUs. Children aged 0 to 18 years admitted to the PICU between January 2015 and January 2016 who received at least 50% of their calculated maintenance fluid requirements parenterally during the first 24 hours of admission were included. Children with known preexisting conditions associated with HCMA, such as renal tubular acidosis and gastrointestinal bicarbonate losses, were excluded. Of the 771 children screened, 543 met eligibility criteria and were included. The commonest prescribed maintenance fluid was 0.9% NaCl (72.9%) followed by lactated Ringer's solution (19.6%) and hypotonic solutions (4.6%). Balanced salt solutions (i.e., lactated Ringer's and Plasma-Lyte) were as commonly administered as unbalanced solutions (0.9% NaCl) for volume expansion (49.6 vs. 48.5%, respectively). Medications contributed to a significant proportion of total daily intake, in excess of bolus fluids. The incidence of hyperchloremia and HCMA was 94.9% (95% confidence interval [CI]: 93.2–96.9; 470/495) and 38.9% (95% CI: 34.6–43.2; 196/504), respectively. Predictors of HCMA were increasing combined bolus and maintenance 0.9% NaCl intake (odds ratio: 1.13; 95% CI: 1.04–1.23) and increasing severity of illness. HCMA was not associated with an increased risk of acute kidney injury, feeding intolerance, or PICU-acquired weakness. Isotonic fluids, specifically 0.9% NaCl, were the most commonly administered maintenance IV fluid in critically ill children. Sources of chloride load are not isolated to resuscitation fluids as previously suggested. Maintenance fluids and fluids administered with medications and IV flushes (fluid creep) are under-recognized significant sources of fluid and electrolyte intake in critically ill children. HCMA is common, and further prospective research is required to determine whether HCMA is indeed harmful in children. However, all significant sources of fluid should be accounted for in the design of future trials comparing balanced and unbalanced salt solutions.

Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study

“…The median length of hospital stay of all the included patients was 17 days (IQR 9-34). The group receiving hypotonic solutions had a longer stay (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38) than the group receiving isotonic solutions (14 days IQR 8-30) (p = 0.000). The use of hypotonic solutions was associated with 8 more days of total hospital stay (difference in means 8, 95% CI 2.67, 13.3, p = 0.001) (Figure 2A).…”

Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children

“…Pediatric studies, although smaller in size, have demonstrated a similar trend in the volume burden associated with maintenance fluids. 14 , 15 Maintenance fluids are primarily used to prevent dehydration and to provide a source of glucose to prevent starvation ketosis. However, our data demonstrate that maintenance fluids are frequently given to patients with fluid in excess of hydration requirements and this practice may represent iatrogenic harm.…”

“…Studies in children have also demonstrated that a large fluid burden may result from non-resuscitation fluids, especially maintenance fluids. 14 , 15 Recently, Al-Lawati et al 15 demonstrated that fluid exposure frequently exceeded hydration requirements on day 3 of pediatric intensive care unit (PICU) admission. However, the degree to which non-resuscitation fluid in excess of hydration requirements impacts clinical outcomes has not been previously studied.…”

0.9% Sodium chloride solution versus Plasma-Lyte 148 versus compound sodium lacTate solution in children admitted to PICU—a randomized controlled trial (SPLYT-P): study protocol for an intravenous fluid therapy trial

“…Compound Sodium Lactate (CSL), containing lower sodium and chloride content, has been available and in use for nearly a century [ 3 ]. More recently, Plasma-Lyte 148 (PL) has become available as an alternative balanced fluid (composition closer to plasma) with a higher sodium concentration as compared to CSL (Additional file 1 ) [ 10 ].…”