Hyperchloremia Kills Kids

Written by Clay Smith

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Hyperchloremia (an increase ≥5meq/L) in the first day of PICU admission was independently associated with 2.3 times greater odds of in-hospital death in critically ill children.

Why does this matter?
We know lower chloride, balanced IV fluid reduced major adverse kidney events at 30 days (MAKE-30) in both critically ill adults (SMART), and in ED patients (SALT-ED). The benefit in the composite MAKE-30 outcome was largely driven by mortality improvement in SMART. This study explored whether hyperchloremia might be associated with harm in critically ill children.

Chloride kills
This was a retrospective study of 1,935 children 90 days to <18 years admitted to the PICU, DKA excluded. They found that if the chloride increased ≥5meq/L in the first day (12% of patients), odds of in-hospital mortality increased 2.3 times after adjustment for known confounders. Although causality can’t be proven in this study, the benefit of balanced fluid has been proven in adults: SMART and SALT-ED. So, it seems that use of balanced, lower chloride fluids would be a good option in critically ill children as well. Of course, hyperchloremia could simply be a marker of receiving more IV fluid, which indicates greater illness severity. But adjustment for such confounders makes the 2.3 times greater odds for mortality in hyperchloremic children believable as an independent risk factor.

Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med. 2018 Dec;44(12):2183-2191. doi: 10.1007/s00134-018-5424-1. Epub 2018 Oct 31.

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