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Septic Kids (And Their Kidneys) Like Balanced Fluids

December 28, 2023

Written by Alex Clark

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The use of balanced crystalloid (PlasmaLyte A) rather than normal saline (0.9% sodium chloride) reduced acute kidney injury and improved other outcomes in these pediatric patients with septic shock.

Don’t forget the KID(NEY)s!
This well-done multi-center, triple-blinded randomized controlled trial performed in both pediatric EDs and ICUs in India examined balanced crystalloid (specifically PlasmaLyte A) versus NS in children with septic shock. All patients received at least one 20 mL/kg bolus, and all subsequent boluses used the same blinded fluid. However, maintenance fluids were not controlled, and their composition was left to the discretion of the primary treatment team.

The primary outcome was new or progressive AKI within 7 days of initial bolus. AKI was defined as an absolute increase in serum creatinine ≥ 0.3 mg/dL, an increase 1.5x the preceding creatinine value, or urine output ≤ 0.5 mL/kg/hr for any 6-hr period. Secondary outcomes included all-cause ICU mortality, adverse effects of hyperchloremia and metabolic acidosis, renal replacement therapy within 7 days, and others.

A total of 708 children were randomized between the balanced crystalloid (n = 351) and NS (n = 357) cohorts. Balanced crystalloid had statistically lower rates of AKI at 7 days (21%) compared to saline (33%), RR 0.62 (95%CI 0.49-0.80, p<0.001). The balanced crystalloid group was also less likely to be treated with renal replacement therapy (9% vs. 16%, p = 0.006). ICU mortality was about the same: balanced crystalloid 33% vs NS 34%; RR 0.97 (95%CI 0.79 to 1.2).

How will this change my practice?
Off the top of my head, I can think of only two situations where I currently give normal saline: hypovolemic metabolic alkalosis and at the Children’s Hospital. Sure, kids aren’t simply little adults. But a little kidney might just be that – a little kidney. This study supports the SMART trial and other recent meta-analyses in adults that favor balanced crystalloids in critically ill adults with sepsis and septic shock. A larger, more generalizable cohort of patients would be beneficial – the SMART trial examined 7,942 patients compared to only 708 above. With several multi-national RCTs (such as PRoMPT) in the works, my prediction is that balanced crystalloid resuscitation may be coming to your pediatric ER or ICU in the not-so-distant future.

Source
Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med. 2023 Nov 1;51(11):1449-1460. doi: 10.1097/CCM.0000000000005952. Epub 2023 Jun 9.