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Association between the use of balanced fluids and outcomes in critically ill children: a before and after study
Matthew F Barhight1,2, Delphine Nelson3, Thomas Moran4
1Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA. mbarhight@luriechildrens.org.
Insights
Switching to balanced fluids in a pediatric intensive care unit did not change acute kidney injury rates. However, this change reduced hyperchloremia and hyperkalemia, while increasing hypochloremia and hypokalemia.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Intensive care
Background:
- Hyperchloremia and high chloride load are linked to adverse outcomes in critically ill patients.
- Fluid resuscitation strategies significantly impact electrolyte balance and patient prognosis.
Purpose of the Study:
- To assess the impact of transitioning from saline to balanced fluids on electrolyte profiles and clinical outcomes in a pediatric intensive care unit (PICU).
Main Methods:
- A before-and-after analysis of 2863 patients admitted to a PICU from August 2018 to March 2020.
- The intervention involved a unit-wide switch to balanced fluids for resuscitation and maintenance in June 2019.
- Primary outcome was day 3 acute kidney injury (AKI); secondary outcomes included mortality, ventilator-free days (VFDs), renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities.
Main Results:
- No significant difference in day 3 AKI rates (adjusted odds ratio 0.96) or other clinical outcomes post-intervention.
- Lower incidence of hyperchloremia (15.5% to 10.4%) and hyperkalemia (3.2% to 1.4%) observed.
- Increased rates of hypochloremia (9.5% to 14.4%) and hypokalemia (38.2% to 47.2%) were noted.
Conclusions:
- Unit-wide implementation of balanced fluids did not alter day 3 AKI or clinical outcomes in the PICU.
- The transition led to a significant reduction in hyperchloremia and hyperkalemia, but increased hypochloremia and hypokalemia.
- Further research is warranted to understand the clinical significance of these electrolyte shifts and the long-term effects of balanced fluids in critically ill children.
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.
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