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Effect of Saline vs Gluconate/Acetate-Buffered Solution vs Lactate-Buffered Solution on Serum Chloride Among Children
Sainath Raman1,2, Kristen S Gibbons1, Adrian Mattke1,2
1Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
Insights
Balanced intravenous fluids, including buffered solutions, significantly reduced elevated plasma chloride levels in critically ill children compared to saline. This finding supports using balanced solutions for pediatric intensive care unit patients.
Area of Science:
- Pediatric critical care medicine
- Intravenous fluid therapy
- Electrolyte balance
Background:
- Intravenous fluids are commonly administered to pediatric intensive care unit (PICU) patients.
- Evidence in adults suggests balanced solutions may improve outcomes compared to saline.
- Optimal fluid choice in critically ill children remains unclear.
Purpose of the Study:
- To compare the effects of balanced solutions versus saline on plasma chloride levels in critically ill children.
- To assess the incidence of increased serum chloride (≥5 mEq/L) within 48 hours of randomization.
Main Methods:
- A single-center, open-label, randomized clinical trial involving 516 children under 16 years old in a 36-bed PICU.
- Participants were randomized 1:1:1 to receive either a gluconate/acetate-buffered solution, a lactate-buffered solution, or 0.9% saline.
- Primary outcome was a rise in serum chloride of 5 mEq/L or more within 48 hours; secondary outcomes included acute kidney injury and length of stay.
Main Results:
- The incidence of a ≥5 mEq/L rise in plasma chloride was 25.2% with gluconate/acetate, 23.9% with lactate, and 40.0% with saline.
- Balanced solutions (gluconate/acetate and lactate) significantly reduced the odds of increased plasma chloride compared to saline (OR 0.50 and 0.47, respectively).
- New-onset acute kidney injury rates were similar across groups (6.1%, 3.7%, and 3.2%).
Conclusions:
- Balanced intravenous fluid solutions effectively reduce the incidence of elevated plasma chloride levels in critically ill children compared to saline.
- These findings support the use of balanced crystalloids for fluid therapy in pediatric intensive care settings.
- Further research may explore long-term clinical outcomes associated with different fluid choices.
Importance:
Most 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.
Objective:
To determine if balanced solutions decrease the rise of plasma chloride compared with saline, 0.9%, in critically ill children.
Design, Setting, And Participants:
This 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.
Interventions:
Enrolled children were 1:1:1 allocated to gluconate/acetate-buffered solution, lactate-buffered solution, or saline as intravenous fluids.
Main Outcomes And Measures:
The 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.
Results:
A 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 Relevance:
Balanced 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 Registration:
anzctr.org.au Identifier: ACTRN12619001244190.
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