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Published on: June 6, 2011
Fluid resuscitation in children with severe infection and septic shock: a systematic review and meta-analysis
Jhuma Sankar1, Rashmi Ranjan Das2, Kiran Kumar Banothu3
1Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India. jhumaji@gmail.com.
Insights
Balanced crystalloids (BC) show no difference in mortality compared to normal saline (NS) for pediatric septic shock. However, BC significantly reduced acute kidney injury (AKI) risk in children. Further research on fluid bolus timing and volume is needed.
Area of Science:
- Pediatric Critical Care Medicine
- Resuscitation Science
- Nephrology
Background:
- Fluid resuscitation is critical for pediatric septic shock management.
- Balanced crystalloids (BC) are hypothesized to be superior to normal saline (NS) due to reduced hyperchloremia and acute kidney injury (AKI).
- Evidence comparing different fluid resuscitation strategies in children remains debated.
Purpose of the Study:
- To systematically review and meta-analyze the evidence on fluid therapy in pediatric septic shock.
- To compare the efficacy and safety of balanced crystalloids (BC) versus normal saline (NS).
- To evaluate the impact of fluid bolus volume and administration speed on mortality and AKI.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials.
- Included children (<18 years) with septic shock requiring fluid resuscitation.
- Compared interventions: BC vs. NS, colloids vs. NS, restricted vs. liberal fluid bolus, slow vs. fast fluid bolus.
Main Results:
- No significant difference in mortality was found between BC and NS, colloids and NS, restricted and liberal fluid bolus, or slow and fast fluid bolus.
- Balanced crystalloids (BC) significantly reduced the risk of acute kidney injury (AKI) compared to normal saline (NS).
- Certainty of evidence for mortality was moderate for BC vs. NS and very low for other comparisons.
Conclusions:
- Fluid type, speed, or volume did not significantly impact mortality in pediatric septic shock.
- Balanced crystalloids (BC) demonstrated a significant reduction in AKI risk compared to normal saline (NS).
- More research is required to establish optimal fluid bolus administration strategies in critically ill children.
Abstract:
This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with septic shock. Systematic review and meta-analysis of clinical trials including children less than 18 years of age admitted to the pediatric emergency and intensive care unit with severe infection and shock requiring fluid resuscitation. The intervention included balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The primary outcome was mortality rate. Of the 219 citations retrieved, 12 trials (3526 children with severe infection with or without malaria and shock) were included. The pooled results found no significant difference in the mortality rate between groups comparing balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The risk of acute kidney injury (AKI) was significantly less in the BC group compared to the NS group. The certainty of evidence for mortality was of "moderate certainty" in the BC vs NS group, and was of "very low certainty" for the other two groups.
Conclusions:
The current meta-analysis found no significant difference in the mortality rate between the types of resuscitation fluid, and their speed or volume of administration. However, a significantly decreased risk of AKI was found in the BC group. More evidence is needed regarding the speed and volume of administration of fluid boluses in critically ill children.Prospero registration: CRD42020209066.
What Is Known:
• Balanced crystalloids (BC) may be better than normal saline (NS) for fluid resuscitation in critically ill children.
What Is New:
• BC are better than NS for fluid resuscitation in critically ill children as they decrease AKI and hyperchloremia.
