UMEM Educational Pearls

Title: Crystalloid fluid choice in Pediatric Sepsis

Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)

Posted: 10/25/2019 by Mimi Lu, MD
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Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment.
Recent publication from the adult literature have suggested that balance crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
Lactated Ringer's (LR) is a common balance crystalloid solution often used for fluid resuscitation and critically ill patients.
However whether resuscitation with balance fluids is associated with improved outcomes compared to NS in pediatric sepsis is unclear.
A matched retrospective cohort study of 12,529 pediatric patient with severe sepsis/septic shock at 382 US hospitals compared outcomes with versus without LR as a part of the initial resuscitation.
Outcomes includesd: 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.
After matching, mortality was not different between LR and NS groups. There were no differences in secondary outcomes except longer hospital length of stay in the LR groups.
The PRoMPT BOLUS randomized control trial pilot was a feasibility study designed to study the comparative effectiveness of LR versus NS fluid resuscitation for pediatic septic shock. Completion of a more robust study may help provide answers to these ongoing questions.

Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.

References

1. Weiss SL, Keele L, Balanmuth F, Vendetti N, Ross R, Fitzgerald JC, Gerber JS. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. J Pdatr.207 Mar:182:304-310.

2. Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med. 2019 Jun 10