Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study

Abstract

Objective: To test the hypothesis that resuscitation with balanced fluids (lactated Ringer [LR]) is associated with improved outcomes compared with normal saline (NS) in pediatric sepsis.

Study design: We performed matched analyses using data from 12 529 patients <18 years of age with severe sepsis/septic shock at 382 US hospitals between 2000 and 2013 to compare outcomes with vs without LR as part of initial resuscitation. Patients receiving LR were matched 1:1 to patients receiving only NS (NS group), including separate matches for any (LR-any group) or exclusive (LR-only group) LR use. Outcomes included 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.

Results: The LR-any group was older, received larger crystalloid volumes, and was less likely to have malignancies than the NS group. After matching, mortality was not different between LR-any (7.2%) and NS (7.9%) groups (risk ratio 0.99, 95% CI 0.98, 1.01; P = .20). There were no differences in secondary outcomes except longer hospital length of stay in LR-any group (absolute difference 2.4, 95% CI 1.4, 5.0 days; P < .001). Although LR was preferentially used as adjunctive fluid with large-volume resuscitation or first-line fluid in patients with lower illness severity, outcomes were not different after matching stratified by volume and proportionate LR utilization, including for patients in the LR-only group.

Conclusions: Balanced fluid resuscitation with LR was not associated with improved outcomes compared with NS in pediatric sepsis. Although the current practice of NS resuscitation is justified, selective LR use necessitates a prospective trial to definitively determine comparative effectiveness among crystalloids.

Keywords: balanced fluids; critically ill children; crystalloids; isotonic saline; mortality; sepsis.

Conflict of interest statement

The authors declare no conflicts of interest.

Copyright © 2016 Elsevier Inc. All rights reserved.

Figures

Figure 4

Hospital mortality for LR-any and NS groups matched within quartile of total crystalloid fluid volume. The x-axis categorizes patients based on quartile of total fluid crystalloid volume received after correcting by estimated weight for age (median total volume in Q1 = 8 mL/kg, Q2 = 17 mL/kg, Q3 = 32 mL/kg, and Q4 = 68 mL/kg). The y-axis shows the adjusted 30-day mortality rate. Patients in the LR-any group were matched within volume quartile to patients who received only NS. There were no significant differences in mortality between the LR-any and NS groups within any of the total volume quartiles.