Welcome to Facts on the Ground a new series brought to you by Natan Cramer from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.
To investigate whether or not balanced fluid (Lactated Ringer’s) is associated with reduced mortality versus unbalanced fluid (Normal Saline)
This was a matched retrospective cohort study using a national acute case database known as the Premier Healthcare database. Data were appraised from 2000-2013 in patients <18 years of age with ICD-9 coded severe sepsis or septic shock who were either given NS or LR balanced fluid boluses during the first 3 days of hospital admission. Inclusion was restricted to patients with blood cultures and broad spectrum antibiotic use within the first 3 days of admission. The hypothesis of the study is that balanced fluid is associated with improved pediatric sepsis mortality and acute kidney injury (AKI).
The primary outcome was 30 day hospital mortality in the NS vs. LR groups.
There was no significant difference in the matched cohort of LR and NS group vs. NS only group in mortality or AKI. Hospital length of stay was longer in the LR and NS group vs. the NS only group. There was no significant difference in the LR only group vs. NS only group in mortality nor in secondary outcomes, but similar to the LR and NS group, the LR only group had a longer length of stay.
This study is subject to sampling bias because it was a voluntary survey. It is also limited by criterion validity because it surveyed opinions and there was no assessment of actual performance. More than 30% of participants had not participated in a disaster response within the last four years.
This retrospective study was prone to misclassification bias, reducing the chance of finding a statistical difference between the bolus fluid types. Plasmalyte, a really balanced fluid was not evaluated. The study also does not account for pre-hospital administered fluids.
The Bottom Line
Per this retrospective study there are no large difference between NS and LR boluses in terms of the outcomes of mortality and AKI for pediatric sepsis. You should bolus to support perfusion using whoever you are comfortable with and what your institution uses, but know that a prospective study comparing balanced crystalloid to unbalanced fluid is needed.
Weiss et al. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. Journal of Pediatrics, 2017.