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Background: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU).We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods: Critically ill children aged ≤ 3 years and invasively ventilated for ≥48 hours between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 hours following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004±284 ml of water daily (153±36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4±4.8 mEq/kg/day of sodium and 13.6± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417±221 ml (64±30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p <0.001). Conclusions: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.

Background: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU).We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods: Critically ill children aged ≤ 3 years and invasively ventilated for ≥48 hours between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 hours following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004±284 ml of water daily (153±36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4±4.8 mEq/kg/day of sodium and 13.6± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417±221 ml (64±30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p <0.001). Conclusions: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.

BACKGROUND: Chloride-rich fluids have been found to associate with an increased risk for acute kidney injury (AKI) among intensive care unit (ICU) patients. Studies evaluating the association of plasma chloride (Cl) with the development of AKI are few. We hypothesized that higher plasma Cl is associated with an increased risk for the development of AKI. METHODS: In this sub-study of the prospective FINNAKI study, we analyzed Cl values measured during ICU stay in two ICUs at a tertiary center including 445 patients. We calculated time-weighted mean values within the first 24h in ICU for plasma Cl (ClTWM 24). We analyzed the association of ClTWM 24 primarily with the development of AKI, and secondarily with 90-day mortality. RESULTS: Based on the first measured Cl value, 350 of 445 patients [78.7 (95 CI, 74.8-82.5)] had hyperchloremia (PCl >106 mmol/L) and 48 [10.8 (95 CI, 7.9-13.7)] severe hyperchloremia (P-Cl > 114 mmol/L). Altogether 217 of 445 [48.8% (95% CI 44.2-53.4%)] patients developed AKI. Of these 217, AKI was diagnosed in 62 (28.6%) after 24h from ICU admission and were included in the analysis regarding development of AKI. ClTWM 24 was associated with an increased risk for the development of AKI (OR1.099; 1.003-1.205) after multivariable adjustments. According to ClTWM 24, no difference in 90-day mortality between severely hyperchloremic patients and others existed. CONCLUSIONS: More than three of four critically ill patients had hyperchloremia and one of ten had its severe form. Higher time-weighted mean chloride was independently associated with an increased risk for AKI.

Since its first reported use during the cholera pandemic in 1831, the potential pitfalls of sodium chloride (saline) as a resuscitative fluid for hypovolemic conditions have been described in numerous animal and human studies (1). Decrease in strong ion difference (SID) leading to hyperchloremic metabolic acidosis (2) and resultant effects on renal blood flow and renal insufficiency (3) and even potential immune dysfunction (4) are well-known phenomenon linked to saline-based resuscitation. Recent clinical studies have highlighted some of these deleterious effects. In a randomized, controlled, double-blinded, crossover study in 12 healthy volunteers, Chowdhury et al (5) demonstrated sustained hyperchloremia, reduced SID, and decreased mean renal artery velocity and renal cortical tissue perfusion when normal (0.9%) saline was administered compared with a more balanced crystalloid solution. In another single-center, prospective, sequential period study, Yunos et al (6) demonstrated significantly less acute kidney injury (AKI) and use of renal replacement therapy after the institution of a chloride restrictive resuscitation strategy when compared with a more liberal saline-based strategy used in the previous 6 months. Yet, despite these well-described deleterious effects, normal saline remains the most commonly used resuscitative crystalloid solution used today (7) and has often been the control fluid used in preclinical and clinical studies comparing resuscitation strategies. Aside from being inexpensive and compatible with many drugs and blood products, its common use likely reflects continued questions surrounding the true clinical significance of hyperchloremia., Published in Critical Care Medicine, v42 n4 p1009-1010, Apr 2014. Prepared in collaboration with the Uniformed Services University of the Health Sciences, Bethesda, MD, and the University of Texas Health Sciences Center San Antonio.