Abstract
INTRODUCTION: Fluid resuscitation is important intervention in children with septic shock. The composition, volume, and timing of resuscitation fluid (fluid boluses) are matter of debate. OBJECTIVE: To study the effects of balanced salt solution (BSS) versus normal saline (NS) as resuscitation fluids in pediatric septic shock. MATERIAL AND METHODS: We conducted this systematic review and meta-analysis using PRISMA guidelines and the protocol was registered at PROSPERO. We searched MEDLINE, Embase, LILAC, Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. Study screening, inclusion, data extraction, and risk of bias assessments were performed by two reviewers independently. Random-effects model was used for analysis of RCTs. We used Cochrane's risk of bias tool for assessing the quality of studies. Primary outcome was mortality and secondary outcomes were rates of acute kidney injury (AKI), need for renal replacement therapy (RRT), and adverse effects (hyperchloremia, metabolic acidosis, and fluid overload); and duration of PICU and hospital stay. RESULTS: Five RCTs with 992 children were included. Resuscitation with BSS versus NS was not associated with reduction in mortality (RR 0.82, 95% CI 0.45-1.50, p=0.52); with similar results on sensitivity analysis (RR 0.76, 95% CI 0.41-1.41, p=0.52). However, resuscitation with BSS was associated with lower rates of AKI (sensitivity analysis RR 0.64, 95% CI 0.50-0.82, p=0.0004); lesser need for RRT (RR 0.52, 95% CI 0.35-0.76, p=0.0008); and lower rate of hyperchloremia (RR 0.74, 95% CI 0.62-0.87, p=0.0002). The data is scant for other secondary outcomes (metabolic acidosis, fluid overload, and duration of PICU and hospital stay) to make any suggestions. The overall ‘risk of bias’ was low and unclear in most domains. DISCUSSION: In this systematic review and meta-analysis, we demonstrated that the use of BSS as resuscitation fluid in pediatric septic shock had no difference on mortality and duration of PICU or hospital stay as compared to NS. However, BSS group had significantly lower rates of hyperchloremia, AKI (on sensitivity analysis), and need of RRT. The results of several meta-analysis involving critically ill adults with shock also demonstrated that resuscitation with BSS was not associated with reduction in mortality, AKI, or need of RRT. However, there was some evidence that it may be associated with significant lower serum chloride levels. CONCLUSION: Use of BSS as resuscitation fluid in pediatric septic shock was not associated with reduction in mortality. However, BSS was associated with decreased risk of AKI, need of RRT, and hyperchloremia.