Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis
- Conditions
- ShockSeptic
- Interventions
- Registration Number
- NCT04102371
- Lead Sponsor
- Children's Hospital of Philadelphia
- Brief Summary
The objectives of this multicenter pragmatic clinical trial are to compare the effectiveness and relative safety of balanced fluid resuscitation versus 0.9% "normal" saline in children with septic shock, including whether balanced fluid resuscitation can reduce progression of kidney injury.
- Detailed Description
Approximately 5,000 children die from septic shock each year in the United States (US); thousands more die worldwide. Most children admitted with sepsis receive initial resuscitation in an emergency department (ED), where septic shock remains one of the most critical of illnesses treated by ED clinicians. Sepsis is also the most expensive hospital condition in the US, and the most common cause of pediatric multiple organ dysfunction syndrome (MODS). While all crystalloid fluids help to reverse shock, the most effective and safest type of crystalloid fluid resuscitation is unknown.
Crystalloid fluids can be categorized as non-buffered (most commonly 0.9% normal saline \[NS\]) or buffered/balanced fluids (BF). In the US, the most common BF is lactated Ringer's (LR), but other example include PlasmaLyte. NS and BF are inexpensive, stable at room temperature, and nearly universally available with identical storage volumes and dosing strategies. Notably, both are also of proven clinical benefit in septic shock and have extensive clinical experience for use in fluid resuscitation of critically ill patients. However, despite data suggesting that BF resuscitation may have superior efficacy and safety, NS remains the most commonly used fluid largely based on historical precedent.
To definitively test the comparative effectiveness of NS and BF, a well-powered randomized controlled trial (RCT) is necessary. A large pragmatic randomized trial embedded within everyday clinical practice provides a cost-efficient and generalizable approach to inform clinicians about best comparative effectiveness of common therapies. Data from a prior single-center feasibility study demonstrated that a pragmatic randomized clinical trial of NS versus BF for children with septic shock presenting to an emergency department is feasible and can be successfully carried out by embedding simple study procedures within routine clinical practice. This multi-center study that will now test for differential clinical effects, as part of a definitive comparative effectiveness trial, of NS versus BF for crystalloid resuscitation of pediatric septic shock.
This multicenter phase trial will include enrollment and study procedures across 30+ US and international sites to compare the effectiveness and relative safety of NS versus BF (LR and PlasmaLyte) for crystalloid resuscitation of children with septic shock. The primary endpoint is major adverse kidney events within 30 days along with other secondary clinical, safety, and kidney biomarker endpoints.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 8800
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Males or females age >2 months to <18 years
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Clinician concern for septic shock, operationalized as:
- a "positive" ED sepsis alert confirmed by a physician OR
- physician decision to treat for septic shock OR
- a physician diagnosis of septic shock requiring parenteral antibiotics and fluid resuscitation
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Administration of at least one IV/Intraosseous (IO) fluid bolus for resuscitation and additional fluid deemed likely to be necessary to treat poor perfusion, or clinician judgment that >1 fluid bolus is highly likely to be required. Poor perfusion is defined as physician's judgement of hypotension or abnormal (either "flash" or "prolonged") capillary refill.
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Receipt of ≤40 mL/kg IV/IO total crystalloid fluid prior to randomization
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Parental/guardian permission (informed consent) if time permits; otherwise, Exception from informed consent (EFIC) criteria met
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Treating physician judges that patient's condition deems it unsafe to administer either NS or BF (since patients will be equally likely to receive NS or BF at time of study enrollment), including:
- Clinical suspicion for impending brain herniation
- Known hyperkalemia, defined as non-hemolyzed whole blood or plasma/serum potassium > 6 mEq/L, based on data available at or before patient meets criteria for study enrollment
- Known hypercalcemia, defined as plasma/serum total calcium >12 mg/dL or whole blood ionized calcium >1.35 mmol/L, based on data available at or before patient meets criteria for study enrollment
- Known acute fulminant hepatic failure, defined as plasma/serum alanine aminotransferase (ALT) >10,000 U/L or total bilirubin >12.0 mg/dL, based on data available at or before patient meets criteria for study enrollment
- Known history of severe hepatic impairment, defined as cirrhosis, "liver failure", or awaiting transplant
- Known history of severe renal impairment, defined as peritoneal dialysis or hemodialysis
- Known metabolic/mitochondrial disorder, inborn error of metabolism, or primary mineralocorticoid deficiency as reported by participant, legally authorized representative (LAR) or accompanying caregiver, or as listed in the medical record
- Other concern for which the treating clinician deems it unsafe to administer either NS or LR
-
Known pregnancy determined by routine history disclosed by patient and/or accompanying acquaintance.
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Known prisoner
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Known allergy to a crystalloid fluid
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Indication of declined consent to participate based on presence of an opt-out bracelet with appropriate messaging embossed into the bracelet, the presence of the patient's name on an opt-out list that will be kept up-to-date and checked prior to randomization, or verbal "opt-out" prior to enrollment.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description 0.9% "Normal" Saline Fluid (NS) Normal Saline 0.9% "normal" saline (NS) fluid will be administered to patients randomized to the active comparator (control) arm. NS will be used for all fluid boluses and maintenance fluids (supplemental electrolytes are allowed) from time immediately after randomization through 11:59 pm of the next calendar day. The determination of when to give fluid, how much fluid to give, how fast to give fluid, and what access to use to administer fluid will remain at the discretion of the treating team. Balanced fluids (BF) Lactated Ringer Balanced fluids (BF), including Lactated Ringer's and Plasma-Lyte (PL), will be administered to patients randomized to the experimental arm. BF will be used for all fluid boluses and maintenance fluids (supplemental electrolytes are allowed) from time immediately after randomization through 11:59 pm of the next calendar day. The determination of when to give fluid, how much fluid to give, how fast to give fluid, and what access to use to administer fluid will remain at the discretion of the treating team. Balanced fluids (BF) Plasma-lyte Balanced fluids (BF), including Lactated Ringer's and Plasma-Lyte (PL), will be administered to patients randomized to the experimental arm. BF will be used for all fluid boluses and maintenance fluids (supplemental electrolytes are allowed) from time immediately after randomization through 11:59 pm of the next calendar day. The determination of when to give fluid, how much fluid to give, how fast to give fluid, and what access to use to administer fluid will remain at the discretion of the treating team.
- Primary Outcome Measures
Name Time Method Proportion of participants with Major Adverse Kidney Events within 30 days (MAKE30) Between randomization and 30 days post enrollment, discharge or death, whichever comes first. A composite of death, initiation of new inpatient renal replacement therapy (RRT), or persistent kidney dysfunction, at 30 days following study enrollment or hospital discharge, whichever comes first.
- Secondary Outcome Measures
Name Time Method Proportion of participants with persistent kidney dysfunction Censored at 30 days Final creatinine greater than or equal to 200% of baseline and a minimum absolute increase of greater than or equal to 0.3 mg/dL
Hospital-free days alive between randomization and day 27 With 27 days of randomization Calendar days alive and out of the hospital between day of randomization and study day 27
Proportion of participants with all-cause mortality at 90 days 90 days Vital status from medical chart and/or data from National Death Index
Proportion of participants with thromboembolism Within 7 calendar days of randomization Therapy for thromboembolism
Proportion of participants with new inpatient renal replacement therapy Censored at 30 days Treatment with any renal replacement therapy that was not a continuation of pre-hospital chronic therapy
Proportion of participants with catheter thrombosis Within 4 calendar days of randomization Catheter thrombosis in participants given Ceftriaxone and BF? (not LR?)
Proportion of participants with hyperlactatemia Within 4 calendar days of randomization At least 1 venous or arterial blood lactate measurement \>4mmol/L
Proportion of participants with hyperkalemia Within 4 calendar days of randomization At least 1 venous or arterial blood potassium measurement \>6 milliequivalents/Liter (mEq/L) (without hemolysis)
Proportion of participants with all-cause hospital mortality Hospital discharge-censored at 90 days Vital status at hospital discharge
Proportion of participants with hypercalcemia Within 4 calendar days of randomization At least 1 venous or arterial blood ionized calcium measurement of \>1.35 mEq/L or total calcium \>12 mEq/L
Proportion of participants with hypernatremia Within 4 calendar days of randomization At least 1 venous, arterial or capillary blood sodium measurement of \>155 mEq/L
Proportion of participants with hyponatremia Within 4 calendar days of randomization At least 1 venous, arterial or capillary blood sodium measurement of \<128 mEq/L
Proportion of participants with hyperchloremia Within 4 calendar days of randomization At least 1 venous, arterial or capillary blood chloride measurement of \>110 mEq/L
Proportion of participants with brain herniation Within 4 calendar days of randomization Treatment with hyperosmolar therapy (as long as a clinical diagnosis of brain herniation is not disproven by radiographic studies)
Trial Locations
- Locations (24)
UCSF Benioff Children's Hospital
🇺🇸San Francisco, California, United States
Cincinnati Children's Hospital Medical Center
🇺🇸Cincinnati, Ohio, United States
Primary Children's: University of Utah
🇺🇸Salt Lake City, Utah, United States
CHLA: Children's Hospital Los Angeles
🇺🇸Los Angeles, California, United States
Children's Colorado: University of Colorado
🇺🇸Denver, Colorado, United States
CS Mott Children's Hospital
🇺🇸Ann Arbor, Michigan, United States
UC Davis: University of California, Davis
🇺🇸Davis, California, United States
Boston Children's Hospital
🇺🇸Boston, Massachusetts, United States
Lurie Children's: Ann & Robert H. Lurie Children's Hospital of Chicago
🇺🇸Chicago, Illinois, United States
Children's Hospital of Atlanta
🇺🇸Emory, Georgia, United States
Washington University
🇺🇸Saint Louis, Missouri, United States
Columbia: New York-Presbyterian Hospital
🇺🇸New York, New York, United States
NYU Langone
🇺🇸New York, New York, United States
Nationwide Children's Hospital
🇺🇸Columbus, Ohio, United States
The Children's Hospital of Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Children's Hospital of Pittsburgh
🇺🇸Pittsburgh, Pennsylvania, United States
Dallas Children's: Children's Medical Center Dallas/UT southwestern
🇺🇸Dallas, Texas, United States
Texas Children's Hospital
🇺🇸Houston, Texas, United States
Universtity of Texas MD Anderson
🇺🇸Houston, Texas, United States
Children's Hospital of Richmond at VCU
🇺🇸Richmond, Virginia, United States
Children's National Medical Center
🇺🇸Columbia, Washington, United States
Seattle Children's Hospital
🇺🇸Seattle, Washington, United States
Milwaukee (MCW): Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Hasbro Children's Hospital
🇺🇸Providence, Rhode Island, United States