Balanced Salt Solutions vs. Normal Saline in Children With Septic Shock

Fluid resuscitation is the cornerstone of pediatric shock management; current practices of fluid resuscitation in children are not evidence based. Normal saline is the preferred crystalloid recommended during initial resuscitation in shock, as the incidence of hyponatremia is lower with normal saline compared to all other fluids available and commonly used.  However, normal saline has its own set of undesired physicochemical actions. Emerging data strongly indicate the increased incidence of hyperchloremia,  metabolic acidosis and consequently, acute kidney injury associated with infusion of large volumes of normal saline. Balanced salt solutions or crystalloids, which have composition resembling plasma but lower chloride concentrations than normal saline, clearly decrease the risk of hypercholremia and metabolic acidosis in adult as well as pediatric studies when used during the peri-operative period. The results favored balanced solutions in comparison to normal saline. However, in the non-surgical setting there is a paucity of evidence on the use of these solutions in children with shock and more evidence needs to be generated to support or refute the use of this fluid as compared to normal saline. Given this background, we decided to compare the two solutions on the incidence of acute kidney injury in the first 7 days in children resuscitated with either of the two fluids. Children receiving volumes of atleast 40 ml/kg in the first hour of resuscitation as boluses would be enrolled and followed up for the proposed outcome variables till death/discharge. We plan to enrol 708 subjects over a period of 3 years. We believe that the proposed study will provide the definitive answer to the optimum crystalloid to be used for fluid resuscitation in children with shock due to hypovolemia or sepsis.