{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T07:19:29Z","timestamp":1789888769102,"version":"4.0.1"},"reference-count":26,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,7,29]],"date-time":"2021-07-29T00:00:00Z","timestamp":1627516800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,7,29]],"date-time":"2021-07-29T00:00:00Z","timestamp":1627516800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Crit Care"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009130) and a mortality rate of 2.8% (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200979) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65\u20131.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009\u2009&lt;\u20090.0001) and hyperkalemia (pre 3.2% vs. post 1.4%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009\u2009&lt;\u20090.0001) and hypokalemia (pre 38.2% vs. post 47.2%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009\u2009&lt;\u20090.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13054-021-03705-3","type":"journal-article","created":{"date-parts":[[2021,7,29]],"date-time":"2021-07-29T08:04:02Z","timestamp":1627545842000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Association between the use of balanced fluids and outcomes in critically ill children: a before and after study"],"prefix":"10.1186","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1954-5823","authenticated-orcid":false,"given":"Matthew F.","family":"Barhight","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Delphine","family":"Nelson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Moran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Christiano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L. Nelson","family":"Sanchez-Pinto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,7,29]]},"reference":[{"issue":"1","key":"3705_CR1","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1186\/s13049-016-0311-7","volume":"24","author":"JY Lee","year":"2016","unstructured":"Lee JY, Hong TH, Lee KW, Jung MJ, Lee JG, Lee SH. Hyperchloremia is associated with 30-day mortality in major trauma patients: a retrospective observational study. Scand J Trauma Resusc Emerg Med. 2016;24(1):117.","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"3705_CR2","doi-asserted-by":"publisher","first-page":"235","DOI":"10.1186\/1471-2369-14-235","volume":"14","author":"Z Zhang","year":"2013","unstructured":"Zhang Z, Xu X, Fan H, Li D, Deng H. Higher serum chloride concentrations are associated with acute kidney injury in unselected critically ill patients. BMC Nephrol. 2013;14:235.","journal-title":"BMC Nephrol"},{"issue":"9","key":"3705_CR3","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1111\/nep.12840","volume":"22","author":"Y Toyonaga","year":"2017","unstructured":"Toyonaga Y, Kikura M. Hyperchloremic acidosis is associated with acute kidney injury after abdominal surgery. Nephrology (Carlton). 2017;22(9):720\u20137.","journal-title":"Nephrology (Carlton)"},{"issue":"1","key":"3705_CR4","doi-asserted-by":"publisher","first-page":"315","DOI":"10.1186\/s13054-016-1499-7","volume":"20","author":"B Suetrong","year":"2016","unstructured":"Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315.","journal-title":"Crit Care"},{"issue":"9","key":"3705_CR5","doi-asserted-by":"publisher","first-page":"1938","DOI":"10.1097\/CCM.0000000000001161","volume":"43","author":"JA Neyra","year":"2015","unstructured":"Neyra JA, Canepa-Escaro F, Li X, Manllo J, Adams-Huet B, Yee J, Yessayan L. Group AKIiCIS: association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med. 2015;43(9):1938\u201344.","journal-title":"Crit Care Med"},{"issue":"9","key":"3705_CR6","doi-asserted-by":"publisher","first-page":"829","DOI":"10.1056\/NEJMoa1711584","volume":"378","author":"MW Semler","year":"2018","unstructured":"Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829\u201339.","journal-title":"N Engl J Med"},{"key":"3705_CR7","doi-asserted-by":"publisher","first-page":"1079","DOI":"10.1007\/s00467-018-3898-2","volume":"33","author":"MF Barhight","year":"2018","unstructured":"Barhight MF, Lusk J, Brinton J, Stidham T, Soranno DE, Faubel S, Goebel J, Mourani PM, Gist KM. Hyperchloremia is independently associated with mortality in critically ill children who ultimately require continuous renal replacement therapy. Pediatr Nephrol. 2018;33:1079.","journal-title":"Pediatr Nephrol"},{"issue":"12","key":"3705_CR8","doi-asserted-by":"publisher","first-page":"2183","DOI":"10.1007\/s00134-018-5424-1","volume":"44","author":"MF Barhight","year":"2018","unstructured":"Barhight MF, Brinton J, Stidham T, Soranno DE, Faubel S, Griffin BR, Goebel J, Mourani PM, Gist KM. Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med. 2018;44(12):2183\u201391.","journal-title":"Intensive Care Med"},{"issue":"2","key":"3705_CR9","doi-asserted-by":"publisher","first-page":"300","DOI":"10.1097\/00003246-200202000-00006","volume":"30","author":"JA Kellum","year":"2002","unstructured":"Kellum JA. Fluid resuscitation and hyperchloremic acidosis in experimental sepsis: improved short-term survival and acid-base balance with Hextend compared with saline. Crit Care Med. 2002;30(2):300\u20135.","journal-title":"Crit Care Med"},{"issue":"3","key":"3705_CR10","doi-asserted-by":"publisher","first-page":"726","DOI":"10.1172\/JCI110820","volume":"71","author":"CS Wilcox","year":"1983","unstructured":"Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Investig. 1983;71(3):726\u201335.","journal-title":"J Clin Investig"},{"issue":"1","key":"3705_CR11","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1097\/SLA.0b013e318256be72","volume":"256","author":"AH Chowdhury","year":"2012","unstructured":"Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte\u00ae 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012;256(1):18\u201324.","journal-title":"Ann Surg"},{"issue":"2","key":"3705_CR12","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1097\/PCC.0000000000001401","volume":"19","author":"EK Stenson","year":"2018","unstructured":"Stenson EK, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald JC, Checchia PA, Meyer K, et al. Hyperchloremia is associated with complicated course and mortality in pediatric patients with septic shock. Pediatr Crit Care Med. 2018;19(2):155\u201360.","journal-title":"Pediatr Crit Care Med"},{"issue":"1","key":"3705_CR13","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1056\/NEJMoa1611391","volume":"376","author":"A Kaddourah","year":"2016","unstructured":"Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med. 2016;376(1):11\u201320.","journal-title":"N Engl J Med"},{"issue":"8","key":"3705_CR14","doi-asserted-by":"publisher","first-page":"1411","DOI":"10.1007\/s00134-015-3934-7","volume":"41","author":"EA Hoste","year":"2015","unstructured":"Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41(8):1411\u201323.","journal-title":"Intensive Care Med"},{"issue":"Suppl 1","key":"3705_CR15","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s00134-019-05877-7","volume":"46","author":"SL Weiss","year":"2020","unstructured":"Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, et al. Executive summary: surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020;46(Suppl 1):1\u20139.","journal-title":"Intensive Care Med"},{"issue":"1","key":"3705_CR16","first-page":"1244","volume":"4","author":"MG Kahn","year":"2016","unstructured":"Kahn MG, Callahan TJ, Barnard J, Bauck AE, Brown J, Davidson BN, Estiri H, Goerg C, Holve E, Johnson SG, et al. A harmonized data quality assessment terminology and framework for the secondary use of electronic health record data. EGEMS (Wash DC). 2016;4(1):1244.","journal-title":"EGEMS (Wash DC)"},{"issue":"5","key":"3705_CR17","doi-asserted-by":"publisher","first-page":"743","DOI":"10.1097\/00003246-199605000-00004","volume":"24","author":"MM Pollack","year":"1996","unstructured":"Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med. 1996;24(5):743\u201352.","journal-title":"Crit Care Med"},{"key":"3705_CR18","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1186\/1471-2431-14-199","volume":"14","author":"C Feudtner","year":"2014","unstructured":"Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14:199.","journal-title":"BMC Pediatr"},{"issue":"4","key":"3705_CR19","doi-asserted-by":"crossref","first-page":"c179","DOI":"10.1159\/000339789","volume":"120","author":"A Khwaja","year":"2012","unstructured":"Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-184.","journal-title":"Nephron Clin Pract"},{"issue":"10","key":"3705_CR20","doi-asserted-by":"publisher","first-page":"1953","DOI":"10.1007\/s00467-017-3670-z","volume":"32","author":"E Hessey","year":"2017","unstructured":"Hessey E, Ali R, Dorais M, Morissette G, Pizzi M, Rink N, Jouvet P, Lacroix J, Phan V, Zappitelli M. Evaluation of height-dependent and height-independent methods of estimating baseline serum creatinine in critically ill children. Pediatr Nephrol. 2017;32(10):1953\u201362.","journal-title":"Pediatr Nephrol"},{"issue":"5","key":"3705_CR21","doi-asserted-by":"publisher","first-page":"1082","DOI":"10.1093\/ndt\/gft277","volume":"29","author":"L Hoste","year":"2014","unstructured":"Hoste L, Dubourg L, Selistre L, De Souza VC, Ranchin B, Hadj-Aissa A, Cochat P, Martens F, Pottel H. A new equation to estimate the glomerular filtration rate in children, adolescents and young adults. Nephrol Dial Transplant. 2014;29(5):1082\u201391.","journal-title":"Nephrol Dial Transplant"},{"issue":"7","key":"3705_CR22","doi-asserted-by":"publisher","first-page":"702","DOI":"10.1093\/aje\/kwh090","volume":"159","author":"G Zou","year":"2004","unstructured":"Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702\u20136.","journal-title":"Am J Epidemiol"},{"issue":"16","key":"3705_CR23","doi-asserted-by":"publisher","first-page":"1701","DOI":"10.1001\/jama.2015.12334","volume":"314","author":"P Young","year":"2015","unstructured":"Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, McGuinness S, Mehrtens J, Myburgh J, Psirides A, et al. Effect of a Buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: The SPLIT randomized clinical trial. JAMA. 2015;314(16):1701\u201310.","journal-title":"JAMA"},{"issue":"4","key":"3705_CR24","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1097\/ALN.0000000000003130","volume":"132","author":"K Maheshwari","year":"2020","unstructured":"Maheshwari K, Turan A, Makarova N, Ma C, Esa WAS, Ruetzler K, Barsoum S, Kuhel AG, Ritchey MR, Higuera-Rueda C, et al. Saline versus lactated Ringer\u2019s solution: the saline or lactated Ringer\u2019s (SOLAR) trial. Anesthesiology. 2020;132(4):614\u201324.","journal-title":"Anesthesiology"},{"key":"3705_CR25","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1016\/j.jcrc.2018.01.019","volume":"45","author":"K de Vasconcellos","year":"2018","unstructured":"de Vasconcellos K, Skinner DL. Hyperchloraemia is associated with acute kidney injury and mortality in the critically ill: a retrospective observational study in a multidisciplinary intensive care unit. J Crit Care. 2018;45:45\u201351.","journal-title":"J Crit Care"},{"issue":"9","key":"3705_CR26","doi-asserted-by":"publisher","first-page":"1938","DOI":"10.1097\/CCM.0000000000001161","volume":"43","author":"JA Neyra","year":"2015","unstructured":"Neyra JA, Canepa-Escaro F, Li X, Manllo J, Adams-Huet B, Yee J, Yessayan L. Acute kidney injury in critical illness study G: Association of Hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med. 2015;43(9):1938\u201344.","journal-title":"Crit Care Med"}],"container-title":["Critical Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13054-021-03705-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13054-021-03705-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13054-021-03705-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,1,5]],"date-time":"2023-01-05T16:04:56Z","timestamp":1672934696000},"score":1,"resource":{"primary":{"URL":"https:\/\/ccforum.biomedcentral.com\/articles\/10.1186\/s13054-021-03705-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,29]]},"references-count":26,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["3705"],"URL":"https:\/\/doi.org\/10.1186\/s13054-021-03705-3","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.3.rs-357546\/v1","asserted-by":"object"}]},"ISSN":["1364-8535"],"issn-type":[{"value":"1364-8535","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,29]]},"assertion":[{"value":"23 March 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 July 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 July 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The Institutional Review Board at Ann & Robert H. Lurie Children\u2019s Hospital approved the study with a waiver of informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"266"}}