Hyperchloremia in Critically ill Pediatric Patients, the HyCCiP Study
CCCF ePoster library. Bulfon A. Oct 2, 2017; 198098
Adrian Bulfon
Adrian Bulfon
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Abstract
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Hyperchloremia in Critically ill Pediatric Patients, the HyCCiP Study

Bulfon A1, Stef S2, Alomani H3, Vanniyasingam T 4, Comrie B 5, Zheng K 6, Laskey S 7, Panchal P8, Rochwerg B 9, Anton N 10, Choong K11


 

(1) Schulich School of Medicine and Dentistry, London, Canada



(2) Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada



(3) Departments of Pediatrics and Critical Care, McMaster University, Hamilton, Canada



(4) Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. Biostatistics Unit, Father Sean O’Sullivan Research Centre, St. Joseph’s Healthcare, Hamilton, ON, Canada



(5) Pediatric Critical Care, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta



(6) McMaster University, Hamilton, Canada



(7) McMaster University, Hamilton, Canada



(8) McMaster University, Hamilton, Canada



(9) 
Department of Critical Care, McMaster University, Hamilton, Canada



(10) Pediatric Critical Care, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta.



(11) Departments of Pediatrics and Critical Care, McMaster University, Hamilton, Canada. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada



 

Introduction:
The debate over what maintenance intravenous (IV) solution is the most appropriate for children has been ongoing for decades (1). Hypotonic fluids were the preferred choice for hospitalized pediatric patients(2). However, recent evidence has demonstrated that hypotonic fluids increase the risk of iatrogenic hyponatremia, its associated morbidities, and mortality (3-6). In contrast, isotonic fluids reduce the risk of hyponatremia (3-6) and are thus the currently recommended fluid of choice for maintenance IV fluids in children. However, it is unclear whether this has translated into clinical practice. Further, isotonic fluids may be associated with hyperchloremic metabolic acidosis (HCMA), which itself may be associated with increased morbidity and mortality (7-12).

Objectives:
In critically ill pediatric patients admitted to the Pediatric Intensive Care Units (PICU), we sought to evaluate:


  1. IV maintenance fluid prescription practice patterns

  2. The incidence of iatrogenic hyperchloremia and HCMA, as well as associated morbidities

  3. Predictors of HCMA in critically ill children 



Methods: This retrospective chart review was conducted at McMaster and Stollery Children’s Hospitals. All patients aged under 18 years admitted between January 1st, 2015 - January 31st, 2016, who received at least 50% of their maintenance fluid requirements parenterally, were included. The primary outcome was IV maintenance fluid prescription practices in the first 72 hours of admission. Secondary outcomes included the incidence of iatrogenic hyperchloremia and of HCMA in the first 72 hours of admission, predictors of iatrogenic HCMA, and the association between HCMA and clinical outcomes. We calculated that a sample size of 700 patients would enable us to achieve our primary and secondary outcomes. Descriptive analyses were used to present demographic data and the primary outcome, and regression analyses were used to evaluate the predictors of HCMA.

Results:
Of 771 patients admitted between January 1st, 2015 - January 31st, 2016, 541 were eligible. The median age was 69 months and 56% were males. 400 (74%) were medical patients and 141 (26%) were surgical patients. Normal Saline was the most commonly prescribed solution for IV maintenance over the first 72h of admission, followed by Ringer’s Lactate, and hypotonic solutions (Figure 1; 74.1%, 23.4%, and 2.5%, respectively). Ringer’s Lactate prescriptions increased while normal saline prescriptions decreased over time, in parallel to the daily prevalence of hyperchloremia. The incidence of hyperchloremia and HCMA over the first 72h of admission was 93.8% and 34.9%, respectively. Ongoing analyses will determine predictors of HCMA and their potential association with adverse events.
 
Conclusion:
Isotonic solutions comprised the overwhelming majority of IV maintenance fluid prescriptions, while balanced salt solutions are not used in these centers. Ringer’s lactate use increased over the first 72h in response to increasing hyperchloremia. Iatrogenic hyperchloremia and HCMA appears to be extremely common in PICUs, observed here at a rate much higher than that reported in critically ill adults. The results of this study will provide a rationale to evaluate what type of isotonic solutions may be more appropriate in critically ill children, in order to minimize IV fluid associated morbidities.   
 

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