Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study

J Pediatr. 2017 Mar;182:304-310.e10. doi: 10.1016/j.jpeds.2016.11.075. Epub 2017 Jan 4.


Objective: To test the hypothesis that resuscitation with balanced fluids (lactated Ringer [LR]) is associated with improved outcomes compared with normal saline (NS) in pediatric sepsis.

Study design: We performed matched analyses using data from 12 529 patients <18 years of age with severe sepsis/septic shock at 382 US hospitals between 2000 and 2013 to compare outcomes with vs without LR as part of initial resuscitation. Patients receiving LR were matched 1:1 to patients receiving only NS (NS group), including separate matches for any (LR-any group) or exclusive (LR-only group) LR use. Outcomes included 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.

Results: The LR-any group was older, received larger crystalloid volumes, and was less likely to have malignancies than the NS group. After matching, mortality was not different between LR-any (7.2%) and NS (7.9%) groups (risk ratio 0.99, 95% CI 0.98, 1.01; P = .20). There were no differences in secondary outcomes except longer hospital length of stay in LR-any group (absolute difference 2.4, 95% CI 1.4, 5.0 days; P < .001). Although LR was preferentially used as adjunctive fluid with large-volume resuscitation or first-line fluid in patients with lower illness severity, outcomes were not different after matching stratified by volume and proportionate LR utilization, including for patients in the LR-only group.

Conclusions: Balanced fluid resuscitation with LR was not associated with improved outcomes compared with NS in pediatric sepsis. Although the current practice of NS resuscitation is justified, selective LR use necessitates a prospective trial to definitively determine comparative effectiveness among crystalloids.

Keywords: balanced fluids; critically ill children; crystalloids; isotonic saline; mortality; sepsis.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Adolescent
  • Age Factors
  • Case-Control Studies
  • Cause of Death
  • Child
  • Child, Preschool
  • Cohort Studies
  • Crystalloid Solutions
  • Databases, Factual
  • Female
  • Fluid Therapy / methods
  • Fluid Therapy / mortality
  • Hospital Mortality / trends*
  • Humans
  • Infant
  • Intensive Care Units, Pediatric
  • Isotonic Solutions / administration & dosage*
  • Male
  • Prognosis
  • Resuscitation / methods*
  • Resuscitation / mortality
  • Retrospective Studies
  • Ringer's Lactate
  • Risk Assessment
  • Sepsis / diagnosis
  • Sepsis / mortality*
  • Sepsis / therapy*
  • Sex Factors
  • Shock, Septic / diagnosis
  • Shock, Septic / mortality
  • Shock, Septic / therapy
  • Sodium Chloride / administration & dosage
  • Survival Analysis


  • Crystalloid Solutions
  • Isotonic Solutions
  • Ringer's Lactate
  • Sodium Chloride