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| EDITORIAL |
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| Year : 2021 | Volume
: 8
| Issue : 3 | Page : 121-122 |
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Plasmalyte versus normal saline as resuscitation fluids: Which one is better?
Ankit Mehta
Department of Pediatric Intensive Care, Zydus Hospital, Ahmedabad, Gujarat, India
| Date of Submission | 30-Apr-2021 |
| Date of Acceptance | 07-May-2021 |
| Date of Web Publication | 21-May-2021 |
Correspondence Address:
Dr. Ankit Mehta
Department of Pediatric Intensive Care, Zydus Hospital, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_40_21
How to cite this article:
Mehta A. Plasmalyte versus normal saline as resuscitation fluids: Which one is better?. J Pediatr Crit Care 2021;8:121-2 |
The concept of intravenous fluid is ever evolving. Fluid therapy now revolves around the ROSE concept where R stands for resuscitation, O stands for optimizations, S stands for stabilization, and E stands for evacuation. Resuscitation fluid is a lifesaving fluid therapy given over few minutes in amount ranging from 40 to 60 ml/kg as per new surviving sepsis guidelines depending on the availability of intensive care facilities. As per the latest guidelines, crystalloids versus balanced salt solution are the fluids of choice. Normal saline was used as the most common crystalloid as it was easily available, cheap, and time trusted.[1] However, over the last decade, many trials have brought out the higher incidence of hyperchloremic acidosis, increased incidence of acute kidney injury, need of renal replacement therapy, and mortality with the use of normal saline compared to balanced salt solution.[2],[3] Balanced salt solution is more physiological compared to normal saline because of the content of sodium, chloride, and pH.[4] There was a paucity of data in children regarding the use of normal saline versus plasmalyte as resuscitation fluids and its outcomes.
In the current issue of the Journal of Pediatric Critical Care, Arya et al. have drafted a randomized control trial of plasmalyte versus normal saline as resuscitation fluid in 400 children. They had seen the impact on acid–base balance, electrolytes, and lactate clearance at the end of 6 h. The study shows the advantage of using plasmalyte resulted in better acid–base profile as compared to normal saline group. The number of patients in the study group is 400 from the age group of 1 month to 14 years. Shock has not be subclassified in the current paper, and most of them have been hypovolemic shock as commonly seen in our country due to acute gastroenteritis. However, the amount of fluid given in each study subgroup has not been given in the study. The children who received plasmalyte had a better pH, less change in chloride and sodium, significantly lesser need for vasopressors (P = 0.04), shorter mean duration of hospital stay (P = 0.01), and lower mortality (P = 0.03) in initial 6 h.[5]
In the last decade, fluids have received the importance which was required. Fluids are part of primary supportive therapy in every sick child. Type, amount of fluids, composition of fluid, and rate of administration of resuscitation fluid therapy have to be seen in more in-depth details before prescribing.[6] In this issue of the journal, a study of composition of resuscitation fluid was studied which suggested favorable outcome in balanced salt solution group.
In the context of Indian subcontinent where cost of the drug does matter for majority of the population, we need to take this knowledge further and decide about the cohort of population where plasmalyte may be very useful. The cohort here refers to objective severity of illness, subgroup of shock, previous chloride levels at admission, and age group of children where we will benefit the patient more compared to others in subgroup. This is a wishful thought as plasmalyte is seven times costlier than normal saline in our country. Plasmalyte has been found useful in many of the previous adult studies and pediatric studies in acute gastroenteritis, perioperative care, diabetic ketoacidosis, and septic shock over number of parameters.[7],[8]
However, there are still many areas where balanced salt solution use has been looked into. In patients with traumatic brain injury, still normal saline holds age as few of the balanced salt solutions are hypotonic. For patients with hypochloremic hyponatremia with metabolic alkalosis, normal saline remains the fluid of choice. Due to availability of different compositions of balanced salt solution, we need to look into the clinical outcomes with different solutions.[8],[9] Important questions remain regarding the mechanism by which balanced crystalloids may influence clinical outcomes, which patients are most likely to benefit from balanced crystalloids versus saline, and whether clinical outcomes differ between the available balanced crystalloids.
| References | |  |
| 1. | Santhanam I, Sangareddi S, Venkataraman S, Kissoon N, Thiruvengadamudayan V, Kasthuri RK. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatr Emerg Care 2008;24:647-55.  |
| 2. | Sankar J, Ismail J, Sankar MJ, CP Suresh, Meena RS. Fluid bolus over 15-20 versus 5-10 minutes each in the first hour of resuscitation in children with septic shock: A randomized controlled trial. Pediatr Crit Care Med 2017;18:e435-45. |
| 3. | Inwald DP, Canter R, Woolfall K, Mouncey P, Zenasni Z, O'Hara C, et al. Restricted fluid bolus volume in early septic shock: Results of the Fluids in Shock pilot trial. Arch Dis Child 2019;104:426-31. |
| 4. | Weiss SL, Keele L, Balamuth F, Vendetti N, Ross R, Fitzgerald JC, et al. Crystalloid fluid choice and clinical outcomes in pediatric sepsis: A matched retrospective cohort study. J Pediatr 2017;182:304-10.e10. |
| 5. | Arya V, Kavitha M, Mittal K, Gehlawat VK. Plasmalyte versus normal saline as resuscitation fluid in children: A randomized controlled trial. J Pediatr Crit Care 2021;8:134-8. [Full text] |
| 6. | Emrath ET, Fortenberry JD, Travers C, McCracken CE, Hebbar KB. Resuscitation with balanced fluids is associated with improved survival in pediatric severe sepsis. Crit Care Med 2017;45:1177-83. |
| 7. | Bampoe S, Odor PM, Dushianthan A, Bennett-Guerrero E, Cro S, Gan TJ, et al. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures. Cochrane Database Syst Rev 2017;9:CD004089. |
| 8. | McFarlane C, Lee A. A comparison of plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia 1994;49:779-81. |
| 9. | Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg 2008;107:264-9. |
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