title: The great fluid debate: saline or so-called "balanced" salt solutions?
abstract: BACKGROUND
  Intravenous fluids are commonly prescribed in childhood. 0.9 % saline is the most-used fluid in pediatrics as resuscitation or maintenance solution. Experimental studies and observations in adults suggest that 0.9 % saline is a poor candidate for fluid resuscitation. Although anesthesiologists, intensive care specialists, perioperative physicians and nephrologists have been the most active in this debate, this issue deserves some physiopathological considerations also among pediatricians.
  
  
  RESULTS
  As compared with so-called "balanced" salt crystalloids such as lactated Ringer, administration of large volumes of 0.9 % saline has been associated with following deleterious effects: tendency to hyperchloremic metabolic acidosis (called dilution acidosis); acute kidney injury with reduced urine output and salt retention; damaged vascular permeability and stiffness, increase in proinflammatory mediators; detrimental effect on coagulation with tendency to blood loss; detrimental gastrointestinal perfusion and function; possible uneasiness at the bedside resulting in unnecessary administration of more fluids. Nevertheless, there is no firm evidence that these adverse effects are clinically relevant.
  
  
  CONCLUSIONS
  Intravenous fluid therapy is a medicine like insulin, chemotherapy or antibiotics. Prescribing fluids should fit the child's history and condition, consider the right dose at the right rate as well as the electrolyte levels and other laboratory variables. It is unlikely that a single type of fluid will be suitable for all pediatric patients. "Balanced" salt crystalloids, although more expensive, should be preferred for volume resuscitation, maintenance and perioperatively. Lactated Ringer appears unsuitable for patients at risk for brain edema and for those with overt or latent chloride-deficiency. Finally, in pediatrics there is a need for new fluids to be developed on the basis of a better understanding of the physiology and to be tested in well-designed trials.
authors.affiliation: Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.
authors.forename: Maristella
authors.initials: M
authors.lastname: Santi
authors.affiliation: University Children's Hospital Berne and University of Berne, 3010 Berne, Switzerland.
authors.forename: Sebastiano A G
authors.initials: SA
authors.lastname: Lava
authors.affiliation: Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.
authors.forename: Pietro
authors.initials: P
authors.lastname: Camozzi
authors.affiliation: Division of Internal Medicine and Nephrology, Ospedale Regionale, 6850 Mendrisio, Switzerland.
authors.forename: Olivier
authors.initials: O
authors.lastname: Giannini
authors.affiliation: Pediatric Emergency Department, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
authors.forename: Gregorio P
authors.initials: GP
authors.lastname: Milani
authors.affiliation: Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.|University Children's Hospital Berne and University of Berne, 3010 Berne, Switzerland.
authors.forename: Giacomo D
authors.initials: GD
authors.lastname: Simonetti
authors.affiliation: Pediatric Emergency Department, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
authors.forename: Emilio F
authors.initials: EF
authors.lastname: Fossali
authors.affiliation: Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland. mario.bianchetti@pediatrician.ch.
authors.forename: Mario G
authors.initials: MG
authors.lastname: Bianchetti
authors.affiliation: Department of Internal Medicine, Ospedale San Giovanni, 6500 Bellinzona, Switzerland.
authors.forename: Pietro B
authors.initials: PB
authors.lastname: Faré
mesh_terms: D058186:Acute Kidney Injury / Q000378:metabolism / Q000628:therapy*; D000818:Animals; D001826:Body Fluids / Q000378:metabolism*; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007262:Infusions, Intravenous; D012965:Sodium Chloride / Q000008:administration & dosage*
chemical_list: D012965:Sodium Chloride