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Hyperchloremia Is Associated With Complicated Course and Mortality in Pediatric Patients With Septic Shock*

Stenson, Erin K. MD1,2; Cvijanovich, Natalie Z. MD3; Anas, Nick MD4; Allen, Geoffrey L. MD5; Thomas, Neal J. MD6; Bigham, Michael T. MD7; Weiss, Scott L. MD8; Fitzgerald, Julie C. PhD, MD8; Checchia, Paul A. MD9; Meyer, Keith MD10; Quasney, Michael MD, PhD11; Hall, Mark MD12; Gedeit, Rainer MD13; Freishtat, Robert J. MD14; Nowak, Jeffrey MD15; Raj, Shekhar S. MD16; Gertz, Shira MD17; Grunwell, Jocelyn R. MD, PhD18; Wong, Hector R. MD1,2

Pediatric Critical Care Medicine: February 2018 - Volume 19 - Issue 2 - p 155-160
doi: 10.1097/PCC.0000000000001401
Late Breaker Articles

Objective: Hyperchloremia is associated with poor outcome among critically ill adults, but it is unknown if a similar association exists among critically ill children. We determined if hyperchloremia is associated with poor outcomes in children with septic shock.

Design: Retrospective analysis of a pediatric septic shock database.

Setting: Twenty-nine PICUs in the United States.

Patients: Eight hundred ninety children 10 years and younger with septic shock.

Interventions: None.

Measurements and Main Results: We considered the minimum, maximum, and mean chloride values during the initial 7 days of septic shock for each study subject as separate hyperchloremia variables. Within each category, we considered hyperchloremia as a dichotomous variable defined as a serum concentration greater than or equal to 110 mmol/L. We used multivariable logistic regression to determine the association between the hyperchloremia variables and outcome, adjusted for illness severity. We considered all cause 28-day mortality and complicated course as the primary outcome variables. Complicated course was defined as mortality by 28 days or persistence of greater than or equal to two organ failures at day 7 of septic shock. Secondarily, we conducted a stratified analysis using a biomarker-based mortality risk stratification tool. There were 226 patients (25%) with a complicated course and 93 mortalities (10%). Seventy patients had a minimum chloride greater than or equal to 110 mmol/L, 179 had a mean chloride greater than or equal to 110 mmol/L, and 514 had a maximum chloride greater than or equal to 110 mmol/L. A minimum chloride greater than or equal to 110 mmol/L was associated with increased odds of complicated course (odds ratio, 1.9; 95% CI, 1.1–3.2; p = 0.023) and mortality (odds ratio, 3.7; 95% CI, 2.0–6.8; p < 0.001). A mean chloride greater than or equal to 110 mmol/L was also associated with increased odds of mortality (odds ratio, 2.1; 95% CI, 1.3–3.5; p = 0.002). The secondary analysis yielded similar results.

Conclusion: Hyperchloremia is independently associated with poor outcomes among children with septic shock.

1Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH.

2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.

3UCSF Benioff Children’s Hospital Oakland, Oakland, CA.

4Children’s Hospital of Orange County, Orange, CA.

5Children’s Mercy Hospital, Kansas City, MO.

6Penn State Hershey Children’s Hospital, Hershey, PA.

7Akron Children’s Hospital, Akron, OH.

8The Children’s Hospital of Philadelphia, Philadelphia, PA.

9Texas Children’s Hospital and Baylor College of Medicine, Houston, TX.

10Miami Children’s Hospital, Miami, FL.

11CS Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI.

12Nationwide Children’s Hospital, Columbus, OH.

13Children’s Hospital of Wisconsin, Milwaukee, WI.

14Children’s National Health System, Washington, DC.

15Children’s Hospital and Clinics of Minnesota, Minneapolis, MN.

16Riley Hospital for Children, Indianapolis, IN.

17Hackensack University Medical Center, Joseph M. Sanzari Children’s Hospital, Hackensack, NJ.

18Children’s Healthcare of Atlanta at Egleston, Atlanta, GA.

*See also p. 171.

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Supported by National Institutes of Health Grants RO1GM099773 and R01GM108025.

Drs. Stenson, Allen, Fitzgerald, Checchia, and Wong’s institutions received funding from the National Institutes of Health (NIH). Drs. Stenson, Cvijanovich, Allen, Fitzgerald, Checchia, Meyer, Freishtat, Grunwell, and Wong received support for article research from the NIH. Dr. Cvijanovich’s institution received funding from Cincinnati Children’s Medical Center, Boston Children’s Hospital, and the UCLA School of Medicine. Dr. Thomas’ institution received funding from GeneFluidics, and he received funding from Therabron and CareFusion. Dr. Weiss’s institution received funding from National Institute of General Medical Sciences K23GM110496, and he received funding from Bristol-Myers Squibb (member of advisory panel). Dr. Gertz’s institution received funding from Cincinnati Children’s Hospital. Dr. Grunwell’s institution received funding from Cincinnati Children’s Hospital. Dr. Wong disclosed that he and the Cincinnati Children’s Hospital Research Foundation hold a U.S. patent for PERSEVERE. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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