Intravenous Maintenance Fluid Therapy in the Pediatric Acute and Critical Care Setting: A European Practice Survey. Intravenous Maintenance Fluids in Pediatric Practice: A European Survey

Background: The ideal fluid for intravenous maintenance fluid therapy (IV-MFT) in acutely and critically ill children is controversial and evidence based clinical practice guidelines are lacking. The current prescribing practices remains unknown.Aim: We aimed to describe the current practices and choice of pediatric acute care clinicians in prescribing IV-MFT in the context of acutely and critically ill children with regards to the amount, tonicity, composition, use of balanced fluid and prescribing strategies in various clinical contexts. Method: A cross-sectional electronic survey was emailed in April-May 2021 to pediatric critical care physicians across European and Middle East countries. The survey instrument was developed by an expert multi-professional panel within ESPNIC. The survey instrument included their practice of prescribing the IV-MFT: indication, amount, tonicity, use of balance solutions & composition of IV-MFT.Results: 154 respondents from 35 European and Middle East countries participated in this survey (response rate 64%). Respondents were staff physicians or nurse practitioners in charge of critically ill children. They all indicated that they routinely use a predefined formula to prescribe the amount of an IV-MFT. The use of balanced solution was preferred in case of altered serum Na and Cl levels or metabolic acidosis. 42% of responders (65/153) believed that balanced solutions should always be used. In terms of the indication and the composition of IV-MFT prescribed, responses were heterogenous among centers. 70% of the respondents (n=107) believed there was a gap between the current practice in their unit and what they considered ideal IV-MFT due to the lack of guidelines and inadequate training of health care professionals.Conclusion: Our study showed considerable variability in clinical prescribing practice of IV-MFT in PICUs across Europe and the middle east. There is an urgent need to develop evidence-based guidelines for IV-MFT prescription in acutely and critically ill children.

Comparison between Glucose Containing Solution D2.5% and Ringer Lactate as a Maintenance Fluid Management in Infants Undergoing Inguinal Hernia Repair

Background Infants and neonates are at particular risk of hypoglycemia when suffering from sepsis, asphyxia and hypothermia. A prospective study showed that up to 20% of preterm infants who were ready for discharge were still at risk of hypoglycemia when a feed was delayed. In contrast, surgery and critical illness may cause hyperglycemia. Objectives The aim of this study is to Assessment of glucose containing solutions 2.5 % as a maintenance fluid management intra operative in infants undergoing hernia repair as regard hyperglycemia and hypoglycemia. Patients and Methods The study was conducted on 100 randomly chosen patients aged from 28 days to 1 year, American Society of Anesthesiologists (ASA) class I scheduled for elective open inguinal hernia repair in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 50 patients each: Ringer lactate Group: patients received ringer lactate as maintenance fluid therapy according to body weight, glucose containing solution: patients received glucose containing solution 2.5% as maintenance fluid therapy according to body weight. Results The results of the study revealed that 12% of patients receiving glucose containing solution 2.5 % had simple hyperglycemia with no hypoglycemic patients recorded while the other group with ringer lactate 2% of patients had simple hyperglycemia and 4% of patients had hypoglycemia . Conclusion The usage of glucose containing solution 2.5% remained controversial, in this study we compared glucose 2.5 % in normal saline 0,9 % to ringer lactate and the results didn’t put a final decision to the usage of glucose containing solutions as The results of the study revealed that 12% of patients receiving glucose containing solution 2.5 % had simple hyperglycemia with no hypoglycemic patients recorded while the other group with ringer lactate 2% of patients had simple hyperglycemia and 4% of patients had hypoglycemia.

606 AUDIT: IV Fluid Prescribing in Surgical Patients

Aim A recent change to electronic fluid prescribing has enabled us to evaluate our adherence to recommendations. NICE clinical guideline 174 states that patients should receive 25-30ml/kg/day water and 1mmol/kg/day of sodium, potassium, and chloride with regards to maintenance fluid therapy. We retrospectively audited our practice in surgical patients. Method Patients were selected from two surgical inpatient wards in a district general hospital utilising random sampling over a one-month period. Prescribed intravenous fluid (IV) therapy over a 24-hour period was collected; in addition to weight, presence of an acute kidney injury (AKI) and indication for IV replacement (maintenance versus resuscitation). Results 50 patients were identified during the period. All of them were emergency presentations. Maintenance fluids were prescribed for 76% of patients. No patients had an AKI at time of data collection. The mean weight was 75kg. Overall, patients received a mean fluid volume of 2.3L/day. The mean concentration of electrolytes administered over a 24-hour period were: Sodium 297mmol, Potassium 13mmol, Chloride 237mmol. When adjusting for patient weight, this resulted in a net administration of: Sodium +221mmol, Potassium -62mmol, Chloride +162mmol. Conclusions Three quarters of surgical patients were administered maintenance fluids. The electrolyte contents of these fluids were inadequate. Patients received 295% excess Sodium, 216% excess Chloride, and 82% less than the recommended daily requirement of Potassium. We aim to introduce a protocol for maintenance fluid prescribing, in addition to teaching sessions, that would allow for adherence to guidelines and improve patient care.

Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults

Purpose Iatrogenic fluid overload is a potential side effect of intravenous fluid therapy in the hospital. Little attention has been paid to sodium administration as a separate cause of harm. With this narrative review, we aim to substantiate the hypothesis that a considerable amount of fluid-induced harm is caused not only by fluid volume, but also by the sodium that is administered to hospitalized patients. Methods We show how a regular dietary sodium intake is easily surpassed by the substantial amounts of sodium that are administered during typical hospital stays. The most significant sodium burdens are caused by isotonic maintenance fluid therapy and by fluid creep, defined as the large volume unintentionally administered to patients in the form of dissolved medication. In a section on physiology, we elaborate on the limited renal handling of an acute sodium load. We demonstrate how the subsequent retention of water is an energy-demanding, catabolic process and how free water is needed to excrete large burdens of sodium. We quantify the effect size of sodium-induced fluid retention and discuss its potential clinical impact. Finally, we propose preventive measures, discuss the benefits and risks of low-sodium maintenance fluid therapy, and explore options for reducing the amount of sodium caused by fluid creep. Conclusion The sodium burdens caused by isotonic maintenance fluids and fluid creep are responsible for an additional and avoidable derailment of fluid balance, with presumed clinical consequences. Moreover, the handling of sodium overload is characterized by increased catabolism. Easy and effective measures for reducing sodium load and fluid retention include choosing a hypotonic rather than isotonic maintenance fluid strategy (or avoiding these fluids when enough free water is provided through other sources) and dissolving as many medications as possible in glucose 5%.

Effect of Feed Intake on Water Consumption in Horses: Relevance to Maintenance Fluid Therapy

Maintenance fluid therapy is challenging in horses that cannot drink or are denied feed and water because of concerns about gastrointestinal tract function and patency. Intravenous fluid delivery to meet water needs based on current recommendations for maintenance requirements were obtained in fed horses and therefore might not apply to horses that are not being fed. This is a critical flaw because of the interdependence between intestinal tract water and extracellular water to support digestion while preserving water balance, a concept explained by the enterosystemic cycle. Because horses drink less when they are not eating and hence have lower water needs than fed horses, maintenance water requirements need to be adjusted accordingly. This article reviews this topic and identifies benefits of adjusting maintenance fluid therapy to meet lower demands from gastrointestinal function, such as reduced volumes, lower cost, avoidance of overhydration.

Significance of hypernatremia due to SARS-CoV-2 associated ARDS in critically ill patients

Background and ObjectivesSARS-CoV-2-induced ARDS is a new entity that should be characterized as it appears to be different from standard ARDS. Hypernatremia is a biological alteration that seems to occur very often in this population without any clear cause. The present study aims to clarify the possible causes of hypernatremia and evaluate its impact on patient outcome.Patients and MethodsWe conducted a retrospective one-day prevalence study in 2 intensive care units, which only treated COVID-19 patients with moderate to severe ARDS. We measured blood and urine electrolytes in all the patients. Patients with chronic renal failure or renal replacement therapy were excluded from the study. Hypernatremia was defined as plasma sodium levels above 145 mmol/L.ResultsInclusion criteria were met in 17 out of 24 patients. Hypernatremia was present in 52% patients. All had a natriuresis higher than 20 mmol/L and a urine osmolality above 600 mOsm/L. Hypernatremia was acquired in ICU as all the patients had a normal serum sodium level at admission.ConclusionThe incidence of hypernatremia was elevated and appears to be linked to significant insensible water losses. This should trigger us to optimize the maintenance fluid therapy in critically ill patients with SARS-CoV-2-induced ARDS.

Effect of Isotonic and Hypotonic Fluid Therapy on Serum Sodium: A Randomized Controlled Trial

There is little consensus about the type of maintenance fluid therapy and it’s the effect on serum sodium in adults. Thus, this study was conducted to assess the effect of maintenance fluid therapy on serum sodium of hospitalized patients in the intensive care unit. This randomized clinical trial was carried out on 64 patients aged 18-90 years hospitalized in the intensive care unit (ICU) of Imam Sadjad and Shahid Beheshti hospitals, Yasuj, Iran, in 2017. These patients were randomly allocated to take 2500-3000 milliliters of intravenous maintenance isotonic (0.9% saline) or hypotonic (0.45% saline) fluids daily. Blood and urine samples were taken to measure biochemical parameters before and 48 hours after the intervention. Data analyses were done by using SPSS 16 software via descriptive and analytic statistics. Twenty-eight patients in the 0.9% saline group (19 male and 9 female) and 32 patients in 0.45% saline (20 male and 12 female) completed the study. There was no significant difference between two groups in sodium (P=0.94), potassium (P=0.21), sugar (P=0.91), creatinine (P=0.21), Blood Urea Nitrogen (P=0.99), systolic (P=0.81) and diastolic (P=0.73) blood pressure, PH (P=0.27), bicarbonate (P=0.8), and urine specific gravity (P=0.73). Based on the results of this study, it was shown that the administration of maintenance hypotonic fluids has been appropriate for the patients and will not face them with the risk of hyponatremia.

Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study

ObjectiveTo examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy.DesignRetrospective consecutive time series intervention study.SettingPaediatric surgery ward at the Children’s Hospital in Lund, during a 7-year period, 2010–2017.PatientsAll children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients).Main outcome measuresPrimary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L).ResultsOverall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51–0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71–2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%.ConclusionsRoutine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.