The Use of a Rapid Fluid Infusion System in Children

Abstract

Fluid resuscitation is the cornerstone of treatment for pediatric shock caused by conditions such as sepsis, dehydration, trauma, and anaphylaxis. Children presenting to the Emergency Department (ED) in shock have a high risk of mortality, and each hour of delay in shock reversal doubles the odds of death1,2. Pediatric Advanced Life Support (PALS) guidelines emphasize the importance of providing rapid fluid resuscitation to prevent the progression to hypotensive or refractory shock3. PALS and other septic shock guidelines recommend that patients receive a 20 mL/kg bolus of crystalloid immediately upon recognition of hypovolemic or distributive shock, with 20 mL/kg to be delivered within 5 minutes and up to 60 mL/kg within the first 15-60 minutes3-6. Studies based on these guidelines show that earlier fluid delivery directed at reversal of shock reversal leads to decreased morbidity7-9, mortality2,7,9-12, and hospital length of stay (LOS)9,11-13. Unfortunately, timely fluid delivery is often not achieved due to the technical challenges of obtaining adequate vascular access and delivering fluid boluses quickly in patients with shock or hypotension11,14-16. Current methods of fluid bolus delivery in the pediatric emergency care setting include infusion pumps, gravity drip, pressure bags, rapid infusers, and the push-pull syringe technique17,18. Each of these methods are limited by speed, ease of use, or safety concerns. Infusion pumps provide a maximum rate of 999 mL per hour, which for a 25kg child would provide a 60 mL/kg bolus in 90 minutes. In most patients, infusion pumps are therefore too slow to provide adequate fluid resuscitation. Gravity drip rates are unpredictable and inadequate for the treatment of shock and hypotension. For example, up to 50 minutes are required for one liter of fluid to flow through a 22G intravenous (IV) line, and up to 200 minutes via the intraosseous (IO) route19-22. A pressure cuff may speed flow modestly, but requires constant re-inflation, makes volume of infusion difficult to track, and carries the risk of inadvertent air embolism3,20,22-25. Rapid infusers can deliver fluids very quickly but are expensive, require frequent training, are not readily available in many emergency care settings, and importantly do not provide adequate flow with the small gauge IV or intraosseous (IO) access typical of pediatric resuscitation19,26. Due to the limitations of these common fluid delivery methods, pediatric emergency providers commonly use a syringe and 3-way stopcock to repeatedly draw fluid from the container of crystalloid and then deliver to the patient. This technique is referred to as the “push-pull” method and is recommended in the PALS guidelines3. An alternate technique involves disconnecting and reconnecting multiple pre-filled 60mL syringes, which often requires two providers18. Both methods may be associated with increased risk of nosocomial infection due to the difficulty of maintaining syringe sterility27-31. The LifeFlow® infuser (410 Medical, Inc; Durham, NC) is a new manually operated device for rapid fluid bolus delivery that overcomes some of these common barriers. The device is currently FDA-cleared for infusion of crystalloid and colloid fluids, and is in use at our center for emergency resuscitation. Using common IV gauges LifeFlow can deliver fluid 2 to 4 times faster than standard techniques, and allows providers to observe a clinical response immediately by improvements in vital signs, mental status and skin perfusion29,32-34. This study describes the use of the LifeFlow device in a busy academic children’s hospital ED with 74,000 patient visits per year.