Fluid Administration In Children Research Articles

Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial

BackgroundPVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. Methods42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either ‘conventional liberal intraoperative fluids’ (liberal group) or ‘goal-directed intraoperative fluids’ (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. ResultsThe mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). ConclusionIntraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy.Type of study: Randomized Clinical Trial.Level of evidence: Treatment Study (LEVEL 1).

The association between carotid flow time and fluid responsiveness in children under general anesthesia

Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia. Prospective observational study of 87 children ages 1-12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8ml/kg with PEEP of 10 cmH2 O, and (3) after a 10ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images. Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p=.005 in fluid responders; 348.3 vs. 365.2 msec, p=.001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p < .001 in fluid responders; 365.2 vs. 397.2 msec, p < .001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness. Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia.

Use of subcutaneous fluids in paediatric palliative care: a case study

Quality of life is a major consideration in children's palliative care, particularly at the end of life. Optimal symptom management is crucial in maintaining quality of life, with the aim being to ensure the child is as comfortable as possible. Ensuring adequate hydration will often be part of symptom management but may be associated with several practical and ethical challenges. Subcutaneous fluid administration in children's palliative care is relatively uncommon, so there is a lack of evidence on the topic. This article demonstrates that it is feasible to use subcutaneous fluid therapy in the children's hospice setting to address patients' hydration needs and manage their symptoms. It presents a case study of a child who received subcutaneous fluids in a children's hospice for dehydration and myoclonus. It uses the case study to discuss subcutaneous fluid therapy in the children's palliative care setting, including its indications and contraindications, administration, complications and important factors to consider.

Comparison of sonographic inferior vena cava and aorta indexes during fluid administered in children

ObjectivesThis prospective, observational study evaluated changes in ultrasound measurements of the inferior vena caval index (IVCI), the aorta diameter/IVC diameter index (Ao/IVCD), and the aorta area/IVC area index (Ao/IVCA) during fluid administration in children requiring intravenous fluid administration. MethodsChildren who presented to the pediatric emergency department with symptoms of dehydration were enrolled between May 2015 and February 2016. The maximum diameter of the aorta, from inner wall to inner wall, and the long and short axis diameters of IVC were measured using a convex array transducer in the transverse view. Subsequently, we measured the diameter of the IVC at the subxiphoid area during inspiration and expiration in longitudinal view. We calculated IVCI, Ao/IVCD, and Ao/IVCA during administration of 10ml/kg and 20ml/kg normal saline boluses. ResultsIVCI and Ao/IVCA significantly changed immediately after administration of initial 10ml/kg of NS. Ao/IVCA showed significant change during the additional administration of 10ml/kg (total 20ml/kg) normal saline boluses (1.43, IQR 1.12–1.86 vs. 1.08, IQR 0.87–1.45, p value<0.001). No significant changes were observed for IVCI and Ao/IVCD. Ao/IVCA was significantly correlated with the volume of fluid administered. The coefficient between initial and administration of the 10ml/kg normal saline bolus was −0.396 (p value=0.010), and that between the 10ml/kg and 20ml/kg normal saline boluses was −0.316 (p value=0.038). ConclusionsAo/IVCA showed better correlations with the volume of fluid administered than IVCI and Ao/IVCA. Ao/IVCA might be a promising index for assessing the effects of fluid administration.

276 Assessing Fluid Status With Ultrasound in Pediatric Emergency Department

Ultrasound measurements of the inferior vena caval index (IVCI), the aorta diameter/IVC diameter index (Ao/IVC), the aorta area/IVC area index (Ao/IVCA) according to fluid administration in children requiring intravenous fluid resuscitation. This is a prospective, observational study. Children who presented to the pediatric emergency department (PED) between May 2014 and January 2015 were enrolled. The maximum diameter of the aorta from inner wall to inner wall, and the long and short axis diameters of IVC were measured using a convex array transducer in transverse view. Subsequently, diameter of IVC was measured at subxyphoid area during inspiration and expiration in longitudinal view IVCI, Ao/IVCD, and Ao/IVCA were calculated per administration of 10ml/kg of normal saline. Immediately after administration of 10ml/kg o NS, IVCI and Ao/IVCA were significantly changed. Significant change was not observed in IVCI and Ao/IVCD, but Ao/IVCA showed significant change between 10ml/kg and 20ml/kg administration of NS, respectively (1.87, IQR 1.41-2.42 vs. 1.43, IQR 1.12-1.86 vs. 1.08, IQR 0.87-1.45, P value <0.001). Ao/IVCA demonstrated significant correlation with fluid administration. Coefficient between no fluid and 10ml/kg administration of normal saline was -0.396 (P value=0.010), and coefficient between 10ml/kg and 20ml/kg administration of normal saline was -0.316 (P value=0.038). Ao/IVCA showed better correlation with fluid status than IVCI an Ao/IVCA. Ao/IVCA might be a promising index for the assessment of effect of fluid administration in children.

Perioperative fluid administration in children: is there consensus?

Perioperative fluid administration in children: is there consensus?

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial

BackgroundThe optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown. ObjectiveOur aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization. MethodsWe performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each). ResultsAfter adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0–3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2–5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6–2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4–1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4–1.5; p = 0.5) did not differ between treatment groups. ConclusionsHigher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

A noninvasive computational method for fluid resuscitation monitoring in pediatric burns: a preliminary report.

The fluid resuscitation needs of children with small area burns are difficult to predict. The authors hypothesized that a novel computational algorithm called the compensatory reserve index (CRI), calculated from the photoplethysmogram waveform, would correlate with percent total body surface area (%TBSA) and fluid administration in children presenting with ≤20% TBSA burns. The authors recorded photoplethysmogram waveforms from burn-injured children that were later processed by the CRI algorithm. A CRI of 1 represents supine normovolemia; a CRI of 0 represents the point at which a subject is predicted to experience hemodynamic decompensation. CRI values from the first 10 minutes of monitoring were compared to clinical data. Waveform data were available for 27 children with small to moderate sized burns (4-20 %TBSA). The average age was 6.3 ± 1.1 years, the average %TBSA was 10.4 ± 0.8%, and the average CRI was 0.36 ± 0.03. CRI inversely correlated with the %TBSA (P < .001). Twenty children were transferred with an average reported %TBSA of 16.5 ± 1.4%, which was significantly higher than the actual %TBSA (P < .001). CRI correlated better with actual %TBSA compared to reported %TBSA (P = .02). CRI correlated with the amount of fluid resuscitation given at the time of CRI measurement (P = .02) and was inversely related to total fluids given per 24 hours for children with adequate urine output (>0.5 ml/kg/hr) (P < .001). The CRI is decreased in children with small to moderate size burns, and correlates with %TBSA and fluid administration. This suggests that the CRI may be useful for fluid resuscitation guidance, warranting further study.

Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children.

Maintenance intravenous fluids are frequently used in hospitalised children who cannot maintain adequate hydration through enteral intake. Traditionally used hypotonic fluids have been associated with hyponatraemia and subsequent morbidity and mortality. Use of isotonic fluid has been proposed to reduce complications. To establish and compare the risk of hyponatraemia by systematically reviewing studies where isotonic is compared with hypotonic intravenous fluid for maintenance purposes in children.Secondly, to compare the risk of hypernatraemia, the effect on mean serum sodium concentration and the rate of attributable adverse effects of both fluid types in children. We ran the search on 17 June 2013. We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), and ISI Web of Science. We also searched clinical trials registers and screened reference lists. We updated this search in October 2014 but these results have not yet been incorporated. We included randomised controlled trials that compared isotonic versus hypotonic intravenous fluids for maintenance hydration in children. At least two authors assessed and extracted data for each trial. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean differences with 95% CIs. Ten studies met the inclusion criteria, with a total of 1106 patients. The majority of the studies were performed in surgical or intensive care populations (or both). There was considerable variation in the composition of intravenous fluid, particularly hypotonic fluid, used in the studies. There was a low risk of bias for most of the included studies. Ten studies provided data for our primary outcome, a total of 449 patients in the analysis received isotonic fluid, while 521 received hypotonic fluid. Those who received isotonic fluid had a substantially lower risk of hyponatraemia (17% versus 34%; RR 0.48; 95% CI 0.38 to 0.60, high quality evidence). It is unclear whether there is an increased risk of hypernatraemia when isotonic fluids are used (4% versus 3%; RR 1.24; 95% CI 0.65 to 2.38, nine studies, 937 participants, low quality evidence), although the absolute number of patients developing hypernatraemia was low. Most studies had safety restrictions included in their methodology, preventing detailed investigation of serious adverse events. Isotonic intravenous maintenance fluids with sodium concentrations similar to that of plasma reduce the risk of hyponatraemia when compared with hypotonic intravenous fluids. These results apply for the first 24 hours of administration in a wide group of primarily surgical paediatric patients with varying severities of illness.

Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration

ObjectiveTo evaluate the cost-effectiveness of recombinant human hyaluronidase–facilitated subcutaneous (rHFSC) fluid administration compared to intravenous (IV) fluid administration in children with mild to moderate dehydration in the emergency department (ED). MethodsA decision analytic model was created based on the results of a controlled clinical trial that compared the administration of isotonic fluids via rHFSC or IV for rehydration. The costs were determined from the hospital’s perspective. The effectiveness unit was successful rehydration in the ED without the need for hospitalization for continued hydration. Mean estimates were determined for both the cost and effectiveness of each treatment. The incremental differences in costs and effectiveness were determined between treatments. Sensitivity analysis testing was also conducted. ResultsThe treatment success rate was 93% with rHFSC fluids and 76% for IV fluids. Across all ages, the mean cost of rHFSC fluids was $722, compared to $889 for IV fluids. The difference in effectiveness was due to the larger number of patients for whom IV access could not be established, necessitating a rescue route of administration to deliver parenteral fluids. The difference in the overall cost was primarily due to the shorter time in the ED for patients receiving rHFSC fluids versus those treated with IV fluids. The cost-effectiveness of rHFSC compared to IV was most apparent in younger patients (<3 years of age), where IV access was more difficult to obtain. ConclusionAnalysis of this clinical trial data revealed that rHFSC fluid administration demonstrated greater treatment effectiveness and cost-effectiveness than traditional IV fluid administration in the ED. The primary reasons for this were the ease of obtaining parenteral access via rHFSC in young patients (especially those under 3) where IV access is difficult, and a shorter ED stay with rHFSC fluid administration.

Hospital-acquired acute hyponatremia and parenteral fluid administration in children.

arenteral fluids administered for the purpose of hydrationhave not traditionally been viewed with the same rigour asmedications. These fluids are usually distributed through thematerials management division of hospital operations. In addition, fluids are often not reviewed by pharmacists as part ofpharmaceutical care activities. Fluid and electrolyte managementis a crucial aspect of overall patient management, and there is anopportunity for pharmacists to offer greater support in this area.This article highlights the issue of hospital-acquired acutehyponatremia in children.

Effects on natremia of the intravenous hypotonic fluid administration in hospitalized children with acute lower respiratory tract infection

Because of the risk of developing hyponatremia, intravenous hydratation prescription in children with lower respiratory tract disease (LRTD) is challenging. To evaluate if intravenous hypotonic fluid administration in children with LRTD leads to hyponatremia. Patients aged 1 month to 18 years, hospitalized for LRTD, requiring intravenous fluids were included. Blood samples to determine sodium levels were obtained before and within the first twenty four hours of fluids administration. A serum sodium decrease >or= 4 mEq/L was considered significative. Student t test and logarithmic regression was used to analyze results (significance level p<0.05). From 1039 patients hospitalized with LRTD (58 received intravenous fluids), 35 patients met the inclusion criteria. Median age was 3 months (1-60 months), 57.1% were males. Patients received 59.3 +/- 24 ml/h of intravenous fluids, 39.2 +/- 16 ml/h of electrolyte free water and 2 +/- 1.3 mEq/kg of sodium. Serum sodium was 141.2 mEq/l in the initial sample and 139.3 mEq/l in the second one. Mean serum sodium decrease was 1.9 +/- 4.8 mEq/l (IC 95%: 0.2-3.5; p< 0.026). Eleven patients had a sodium decrease >or=4 mEq/l, none showed clinical manifestation of hyponatremia. For each mEq/l of increase in initial natremia the odds of achieving a decrease in serum sodium >or=4 mEq/l increases in 40% (OR=1.39; IC 95%: 1.1-1.8). A significant decrease in initial serum sodium has been observed in 11 of 35 patients. Higher initial serum sodium values increase the odds of a significant decrease.

109: Subcutaneous Hydration in Children Using Recombinant Human Hyaluronidase: Safety and Ease of Use

Dehydrated children often receive parenteral fluids and electrolytes on an emergency basis. However, starting an intravenous line can be challenging and time-consuming in dehydrated children, especially if they have difficult venous access (DVA) due to small, delicate, or collapsed veins. Multiple attempts are painful and upsetting to the child, as well as distressing to parents and clinicians. They also delay treatment and may raise the risk of complications. The objective of this study is to explore the utility, safety, and effectiveness of an alternate route of fluid administration in children: subcutaneous (SC) hydration enhanced with the enzymatic spreading agent recombinant human hyaluronidase (rHuPH20).

High Antidiuretic Hormone Levels and Hyponatremia in Children With Gastroenteritis

Nonosmotic antidiuretic hormone (ADH) activity can cause severe hyponatremia during involuntary fluid administration. We looked for evidence of this before and during intravenous (IV) fluid administration in children treated for gastroenteritis. In this prospective observational study, plasma ADH, electrolytes, osmolality, and glucose were measured in 52 subjects before (T0) and 4 hours after (T4) starting 0.45% saline + 2.5% dextrose and subsequently when indicated. Hormonal markers of stress were measured at T0. Urine samples were collected to measure electrolytes and osmolality. The nonosmotic stimuli of ADH secretion that we identified were vomiting (50 of 52), dehydration (median: 5%; range: 3-8%), hypoglycemia (2 of 52), and raised hormonal markers of stress (mean +/- SD: cortisol, 1094 +/- 589 nmol/L; reverse triiodothyronine, 792 +/- 293 pmol/L). At T0, half the children were hyponatremic (plasma sodium concentration of < 135 mmol/L; n = 27). The median plasma ADH concentration at T0 was significantly elevated (median: 7.4 pg/mL; range: < 1.9-85.6 pg/mL). ADH was high in both hyponatremic and normonatremic children and remained high at T4 in 33 of the 52 children, 22 of whom were concurrently hyponatremic. At T4, mean plasma sodium concentration was unchanged in the hyponatremic children but was 2.6 mmol/L (+/-2.0) lower in those who were initially normonatremic. Urine tonicity was high compared with 0.45% saline in 16 of 19 children at baseline and in 20 of 37 children after 3 to 12 hours of IV fluids. Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis. Their persistence during IV-fluid administration predisposes to dilutional hyponatremia. The use of hypotonic saline for deficit replacement needs to be reassessed.

Problems associated with intravenous fluid administration in children: do we have the right solutions?

Edema, both in its cellular and tissue form, is a frequent complication in critically ill patients. In health, a balance is struck between intracellular and extracellular osmotic forces and interstitial and intravascular oncotic forces, which in turn governs fluid distribution between the intracellular, extracellular and interstitial fluid compartments. The use of hypo- and hypernotic electrolyte solutions has major effects on brain cells, which can be detrimental or beneficial. The controversy over the use of colloids versus crystalloid solutions in critically ill patients remains unresolved.

Bacterial Meningitis: Fluid Balance and Therapy

Fluid administration in children with meningitis should be conservative in an attempt to minimize cerebral edema and electrolyte disturbances that frequently complicate the course of meningitis. Since these complications have been shown to correlate with poor neurologic outcome, it is believed that appropriate fluid management will minimize the morbidity and mortality associated with bacterial meningitis in children.

Complications of excessive operative fluid administration in children receiving steroids for inflammatory bowel disease

Twenty-five adolescents receiving chronic steroid therapy for inflammatory bowel disease underwent major intestinal surgery and each experienced vasodilation during induction of anesthesia. Systemic hypotension occurred in each patient and was treated by large volumes of intravenous crystalloid solution which caused intraoperative and postoperative water retention with resultant hypertension as well as occasional pulmonary edema and seizures. Ten adolescents who did not receive steroids and who underwent similar operations had higher urine outputs during and immediately after surgery, but did not experience these complications. Intravenous fluid administration in excess of maintenance requirements and calculated fluid losses should be given with caution to children receiving high-dose steroids who undergo major intestinal surgery. Perioperative fluid retention under those circumstances may be best treated with early diuretic administration.

65. Fluid administration in children during the anesthesia and surgical procedurs

65. Fluid administration in children during the anesthesia and surgical procedurs