Maintenance intravenous fluid prescribing practices among paediatric residents

Abstract

Aim To investigate the sodium composition of maintenance intravenous fluids used by paediatric residents throughout the United States in common clinical scenarios of arginine vasopressin excess. Methods We distributed an online survey to paediatric residency programs asking what type of maintenance intravenous fluids (0.2%, 0.45%, 0.9% NaCl or Lactated Ringers) they would administer in four common clinical scenarios of arginine vasopressin excess (gastroenteritis, pneumonia, meningitis and post-operative) in both a 6-month-old (mo) and a 13-year-old (yo) child. Results We had 472 responses, representing 5% of the total paediatric residency population in the US. Hypotonic maintenance intravenous fluids were selected in 78% of children (88.2% of 6 mo and 68.5% of 13 yo). Isotonic maintenance intravenous fluids were selected approximately twice as often for patients with meningitis as for those without (21.4% vs 8.7% 6 mo and 42.8% vs 27.7% 13 yo; p <.0.001). Conclusions The majority of US paediatric residents would prescribe hypotonic maintenance intravenous fluids in disease states associated with arginine vasopressin excess. However, a significant number of residents are using isotonic maintenance intravenous fluids. Isotonic fluids are more likely to be prescribed in older children and children with meningitis.

Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis

“…Solutions were classified as isotonic if they had the same or near osmotic pressure as blood (eg, 0.9% saline, Hartmann' s solution, or Ringer' s solution) or hypotonic if they had a lower osmotic pressure than blood (eg, 0.45% saline, 0.3% saline, or 0.18% saline). Exclusion criteria were 1 non-RCT studies, 2 letters and case reports, 3 studies published as abstracts only, 4 studies involving neonates, 5 studies of fluid resuscitation or rehydration, 6 and patients with preexisting hyponatremia or comorbidities that resulted in sodium disturbance (eg, renal diseases, liver cirrhosis, congestive heart failure, and diuretic therapies).…”

“…Discrepancies were resolved through group discussion. The inclusion criteria were as follows: 1 studies on RCTs, 2 studies on hospitalized children aged from 1 month to 17 years, 3 and studies comparing isotonic and hypotonic maintenance IV fluid therapy. Solutions were classified as isotonic if they had the same or near osmotic pressure as blood (eg, 0.9% saline, Hartmann' s solution, or Ringer' s solution) or hypotonic if they had a lower osmotic pressure than blood (eg, 0.45% saline, 0.3% saline, or 0.18% saline).…”

“…After Holliday and Segar made recommendations for maintenance fluid in children, 1 hypotonic fluids are still the most commonly prescribed IV fluids for pediatric hospitalized patients. [2][3][4] Their hypotonic formula was based on the energy expenditure of healthy children and the composition of human breast and cow milk. 1 Hypotonic fluids according to their recommendations may be appropriate for healthy children.…”

Impact of perioperative hyponatremia in children: A narrative review

“…As the use of hypotonic fluids is related to a higher risk of hyponatremia compared with isotonic fluids [90][91][92][93] , it is difficult to justify their widespread use as a standard maintenance fluid in children during surgery. An ideal intraoperative fluid should have a tonicity and sodium concentration close to the physiologic range [94] .…”

Therapeutic Approach to the Critically Poisoned Patient

“…Traditionally, hypotonic solutions were administered to both adults and children [82,83]. Isotonic solutions were avoided due to concerns for the development of volume overload, hypernatremia, and hypertension.…”