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Wang L, Dixon C, Nhan J, Kakajiwala A. A balancing act: drifting away from the reflexive use of "ab"normal saline. Pediatr Nephrol 2024; 39:2325-2335. [PMID: 38233719 DOI: 10.1007/s00467-023-06271-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.
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Affiliation(s)
- Linda Wang
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA.
| | - Celeste Dixon
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Jennifer Nhan
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | - Aadil Kakajiwala
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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Mittal S, Knerr S, Prasto J, Hunt J, Mattern C, Chang T, Marchese R, Jessee M, Marlowe L, Haupt J. Closing the Fluid Gap: Improving Isotonic Maintenance Intravenous Fluid Use in a Community Hospital Network. Pediatr Qual Saf 2023; 8:e696. [PMID: 37818202 PMCID: PMC10561811 DOI: 10.1097/pq9.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/19/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction The American Academy of Pediatrics recommends using isotonic intravenous fluids (IVF) for maintenance needs to decrease the risk of hyponatremia. We conducted a quality improvement project to increase the use of isotonic maintenance IVF in pediatric patients admitted to three sites in a community hospital network to >85% within 12 months. Methods We used improvement methodology to identify causes of continued hypotonic fluid use, which involved provider behavior and systems factors. We implemented interventions to address these factors including: (1) education; (2) clinical decision support; and (3) stocking automated medication dispensing systems with isotonic IVF. We compared isotonic IVF use before and after interventions in all admitted patients aged 28 days to 18 years who received maintenance IVFs at the rate of at least 10 mL/hour. We excluded admissions of patients with active chronic medical conditions like diabetic ketoacidosis. Balancing measures were the occurrence of adverse events from hypo- or hypernatremia. Data were analyzed using Laney P' statistical process control charts. Results Isotonic IVF use among patients requiring maintenance fluids at all three sites surpassed the goal of >85% within 12 months. There were no reports of hypo- or hypernatremia or other adverse outcomes related to the use of isotonic IVF. Conclusion A combination of interventions aimed at provider behavior and systems factors was critical to successfully adopting the American Academy of Pediatrics guideline regarding the use of maintenance isotonic IVF in hospitalized children.
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Affiliation(s)
- Shraddha Mittal
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Sheila Knerr
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Grand View Health, Sellersville, Pa
| | - Julianne Prasto
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Penn Medicine Princeton Medical Center, Plainsboro, N.J
| | - Jessica Hunt
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | | | - Tsae Chang
- Department of Pharmacy, Penn Medicine Princeton Medical Center, Plainsboro, N.J
| | - Ronald Marchese
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Morgan Jessee
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Lauren Marlowe
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pharmacy, Virtua Voorhees, Voorhees, N.J
| | - Josh Haupt
- Center for Healthcare Quality & Analytics (CHQA), Children’s Hospital of Philadelphia, Philadelphia, Pa
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Soulages Arrese N, Green ML. Fluid management of the critically Ill child. Curr Opin Pediatr 2023; 35:239-244. [PMID: 36472133 DOI: 10.1097/mop.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload. RECENT FINDINGS Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics. SUMMARY Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.
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Affiliation(s)
- Natalia Soulages Arrese
- University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Critical Care Medicine, Dallas, Texas, USA
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Hasim N, Bakar MAA, Islam MA. Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. CHILDREN-BASEL 2021; 8:children8090785. [PMID: 34572217 PMCID: PMC8471545 DOI: 10.3390/children8090785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023]
Abstract
Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.
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Affiliation(s)
- Norfarahin Hasim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mimi Azliha Abu Bakar
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (M.A.A.B.); or (M.A.I.)
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