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A summary of the ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children

Brossier, D.W., Tume, L.N., Briant, A.R., Jotterand Chaparro, C., Moullet, C., Rooze, S., Verbruggen, S.C., Marino, L.V., Alsohime, F., Beldjilali, S. and Chiusolo, F., 2022. ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children—a systematic review and meta-analysis. Intensive care medicine, pp.1-18.

We have been debating giving fluids to unwell patients for a long time – give crystalloid or colloid, how much should we give, how quickly should we give it… the list goes on. These debates can become academically and scientifically challenging, and good quality local or national guidelines can often be vague.

Administering intravenous fluid therapy is one of the most common interventions performed in hospitals. Every prescriber working with acutely unwell children (and adults) has prescribed intravenous fluids, yet we rarely discuss the underpinning science in daily practice. With such a standard treatment, we should be able to have these conversations.

One question that has entered discussions over recent years is around using balanced crystalloid solutions instead of 0.9% sodium chloride-based fluids for resuscitation and maintenance, with variable inter-clinician and inter-hospital practices.

‘Balanced crystalloids’ are fluids with an electrolyte content closer to that of the extracellular fluid (i.e., the fluid outside cells and in the intravascular space)2. These include Compound Sodium Lactate (Hartmann’s), Plasma-Lyte®, and Ringer’s Lactate. Whilst the exact makeup varies, they all try to better match extracellular fluid than pure sodium chloride-based solutions (0.9% Saline, for example).

Why might this be useful? It’s mostly to do with acid-base balance. 0.9% sodium chloride contains 154mmol/L of sodium and 154mmol/l of chloride. That can be problematic; the body has a normal sodium range of 135-145mmol/L. So we’re delivering excess sodium, but the greater issue is the chloride. The normal range of chloride in the blood is 96-106mmol/L. With each litre of 0.9% Saline, we’re giving an excessive amount of total chloride, but we’re also giving an excessive amount compared to sodium. The body usually has about 1 chloride ion for every 1.4 sodium ions, but in saline solutions, this ratio is 1 to 1. This might be problematic for pH.

There is complex biochemistry at play here. This is best explained by the often-untaught Stewart’s approach to acid-base balance. Whereas at medical school, we often consider blood pH merely in terms of carbon dioxide and bicarbonate (the Henderson-Hasselbalch equation, if you remember), Stewart’s considers a broader range of acids and bases, better representing the body. This approach considers the ‘strong ion difference’. This is the difference between positively and negatively charged ions.

In the blood, the strongest (most abundant) positively charged ion is sodium, and the strongest negatively charged ion is chloride. As the difference between the number of these ions shrinks, the blood becomes more acidic, and as the difference increases, the blood becomes more alkaline3. In essence, if you add more negatively charged chloride, there will be less ‘space’ for negatively charged alkaline bicarbonate, and so the pH will drop (this is to do with electroneutrality; there are lots of papers available explaining this in greater depth, but it is beyond this review article)3,4.

We are alert to acidosis on blood gases because we know acidic patients probably don’t do so well. You can already see that if we add chloride in a 1:1 ratio with sodium, we will close the strong ion difference, reduce the space for bicarbonate, and make the patient more acidaemic.

This is one of the reasons balanced crystalloids are so appealing; for example, Plasma-Lyte 148® contains 140mmol/L of sodium and 98mmol/L of chloride (amongst other things: see table below), which is much more physiological, and maintains a more normal strong ion difference6. They have been researched at length in many settings, mostly in adult intensive care. The data is quite nuanced and, again, is beyond the scope of this review. Still, a systematic review and meta-analysis published by Hammond and colleagues in 2022 in the New England Journal of Medicine concluded that the average effect of using balanced crystalloids is to reduce mortality, compared to Saline. Many clinicians are using them instead of giving large volumes of Saline solutions7.

Maintenance fluids are the ‘water and electrolyte prescription designed to replace anticipated water and electrolyte losses over the ensuing 24-hour period in primarily euvolemic children9. We prescribe them to children of all ages, and in most places in the UK, the standard would be to use 0.9% Sodium Chloride with 5% Glucose, with or without added potassium chloride.

Given the potentially harmful acid-base issues created by saline solutions and the frequency with which we prescribe maintenance fluids, we should consider whether balanced crystalloids may be a better choice. Enter the ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children – a systematic review and meta-analysis1.

Published in the Journal of Intensive Care Medicine in October 2022, Brossier and colleagues performed a systematic review looking at intravenous maintenance fluids in acutely and critically unwell children. They produced sixteen recommendations on behalf of the European Society of Paediatric and Neonatal Intensive Care.

They cover the use of balanced crystalloids as well as other important questions regarding intravenous maintenance fluid therapy, such as the use of isotonic (sodium content similar to the physiological range) or hypotonic (low sodium content) fluids, enteral versus parenteral fluids and restricted volumes compared to the standard Holliday-Segar calculation (100mls/kg for the first 10kg, 50mls/kg for the next 10kg, 20mls/kg for each kg above 20kg)10.

The recommendations

1. In acutely ill children, the enteral or oral route should be considered for the delivery of maintenance fluid therapy to reduce the failure rate of hydration access and costs.

2. In critically ill children with improving haemodynamic state, the enteral or oral route for the delivery of maintenance fluid therapy should be considered, if tolerated, to reduce the length of stay in term neonates.

3. In acute and critically ill children, isotonic maintenance fluid should be used to reduce the risk of hyponatraemia.

4. In critically ill children, balanced solutions should be favoured when prescribing intravenous maintenance fluid therapy to slightly reduce the length of stay.

5. In acutely ill children, balanced solutions should be used when prescribing intravenous maintenance fluid therapy to slightly reduce the length of stay.

6. In acute and critically ill children, lactate buffer solution should not be considered in the case of severe liver dysfunction to avoid lactic acidosis.

7. In acute and critically ill children, glucose provision in intravenous maintenance fluid therapy should be considered in sufficient amounts and guided by blood glucose monitoring (at least daily) to prevent hypoglycaemia.

8. In critically ill children, glucose provision in intravenous maintenance fluid therapy should not be excessive and should be guided by blood glucose monitoring (at least daily) to prevent hyperglycaemia.

9. In acute and critically ill children, there is insufficient evidence to recommend routine supplementation of magnesium, calcium and phosphate in intravenous maintenance fluid therapy.

10. In acute and critically ill children, an appropriate amount of potassium should be considered and added to intravenous maintenance fluid therapy. This should be based on the child’s clinical status. There should be regular potassium level monitoring to avoid hypokalaemia.

11. In acute and critically ill children, there is insufficient evidence to recommend routine supplementation of vitamins and trace elements in intravenous maintenance fluid therapy in the absence of signs of deficiency.

12. In acute and critically ill children, in order to prevent fluid creep and reduce fluid intake, the total daily amount of maintenance fluid therapy should be considered, including IV fluids, blood products, all IV medications (both infusions and bolus drugs), arterial and venous line flush solutions and enteral intake, but does not include replacement fluids and massive transfusion.

13. In acute and critically ill children, avoidance of fluid overload and cumulative positive fluid balance should be considered, to avoid prolonged mechanical ventilation and length of stay.

14. In acute and critically ill children, who are at risk of increased endogenous secretion of ADH, restriction of total intravenous maintenance fluid therapy volume (calculated by Holliday and Segar formula) should be considered to some extent, to avoid a decrease in natraemia, but the amount and duration of this restriction is uncertain.

15. In acute and critically ill children who are at risk of increased endogenous secretion of ADH, restricting maintenance fluid therapy volume to between 65-80% of the volume calculated by the Holliday and Segar formula should be considered to avoid fluid overload.

In children at greater risk of oedematous states, e.g., heart failure, renal failure or hepatic failure, restricting maintenance fluid therapy volume to between 50% to 60% of the volume calculated by the Holliday and Segar formula should be considered to avoid fluid overload.

16. Whilst receiving intravenous maintenance fluid therapy, re-assessment of acutely and critically ill children should be considered at least daily in terms of fluid balance and clinical status and regularly regarding electrolytes, especially sodium level.

Acutely ill children present with an acute non-critical condition and require in-hospital care. Critically ill children present with severe organ failure(s) or require paediatric intensive care. This includes term infants up to 18 years old and excludes preterm babies (<37 weeks gestation) and intra-operative settings.

What did they do?

Three project leaders created a working group formed of doctors, nurses, pharmacists, and dietitians, who teamed up with an academic librarian, systematic review methodologist, epidemiologist, and biostatistician. There was no industry involvement in this project.

Five PICO (Population, Intervention, Comparison, Outcome) questions were formulated to consider key areas of debate around intravenous maintenance fluid therapy (IV MFT), where were:

  1. Indication: IV MFT versus none, oral, or enteral maintenance fluid and the impact on the outcome.
  2. Tonicity: isotonic versus hypotonic fluids and the impact on sodium levels.
  3. Balanced: the use of balanced versus non-balanced fluids and the impact on chloride levels and pH.
  4. Composition: adding of Glucose, Magnesium, Potassium, Calcium, vitamins, and trace elements to IV MFT.
  5. Volumes: restricted volumes versus Holliday-Segar volumes and the effect on fluid balance.

In addition, each PICO question considered the length of stay and mortality as important outcomes.

A total of 18399 abstracts were screened by at least two working group members assigned to each PICO question, blinded from each other, to select only the abstracts that met inclusion criteria. Once abstracts were selected, the process was repeated with the complete studies until the most relevant publications were selected.

In total, 56 publications were selected, covering 1969-2021, including 11689 patients.

PICO 1: Does IV MFT versus other hydration therapies (none, oral or enteral) impact clinical outcomes?

Key recommendations

1. In acutely ill children, the enteral or oral route for maintenance fluid therapy should be considered. The aim is to reduce the failure rate of IV access and associated costs.

2. In critically ill children with improving haemodynamic status, the enteral or oral route for maintenance fluid therapy should be considered, if tolerated, to reduce the length of stay in term neonates.

Who was included?

Twelve studies met the inclusion criteria, with a total of 1668 patients. Nine were acutely unwell children, with presentations including acute gastroenteritis, bronchiolitis, pancreatitis, meningitis, and following tonsillectomy. Three studies included term neonates, one receiving an inotrope infusion and the others undergoing phototherapy for hyperbilirubinaemia. Eleven RCTs were rated as high-level evidence, and one was a case-control study.

Studies were conducted in developing and developed countries; three included term neonates, one of which included critically unwell neonates on inotropes.

Findings

There was a trend towards reduced length of stay in children receiving enteral maintenance fluids over IV MFT, but this was not statistically significant.

Costs were significantly higher in IV MFT than in enteral fluid therapy in the two papers reviewed.

There was no significant difference in the degree of hyponatraemia, rehydration failure, or mortality between the two groups.

In the four papers reviewing the length of stay, there was no statistically significant difference between the two groups. Still, there was a trend towards reduced LOS in the enteral group. However, the mean reduction in LOS was 9.09 hours.

There were significantly more failures to achieve IV access than to insert a nasogastric tube. Still, in the two papers looking at vomiting, there was statistically less vomiting in those receiving IV MFT than enteral fluids.

Critique

The reviewed papers covered some common conditions seen regularly in acutely ill children, such as bronchiolitis and acute gastroenteritis. Of note, all the papers about gastroenteritis included dehydrated children, the management of which would not typically include maintenance fluid therapy. This may affect other results, such as failure to secure IV access. There was a serious risk of bias in all but two of the papers, with methodological issues identified in all RCTs.

Bottom Line

The trend towards the reduced length of stay in the enteral group is unsurprising. In clinical practice, there is sometimes hesitation in switching patients from intravenous fluid therapy to enteral or oral fluids. Those who received IV-MFT might have been sicker. A 9-hour reduction may seem unremarkable, but in a health system with significant pressure for beds, that 9 hours could make a huge difference to patient flow.

Equally important is the cost of therapy. There is an ethical responsibility to deliver value for money because individuals are paying for their care or as part of a socially funded health system. A reduction of $77.85 with no significant effect on mortality or other important outcomes is an easy saving.

Intravenous access can be problematic in children. Nasogastric tube insertion is easy and safe, and this should be considered in children requiring maintenance fluid who cannot tolerate oral fluids. For whom enterally administered maintenance is suitable. This review found, unsurprisingly, less failure of insertion of NG tubes. I suspect this may be safer overall, with a reduced risk of prescription or administration errors and less risk of infection from intravenous access devices.

PICO 2: Do isotonic solutions versus hypotonic solutions (as IV MFT) impact clinical outcomes?

Key recommendations

3. In acute and critically ill children, isotonic maintenance fluid should be used to reduce the risk of hyponatraemia.

Who was included?

Twenty-four studies, 21 RCTs and 3 cohort studies were performed in emergency or critical care settings but varied with diagnosis and patient age. The only outcome common to most was the presence of hyper- or hyponatraemia; therefore, this was the only outcome assessed in the meta-analysis. The predominant isotonic solution was 0.9% saline, with 0.18% and 0.45% the hypotonic solutions surveyed.

Findings

Meta-analysis of 17 RCTs involving 3356 patients showed that isotonic solutions significantly reduced the risk of developing hyponatraemia compared to hypotonic solutions, with a reported odds ratio of 0.41 (95% CI 0.26-0.67). However, there was no significant difference between groups for severe hyponatraemia (sodium <130mmol/L).

Of note, in this meta-analysis, there was also no significant difference between groups for hypernatraemia, i.e., the use of isotonic solutions does not appear to cause high sodium levels.

Due to study heterogeneity, it was impossible to analyse data for the length of stay or mortality.

Critique

Many of the studies included were graded as at serious or critical risk of bias, but there was a good mix of studies looking at acutely and critically unwell children. It is unsurprising that fluids containing less sodium caused lower serum sodium. However, the question remains, how important was this clinically? There was no significant difference between groups for severe hyponatraemia (less than 130mmol/L), and a sodium of 130-134 is unlikely to be problematic for most patients. It was impossible to determine whether isotonic fluids were associated with reduced mortality or length of stay. The recommendation does not cover this.

Bottom Line

The events in Belfast in the early 2000s warn clinicians everywhere of the dangers of hyponatraemia in children11. This data shows that using isotonic fluids reduces the risk of hyponatraemia with no evidence of harm. For purely maintenance therapy, it is reasonable that isotonic fluids are used as the first line to maintain more normal sodium levels.

There may be situations in which hypotonic fluids may be considered more appropriate. Still, these are likely to be decisions made by experts in specific circumstances on a per-patient basis.

PICO 3: Do balanced solutions versus non-balanced solutions (as IV MFT) impact clinical outcomes?

Key recommendations

4. In critically ill children, balanced solutions should be favoured when prescribing intravenous maintenance fluid therapy to slightly reduce the length of stay.

5. In acutely ill children, balanced solutions should be used when prescribing intravenous maintenance fluid therapy to slightly reduce the length of stay.

6. In acutely and critically ill children, lactate buffer solution should not be considered in the case of severe liver dysfunction to avoid lactic acidosis.

Who was included?

2612 children were included across 11 relevant studies. Presentations varied, including following neurosurgery, severe diarrhoea, pancreatitis, septic shock, and DKA. The balanced fluid groups mainly had Hartmann’s or Ringer’s Lactate, compared to 0.9% Saline.

Findings

There was a statistically significant reduction in the length of stay (-0.2 days) in acute care, and PICU stays in the meta-analysis of five studies in children who received balanced fluids.

There was no statistically significant difference in delta-chloremia, hyperchloremia, chloremia, delta-natremia, hyponatraemia, or natremia in either the balanced or unbalanced groups. There was a trend towards a decreased delta-chloremia in the balanced group.

There was no difference in mortality between the two groups; neither was there a difference in base excess or time to resolution of DKA.

Notably, the potassium level was higher in the balanced fluids group than saline in the two papers that contained this data. Still, the absolute levels stated are unlikely to be clinically significant.

Critique

The studies included in this analysis make for interesting reading. One focussed on perioperative fluid administration during brain tumour resection until 24 hours following surgery. Perioperative fluid management was beyond the scope of this guideline.

Four studies are based on the replacement of fluid in children with severe diarrhoea, three of which use WHO Plan C as their treatment guideline. WHO Plan C involves the administration of 90-100mls/kg of fluid over approximately 3 hours, which does not represent maintenance fluid12.

One study, the PRoMPT BOLUS feasibility trial, examined septic shock in the emergency department. Here, patients received around 100mls/kg of fluid in the balanced or unbalanced arms. Again, this is not maintenance fluid. Another study investigated the use of balanced crystalloids in DKA. Patients with DKA are often fluid deplete, requiring both replacement and maintenance, rather than pure IV-MFT.

This represents the lack of evidence available on this topic. This is alluded to in the authors’ conclusions. However, it may not be possible to conclude that using balanced crystalloids for IV maintenance therapy alone is associated with a reduction in the length of stay based on the data. It is difficult to draw any firm conclusions from the studies about IV maintenance therapy.

One paper, however, highlighted the importance of including all administered fluids when considering maintenance and talks of ‘fluid creep’.

Bottom Line

There remains significant uncertainty over the benefits of balanced crystalloids in both adult and paediatric care, especially for maintenance therapy. Whilst many will not disagree with the recommendations in this guideline, it is difficult to say the evidence supports them. However, the evidence does not refute these recommendations. There is strong expert consensus favouring the use of balanced solutions based on available data. Any possible reduction in length of stay is a net positive for both patients and health services.

One legitimate concern is the safety implications of using balanced solutions. Commercially available balanced solutions often do not contain the potassium or glucose required for longer-term maintenance fluid therapy, unlike available 0.9% Saline solutions. Thus, high concentration potassium chloride may need to be added. This brings with it an inherent risk. There may also be an economic concern with the use of balanced crystalloids. This should be considered, mainly as no clear evidence of benefit exists.

Until there is greater evidence available to determine, one way or the other, whether either balanced or unbalanced fluids have a negative effect, there remains a degree of equipoise. As more units are moving towards using balanced crystalloids for maintenance fluid therapy, this may pave the way for larger-scale data collection focussing purely on IV-MFT, which may help settle this debate.

In the meantime, given the strong expert consensus recommending their use, with no evidence of harm, it is reasonable to move towards using balanced solutions for IV-MFT unless the electrolyte and glucose composition does not meet the needs of the individual patient.

Whilst beyond the scope of this guideline, we should continue to advocate the use of balanced crystalloid solutions for fluid resuscitation, both in line with the findings of these studies and the broader literature available.

PICO 4: Does the composition of IV-MFT in terms of glucose, electrolytes, vitamins and trace elements impact clinical outcomes?

Key recommendations

7. In acutely and critically ill children, glucose provision in intravenous maintenance fluid therapy should be considered in sufficient amounts and guided by blood glucose monitoring (at least daily) to prevent hypoglycaemia.

8. In critically ill children, glucose provision in intravenous maintenance fluid therapy should not be excessive and should be guided by blood glucose monitoring (at least daily) to prevent hyperglycaemia.

9. In acutely and critically ill children, there is insufficient evidence to recommend routine supplementation of magnesium, calcium, and phosphate in intravenous maintenance fluid therapy.

10. In acutely and critically ill children, an appropriate amount of potassium should be considered and added to intravenous maintenance fluid therapy based on the child’s clinical status and regular potassium level monitoring to avoid hypokalaemia.

11. In acutely and critically ill children, there is insufficient evidence to recommend routine supplementation of vitamins and trace elements in intravenous maintenance fluid therapy, in the absence of signs of deficiency.

Who was included?

Four studies were considered in developing this guideline; however, it was impossible to include them in a meta-analysis due to methodological issues.

Critique

The recommendations provided are sensible, considering the lack of high-quality evidence. Data from adult and paediatric literature suggest that hyperglycaemia is associated with poorer outcomes in critically unwell patients. The risks of hypoglycaemia are well recognised.

Bottom Line

The important take-home message here is about monitoring. It is not uncommon in acute care settings that IV-MFT may continue for some days without the child having their electrolytes or blood glucose monitoring. NICE, since 2015, has recommended daily electrolyte and glucose monitoring, and this guideline is consistent with that. Unless children are monitored for their hydration status, fluid balance, electrolytes, and blood glucose, it isn’t easy to adjust IV-MFT prescriptions appropriately, and this should be carefully considered in all inpatient areas.

The other critical thought process is considering whether nutrition can be started instead of leaving a child languishing on IV-MFT for days. Is it possible to commence enteral nutrition to meet these requirements, or should consideration be given to parenteral nutrition if there is likely to be a longer-term need for intravenous fluid therapy? Nutrition is essential for all patients and requires thought in acute and critical care environments.

PICO 5: Does the use of a restrictive IV-MFT volume versus the standard Holliday-Segar calculated volume impact clinical outcomes?

Key recommendations

12. In acutely and critically ill children, in order to prevent fluid creep and reduce fluid intake, the total daily amount of maintenance fluid therapy should be considered, including IV fluids, blood products, all IV medications (both infusions and bolus drugs), arterial and venous line flush solutions and enteral intake, but does not include replacement fluids and massive transfusion.

13. In acutely and critically ill children, avoidance of fluid overload and cumulative positive fluid balance should be considered to avoid prolonged mechanical ventilation and length of stay.

14. In acutely and critically ill children, who are at risk of increased endogenous secretion of ADH, restriction of total intravenous maintenance fluid therapy volume (calculated by Holliday and Segar formula) should be considered to some extent to avoid a decrease in serum sodium, but the amount and duration of this restriction are uncertain.

15. In acutely and critically ill children who are at risk of increased endogenous secretion of ADH, restricting maintenance fluid therapy volume to between 65-80% of the volume calculated by the Holliday and Segar formula should be considered to avoid fluid overload.

In children at greater risk of oedematous states, e.g., heart failure, renal failure or hepatic failure, restricting maintenance fluid therapy volume to between 50% to 60% of the volume calculated by the Holliday and Segar formula should be considered to avoid fluid overload.

16. Whilst receiving intravenous maintenance fluid therapy, re-assessment of acutely and critically ill children should be considered at least daily in terms of fluid balance and clinical status and regularly regarding electrolytes, especially sodium level.

Who was included?

Eight studies were identified and reviewed, 1 cohort and 7 RCTs, with 599 children. In almost all cases, the calculated volume was considered ‘full maintenance’, with restricted therapies being between half and two-thirds of this total. Some of the studies were not suitable for inclusion in the meta-analysis. They mainly included critically ill patients. The underlying pathologies included sepsis, ARDS, post-operative patients, meningitis, and respiratory infections requiring mechanical ventilation.

Findings

There was no statistically significant difference between restricted and standard fluid strategies regarding mortality, hyponatraemia, adverse neurological outcomes, plasma osmolality, length of stay, or fluid bolus administration.

Unsurprisingly, the restrictive fluid group received significantly less fluid. The restricted fluid group also had a statistically significant delta-osmolarity, delta-natremia, and natremia.

Critique

There were some quality issues with the papers included, with a serious to critical risk of bias in almost all studies. The statistically significant changes in sodium level and osmolarity are probably not clinically significant, with the highest mean difference in sodium level being in children who were hyponatraemic at the start of therapy. The mean difference was 4.2mmol/L.

Bottom Line

There is a lack of evidence available to answer most questions about using a restricted or standard fluid regime. With evidence suggesting worse outcomes in patients who are fluid-overloaded, it seems sensible to restrict fluid volumes to prevent this from occurring. However, the extent to which patients should be restricted, the circumstances, and the duration of that restriction still need to be clarified.

The formula for ‘maintenance’ fluid therapy proposed by Holliday and Segar in 1957 continues to be ubiquitous in current practice, but there are issues with this. Firstly, this formula was designed predominantly for well, euvolemic children, which does not represent the cohort of children we see in acute and critical care requiring IV-MFT. Secondly, our population of children has changed massively since then, with considerable variations in size and weight.

Longer term, there needs to be a review of the Holliday-Segar formula, alongside determining the unanswered questions about fluid restriction. In the interim, it seems sensible to fluid-restrict patients at increased risk of fluid overload and, as previously mentioned, ensure that regular (at least daily) reviews of fluid status and electrolytes take place.

In conclusion

The authors have undertaken a vast amount of work, aiming to fill a hole in international guidance around such a common and essential part of medical treatment for acute and critically unwell children. The recommendations they have created are sensible and are of little surprise to most clinicians.

The most significant criticism of these recommendations is around PICO3. Here, the data used to create the recommendation for balanced crystalloids for IV-MFT was almost entirely based on resuscitation fluids rather than maintenance. However, there is no evidence that balanced crystalloids are worse than unbalanced fluids. I suspect many will agree that there may be a benefit to their use based on literature around resuscitation and the application of clinical biochemistry. The strong expert consensus is likely to result in a shift towards their use as maintenance.

The importance of further research in this area cannot be overstated; with such little data available, most of which is heterogenous and riddled with bias, it was always going to be a near-impossible task to develop a guideline with high-grade recommendations.

This is my TL:DR summary.

Use the enteral route where possible.

Use isotonic, not hypotonic, fluids.

Monitor fluid status, electrolytes, and glucose at least daily for patients receiving IV-MFT and adjust treatment as appropriate.

Use balanced crystalloids for maintenance if they are available, as long as they meet the glucose and electrolyte needs of the patient in front of you.

Consider restricting fluid in patients who are at greater risk of fluid overload but monitor them closely.

Be aware of fluid creep: consider all fluids the patient is receiving.

References

  1. Brossier, D.W., Tume, L.N., Briant, A.R. et al. ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children— a systematic review and meta-analysis. Intensive Care Med (2022). https://doi.org/10.1007/s00134-022-06882-z.
  2. Semler MW, Kellum JA. Balanced Crystalloid Solutions. Am J Respir Crit Care Med (2019) Apr 15;199(8):952-960. doi: 10.1164/rccm.201809-1677CI. PMID: 30407838; PMCID: PMC6467313.
  3. Kenny JES. An introduction to Stewart acid-base: Clinically useful or chemical bookkeeping? Physiology News (2021) Jun; 122. doi: https://doi.org/10.36866/122.26..
  4. Lillie J., Lambert J. Paediatric Critical Care: Acid Base Interpretation [Clinical Guideline] (2022). 2nd Edn. Evelina London. https://www.evelinalondon.nhs.uk/resources/our-services/hospital/south-thames-retrieval-service/Acid-base-interpretation-2017.pdf.
  5. Hall JE., Hall ME. Acid-Base Regulation (Chapter 31) in Guyton and Hall Textbook of Medical Physiology (14th Edn) (2021). Elsevier: Philadelphia.
  6. Electronic Medicines Compendium. Plasma-Lyte 148 (pH 7.4) solution for infusion. [Internet] https://www.medicines.org.uk/emc/product/1795/smpc#gref.
  7. Hammond NE., Zampieri FG., Di Tanna GL. Balanced Crystalloids versus Saline in Critically Ill Adults – A Systematic Review with Meta-Analysis. NEJM Evid (2022); 1(2). DOI:https://doi.org/10.1056/EVIDoa2100010.
  8. Rubens M., Kanaris C. Fifteen minute consultation: Emergency management of children presenting with hyperkalaemia. Arch Dis Child Educ Pract Ed (2022). 107:344-350.
  9. Friedman AL., Ray PE. Maintenance fluid therapy: what it is and what it is not. Pediatric Nephrology (2008) 23;677-680 https://doi.org/10.1007/s00467-007-0610-3.
  10. Holliday MA., Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics (1957). 19(5): 823-832. DOI: https://doi.org/10.1542/peds.19.5.823.
  11. BBC News. Hyponatraemia: Five children’s deaths led to 14-year quest. 31 January 2018 [Internet]. https://www.bbc.co.uk/news/uk-northern-ireland-24940730.
  12. Medecins Sans Frontieres. 5.3 Severe Dehydration. MSF Medical Guidelines. https://medicalguidelines.msf.org/en/viewport/CHOL/english/5-3-severe-dehydration-32409706.html#section-target-1.

Authors

  • Richard is a paediatric registrar in Yorkshire, with interests in paediatric intensive care, emergencies, resuscitation, and pre-hospital medicine. He is passionate about teaching and doing the basics well. Outside of work, he is often found walking in the Peak District.

  • Costas Kanaris is a Paediatric Intensive Care Consultant in Cambridge and an Associate Editor of the Journal of Child Health Care. He has a PhD in Medical Ethics and Law and is an Honorary Senior Lecturer at Queen Mary University of London.

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