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| EDITORIAL |
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| Year : 2023 | Volume
: 10
| Issue : 2 | Page : 45-46 |
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Fluid prescription: It is time to act
Mullai Baalaaji
Pediatric Intensive Care Unit, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| Date of Submission | 05-Jan-2023 |
| Date of Decision | 20-Jan-2023 |
| Date of Acceptance | 27-Jan-2023 |
| Date of Web Publication | 23-Mar-2023 |
Correspondence Address:
Dr. Mullai Baalaaji
Pediatric Intensive Care Unit, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_1_23
How to cite this article:
Baalaaji M. Fluid prescription: It is time to act. J Pediatr Crit Care 2023;10:45-6 |
Maintenance intravenous fluids (mIVFs) are one of the commonly prescribed supportive care therapies to children. Maintenance IVFs are administered when sufficient fluids cannot be reliably administered through the enteral route, or when the enteral route is contraindicated due to respiratory compromise, neurological impairment, gastrointestinal problems, or during the perioperative states. Despite being such a common intervention in hospitalized children, there has been wide variation in the practices across the globe.[1],[2] Lack of standard guidelines, evolution of our understanding on the topic, and inadequate training of the health-care professionals are some of the reasons for these varied practice patterns.
There cannot be a single uniform guideline that is applicable for mIVFs across all age groups and disease processes, as it varies with the illness, phase of disease process, preexisting nutrition status, and underlying metabolic derangements that are already in existence. Four distinct phases of fluid repletion have been identified, which are as follows: resuscitative phase is where fluids are used to restore tissue perfusion and replenish end-organ perfusion. The titration phase is when fluid therapy is transitioned from the bolus resuscitative phase to the maintenance phase. The maintenance phase is when the intravascular compartment is already restored, and fluids are just needed to balance the losses. Deresuscitation phase is when the child is able to regulate fluid homeostasis on their own and extraneous fluids are stopped, and sometimes, active interventions are required to remove the accumulated fluids during the previous phases of fluid therapy.
The following things need to be determined before embarking on fluid prescription, namely, the volume of fluids that need to be administered, tonicity of fluids, and the composition of dextrose and other electrolytes that are to be provided. The volumes calculated were originally based on the Holliday and Segar formula, which is widely used even in the current era due to its simplicity of calculation and the fact that it has stood the test of time.[3] However, there have been questions that are raised on this calculation, as it was based on the energy needs of healthy children and the same is altered in disease states, as there is no energy expenditure on activities and growth in acute illness.[4] This has led to the overestimation of actual energy expenditure and water requirements. Furthermore, there is impaired free water excretion due to many nonosmotic stimuli during acute illness. The net result is that the administration of exogenous water in the form of hypotonic maintenance fluids would result in more free water retention and potentiate hyponatremia.[5],[6] There have been numerous cases of hyponatremia in hospitalized children attributable to inappropriate hypotonic fluid therapy,[7] and the same is associated with serious morbidity and mortality. The use of isotonic fluids in recent randomized trials has consistently reported that isotonic maintenance fluids decrease the risk of iatrogenic hyponatremia without causing side effects.[8],[9],[10] This has led to recent guidelines favoring the administration of isotonic fluids in children to decrease the risk of hyponatremia. Furthermore, there is a strong consensus to provide fluids through the enteral route, if tolerated.[5],[11]
Given these developments in our understanding of fluid therapy, it is imperative for us to get a glimpse of what is happening in the real-life scenario. In the current issue of the Journal of Pediatric Critical care, Harish et al. have looked at the fluid prescriptions by pediatricians in various clinical settings using a predesigned questionnaire survey.[12] The study looked at the volume and types of maintenance fluids employed by the respondents for a wide variety of clinical scenarios and age groups. The respondents included qualified pediatricians as well as pediatric residents working across different grades of health facilities ranging from independent clinics to specialist hospitals. Furthermore, the group comprised varying cader of experiences, with more than half having experience of 5 years and more. The survey revealed that hypotonic fluids continued to be preferred by majority of the respondents (53%), contrary to the current emerging guidelines. Furthermore, the preference was not influenced by the seniority, clinical experience, or clinical position of the respondents. Being an online predesigned survey, the authors could not find the rationale for fluid preferences among the respondents.
The study reiterates the fact that a wide gap exists between available evidence and the clinical practices among pediatricians. Given the fact that fluid therapy is a common intervention employed, it is essential to disseminate emerging knowledge to change the practice patterns. Formation of consensus guidelines is only the first step; the real challenge is to make the guidelines accessible and available and also to transform the knowledge to action at the bedside. Ongoing continuing medical education, seminars, and workshops hosted by professional bodies will go a long way in disseminating the existing guidelines. Little steps taken toward creating awareness among pediatricians in this regard will reap huge benefits, and the ultimate beneficiaries would be the sick kids.
| References | |  |
| 1. | Freeman MA, Ayus JC, Moritz ML. Maintenance intravenous fluid prescribing practices among paediatric residents. Acta Paediatr 2012;101:e465-8.  |
| 2. | Lee JM, Jung Y, Lee SE, Lee JH, Kim KH, Koo JW, et al. Intravenous fluid prescription practices among pediatric residents in Korea. Korean J Pediatr 2013;56:282-5. |
| 3. | Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32. |
| 4. | Illner K, Brinkmann G, Heller M, Bosy-Westphal A, Müller MJ. Metabolically active components of fat free mass and resting energy expenditure in nonobese adults. Am J Physiol Endocrinol Metab 2000;278:E308-15. |
| 5. | Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, et al. Clinical practice guideline: Maintenance intravenous fluids in children. Pediatrics 2018;142:e20183083. |
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| 7. | Hoorn EJ, Geary D, Robb M, Halperin ML, Bohn D. Acute hyponatremia related to intravenous fluid administration in hospitalized children: An observational study. Pediatrics 2004;113:1279-84. |
| 8. | Friedman JN, Beck CE, DeGroot J, Geary DF, Sklansky DJ, Freedman SB. Comparison of isotonic and hypotonic intravenous maintenance fluids: A randomized clinical trial. JAMA Pediatr 2015;169:445-51. |
| 9. | Flores Robles CM, Cuello García CA. A prospective trial comparing isotonic with hypotonic maintenance fluids for prevention of hospital-acquired hyponatraemia. Paediatr Int Child Health 2016;36:168-74. |
| 10. | McNab S, Duke T, South M, Babl FE, Lee KJ, Arnup SJ, et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): A randomised controlled double-blind trial. Lancet 2015;385:1190-7. |
| 11. | Brossier DW, Tume LN, Briant AR, Jotterand Chaparro C, Moullet C, Rooze S, 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;48:1691-708. |
| 12. | Harish K, Gupta G, Kumar D, Pemde HK, Royhcoudhuri S. Prescription practices related to maintenance intravenous fluid in children: A cross sectional, electronic media based survey. J Pediatr Crit care 2023;10:56-62. [Full text] |
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