Do we still treat children with hypotonic fluids

Do we still ‘treat’ children with hypotonic fluids? Williams L, Caldwell NA, Rackham O, Morecroft CW

Background Intravenous fluids are administered to children for 4 main reasons: Maintenance Electrolyte imbalance Circulatory support On-going replacement losses 0. 18% Sodium Chloride + 4% Glucose became the fluid of choice following the findings of Holliday and Segar in 1957 4 child deaths and 1 near miss lead to concerns regarding use The NPSA published ‘Reducing the risk of hyponatraemia when administering intravenous fluids’ in 2007

Overview Does the NPSA alert influence practice? This study aimed to assess: Fluid types administered 0. 18% Sodium chloride + 4% Glucose Extent of hyponatraemia Clinical guideline implementation

Related Work NPSA publication Armon K et al. Hyponatraemia and hypokalaemia during intravenous fluid administration. Archives and disease in children (BMJ Group), 2008: 93: 285 -287. Baker J et al. The use of hypotonic fluids in paediatric practice. Archives of Disease of Childhood 2011: 96(1).

1 2 3 4 5 27 6 7 12, 13 8 14 28 15 9, 10, 11 17 16 19 18 24 20, 21, 22 23 25 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 No. of patients 13 11 6 3 3 4 7 2 8 2 6 19 21 2 24 5 10 3 4 10 12 5 4 7 25 4

1 2 3 4 5 27 6 7 12, 13 8 14 28 15 9, 10, 11 17 16 19 18 24 20, 21, 22 23 25 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 No. of patients 13 11 6 3 3 4 7 2 8 2 6 19 21 2 24 5 10 3 4 10 12 5 4 7 25 4

Method Participants 0 -18 years Design Medical and Surgical challenges 1 -4 days data collection ITU excluded Data collection tool used Sample Size Currently on IV fluids (or halted within the Bias previous 24 hours)

Method Data collection Information we required from each trust: • Are guidelines available? • What fluids are used within the trust? Information we required for each patient: • Basic demographics • Age • Weight • Clinical background • Reason for IV fluids • Maintenance fluid administered • Replacement fluids administered • Duration of fluids • Electrolyte monitoring • Time and date of last recording • Current sodium level • Rate of fluid administration

Method Participants 0 -18 years Design Medical and Surgical challenges 1 -4 days data collection ITU excluded Data collection tool used Sample Size Currently on IV fluids (or halted within the Bias previous 24 hours)

Results Sodium Chloride 0. 45% + 5% Glucose accounted for 91% of all hypotonic fluids Fluid administration hypotonic isotonic No Patients received Sodium Chloride 0. 18% + 4% Glucose 5 neonates received Sodium Chloride 0. 18% + 10% Glucose hyprtonic Just over one third of all isotonic fluids were administered for fluid replacement purposes

Results Percentage maintenance volume of fluid Number of children 80 70 60 High Na 50 40 Normal Na Low Na 30 20 10 0 -2 21 0 --4 0 41 -6 0 61 -8 81 0 -1 10 00 112 12 0 11 14 40 11 16 60 11 18 80 120 0 20 U nk 1+ no w n 0 Maintenance Volume (%)

Results Other Hyponatraemia 30% of hyponatraemic cases were surgical patients o 57% of surgical patients received hypotonic fluids 45% received isotonic fluids Electrolyte monitoring was not completed for 22% of patients The majority (89%) of all trusts had clinical guidelines in place

Future work Plasmalyte 148 + 5% glucose Glucose Na+ 140 mmol/L Cl- 98 mmol/L K+ 5 mmol/L Mg+ 1. 5 mmol/L Acetate 27 mmol/L Gluconate 23 mmol/L

Summary Practice is changing following NPSA publication No patients received 0. 18% sodium chloride + 4% glucose A large percentage of patients are still administered hypotonic fluids Isotonic fluids are used commonly as fluid replacement Most trusts have guidelines available (60% increase since 2004) More care is required in regards to electrolyte monitoring and volume of fluid administered

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