Fluid Management in Pediatric Urology: A Review of the Literature and Call for a Change in Practice
Abstract
Introduction:
We investigate the intravenous fluid ordering practices of pediatric urologists. We also provide evidence for the use of isotonic fluids and, thus, establish a new standard for the field.
Methods:
An online questionnaire was distributed via the listserve of the American Academy of Pediatrics Section on Urology. For 3 patient scenarios the respondents were asked to select which intravenous fluid they would prescribe and which infusion rate they would choose. Fluid choices were listed as lactated Ringer solution, normal saline, 0.45% normal saline, 5% dextrose in lactated Ringer solution, 5% dextrose in 0.45% normal saline, none and other (with write-in option). Infusion rate choices were listed as maintenance (defined according to the Holliday-Segar 4-2-1 nomogram), ½x maintenance, 1.5x maintenance, 2x maintenance and other (with write-in option). A final question probed physician reason(s) for selections.
Results:
The survey had a 35% response rate. The majority of respondents use 5% dextrose in 0.45% normal saline, and the most common infusion rate is 1.5x maintenance. Additionally, choices for fluid use and infusion rate were based on a combination of physician training and personal experience. Only 13% of respondents stated that they routinely avoid isotonic fluids. A PubMed® literature search demonstrated that the general pediatric and surgical specialty literature discourages hypotonic fluids and favors the judicious use of isotonic hydration and dextrose.
Conclusions:
A change in pediatric urology needs to occur such that isotonic fluids at maintenance rate become the standard, with the addition of dextrose and/or increasing of rate only for carefully selected patients.
References
- 1 : The maintenance need for water in parenteral fluid therapy. Pediatrics1957; 19: 823. Google Scholar
- 2 : A randomised controlled trial of Hartmann’s solution versus half normal saline in postoperative paediatric spinal instrumentation and craniotomy patients. Arch Dis Child2012; 97: 491. Google Scholar
- 3 : Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial. Pediatrics2011; 128: 857. Google Scholar
- 4 : Incidence of postoperative hyponatremia and complications in critically-ill children treated with hypotonic and normotonic solutions. J Pediatr2008; 152: 33. Google Scholar
- 5 : Intravenous fluid regimen and hyponatraemia among children: a randomized controlled trial. Pediatr Nephrol2010; 25: 2303. Google Scholar
- 6 : Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics2014; 133: 105. Google Scholar
- 7 : Perioperative fluid therapy in pediatrics. Pediatr Anesth2008; 18: 363. Google Scholar
- 8 : Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. J Pediatr2010; 156: 313. Google Scholar
- 9 : Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health2009; 45: 9. Google Scholar
- 10 : Risk of acute hyponatremia in hospitalized children and youth receiving maintenance intravenous fluids. Paediatr Child Health2013; 18: 102. Google Scholar
- 11 : The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: a randomized, controlled open study. Pediatr Crit Care Med2008; 9: 589. Google Scholar
- 12 : Pediatric Anesthesia. New York: Churchill Livingstone2002. Google Scholar
- 13 : Acute hospital-induced hyponatremia in children: a physiologic approach. J Pediatr2004; 145: 584. Google Scholar
- 14 : The stress response to trauma and surgery. Br J Anaesth2000; 85: 109. Google Scholar
- 15 : Hyponatraemia in premature babies and following surgery in older children. Acta Paediatr Scand1987; 76: 385. Google Scholar
- 16 : Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: the role of fluid management. Spine (Phila Pa 1976)1996; 21: 724. Google Scholar
- 17 : Perioperative infusions in paediatric patients: rationale for using Ringer-lactate solution with low dextrose concentration. J Clin Pharm Ther2003; 28: 31. Google Scholar
- 18 : Measurement of “true” glucose production rates in infancy and childhood with 6,6-dideuteroglucose. Diabetes1977; 26: 1016. Google Scholar
- 19 : Evaluation of current paediatric guidelines for fluid therapy using two different dextrose hydrating solutions. Pediatr Anesth1991; 1: 95. Google Scholar
- 20 : Four different fluid regimes during and after minor paediatric surgery–a study of blood glucose concentrations. Pediatr Anesth1994; 4: 235. Google Scholar
- 21 : Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology2010; 112: 860. Google Scholar
- 22 : Does tight glycemic control improve outcomes in pediatric patients undergoing surgery and/or those with critical illness?. Int J Gen Med2013; 7: 1. Google Scholar
- 23 : Blood glucose control in critically ill adults and children: a survey on stated practice. Chest2008; 133: 1328. Google Scholar
- 24 : Reducing glucose infusion safely prevents hyperglycemia in post-surgical children. Clin Nutr2011; 30: 786. Google Scholar
- 25 : Carbohydrate as nutrient in the infant and child: range of acceptable intake. Eur J Clin Nutr1999; 53: S94. Google Scholar
- 26 : Why are response rates in clinician surveys declining?. Can Fam Physician2012; 58: e225. Google Scholar
- 27 Flanigan TS, McFarlane E and Cook S: Conducting survey research among physicians and other medical professionals: a review of current literature. Presented at American Association for Public Opinion Research Annual Conference, New Orleans, Louisiana, May 15-18, 2008. Google Scholar
- 28 : Practice patterns among pediatric urologists in the use of Deflux® for vesicoureteral reflux: a survey. J Pediatr Urol2013; 9: 955. Google Scholar