ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis

PURPOSE Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance

Płynoterapia śródoperacyjna w praktyce pediatrycznej — porównanie wybranych płynów infuzyjnych

Background: Fluid therapy is essential for safe perioperative management. Numerous reports of serious complications, including brain damage and death of children, as a result of inappropriate fluid management, have been published. The aim of this study was to assess the effects of intraoperative fluids on serum glucose and electrolytes concentrations as well as serum osmolality. Methods: 91children, ASA I and II, undergoing elective ENT surgery were enrolled to this prospective, randomized, open-label study. They were randomly assigned to receive: group G5W: 5% glucose in water solution, group GNaCl: 3.33% glucose in 0.3% NaCl, and group RA: Ringer’s acetate. Serum glucose, sodium, potassium, phosphate concentrations and serum osmolality were analysed before induction of anaesthesia, immediately after completion of surgery and 60 min later. Results: Postoperative hyperglycaemia was observed in 94% of children in group G5W and in 37% of group GNaCl. In all the groups glucose concentration increased significantly after surgery. Postoperative hyponatraemia occurred in 36% of patients in the group G5W, and in 3.7% in the group GNaCl. Neither hyperglycaemia nor hyponatremia occurred in the group RA. Postoperative osmolality decreased significantly in groups G5W and GNaCl and remained unchanged in the group RA. Conclusions: Ringer’s acetate did not cause significant changes in glucose and electrolyte concentrations, so it seems to be the safest for intraoperative use in children undergoing elective surgery. Hypotonic fluids may cause hyperglycaemia and hyponatraemia so they should be avoided intraoperatively.Background: Fluid therapy is essential for safe perioperative management. Numerous reports of serious complications, including brain damage and death of children, as a result of inappropriate fluid management, have been published. The aim of this study was to assess the effects of intraoperative fluids on serum glucose and electrolytes concentrations as well as serum osmolality. Methods: 91children, ASA I and II, undergoing elective ENT surgery were enrolled to this prospective, randomized, open-label study. They were randomly assigned to receive: group G5W: 5% glucose in water solution, group GNaCl: 3.33% glucose in 0.3% NaCl, and group RA: Ringer’s acetate. Serum glucose, sodium, potassium, phosphate concentrations and serum osmolality were analysed before induction of anaesthesia, immediately after completion of surgery and 60 min later. Results. Postoperative hyperglycaemia was observed in 94% of children in group G5W and in 37% of group GNaCl. In all the groups glucose concentration increased significantly after surgery. Postoperative hyponatraemia occurred in 36% of patients in the group G5W, and in 3.7% in the group GNaCl. Neither hyperglycaemia nor hyponatremia occurred in the group RA. Postoperative osmolality decreased significantly in groups G5W and GNaCl and remained unchanged in the group RA. Conclusions: Ringer’s acetate did not cause significant changes in glucose and electrolyte concentrations, so it seems to be the safest for intraoperative use in children undergoing elective surgery. Hypotonic fluids may cause hyperglycaemia and hyponatraemia so they should be avoided intraoperatively

Przedoperacyjna doustna podaż roztworu węglowodanów u dzieci — ocena tolerancji i odpowiedzi metabolicznej — doniesienie wstępne

Background: The need for long preoperative fasting has been questioned. Recent data shows that intake of oral carbohydrate-containing clear fluid prior to anaesthesia is safe and may have positive impact on recovery, metabolic status and improve glucose tolerance. Such solutions are routinely used in adults but not children. The aim of this study was to evaluate safety, tolerance and influence of oral carbohydrate on selected metabolic parameters in children.Methods: With the ethics committee approval and parental informed consent 20 children, aged 4–17 years, ASA status I or II, scheduled for abdominal or thoracic surgery were randomized to group 1 — receiving a 12.6% carbohydrate-containing drink (10 mL kg-1 the evening before surgery and 2 hours before anaesthesia) or control group 2 — fasting. Serum glucose and insulin concentration were measured four times: before and after anaesthesia, in the evening after surgery and the following morning. IGF-1 concentration was measured once, before surgery. Insulin resistance was assessed by the HOMA-IR equation.Results: Oral carbohydrate solution was well tolerated and no adverse events were noted. Glucose concentrations were within the normal range in both groups. Insulin concentration did not show significant differences between groups, however before surgery it tended to be lower in group 1. Insulin resistance after surgery was significantly higher in group 2 (2.0 vs. 0.62, P = 0.03), also the increase in insulin resistance after operation was significant only in control group (P = 0.03).Conclusion: Oral carbohydrates were safe, well tolerated and did not cause any perioperative adverse events. They seem to improve postoperative metabolism by decreasing insulin resistance.Background: The need for long preoperative fasting has been questioned. Recent data shows that intake of oral carbohydrate-containing clear fluid prior to anaesthesia is safe and may have positive impact on recovery, metabolic status and improve glucose tolerance. Such solutions are routinely used in adults but not children. The aim of this study was to evaluate safety, tolerance and influence of oral carbohydrate on selected metabolic parameters in children.Methods: With the ethics committee approval and parental informed consent 20 children, aged 4–17 years, ASA status I or II, scheduled for abdominal or thoracic surgery were randomized to group 1 — receiving a 12.6% carbohydrate-containing drink (10 mL kg-1 the evening before surgery and 2 hours before anaesthesia) or control group 2 — fasting. Serum glucose and insulin concentration were measured four times: before and after anaesthesia, in the evening after surgery and the following morning. IGF-1 concentration was measured once, before surgery. Insulin resistance was assessed by the HOMA-IR equation.Results: Oral carbohydrate solution was well tolerated and no adverse events were noted. Glucose concentrations were within the normal range in both groups. Insulin concentration did not show significant differences between groups, however before surgery it tended to be lower in group 1. Insulin resistance after surgery was significantly higher in group 2 (2.0 vs. 0.62, P = 0.03), also the increase in insulin resistance after operation was significant only in control group (P = 0.03).Conclusion: Oral carbohydrates were safe, well tolerated and did not cause any perioperative adverse events. They seem to improve postoperative metabolism by decreasing insulin resistance