Intravenous fluid regimen and dyselectrolytemia among children

Balaji Chinnasami, Kanimozhi Sadasivam, P. Sekar, Saravanan

Aim: The aim of this study is to compare the effect of three different intravenous (i.v.) fluid regimes I.e. Isolyte P, DNS and Plasma-Lyte 148 on the incidence of dyselectrolytemia in hospitalized children ranging in age from 3 months to 12 years.

Brief Introduction: The administration of intravenous (i.v.) maintenance fluid is an essential part of the management of sick children. In pediatric patients, the administration of 0.18% saline in 5% dextrose as i.v. maintenance fluid is the currently accepted standard practice despite there being concerns regarding the potential for hospital-acquired hyponatraemia associated with hypotonic i.v. fluid administration. In 2003, Moritz and Ayus introduced the concept of using 0.9% saline as a maintenance parenteral fluid for the prevention of hospital-acquired hyponatraemia in children. However excessive use of saline has been observed to result in hyperchloremic acidosis. It has been suggested that the use of balanced solutions may avoid this effect. British Consensus Guidelines on Intravenous Fluid therapy for Adult Surgical Patients clearly recommend the use of balanced crystalloids rather than saline.

Study Design : It will be a prospective study carried out on 150 children between 3mths to 12yrs of age. The study will be conducted in department of pediatrics from August 2015 to Janauary 2015. Children who require the administration of i.v. maintenance fluid for at least 24hrs following hospitalization will be eligible for inclusion. After obtaining consent from parents the children will be randomized into three i.v. fluid groups: Group A, 0.18% saline in 5% dextrose (Isolyte P); Group B, Plasma-Lyte 148; Group C, 0.9% saline in 5% dextrose. All three groups will be receiving fluids at standard maintenance rate.

Inclusion Criteria : Children who are judged by the treating physician to require i.v. maintenance fluid administration for at least the following 24 h of their hospital stay will be eligible for inclusion in the study.

Exclusion Criteria : Children with hyponatraemia (plasma sodium <130 mEq/L), hypernatraemia (plasma sodium >150 mEq/L) or hyperglycaemia (blood glucose>180 mg/dL), dehydration, shock, severe malnutrition, cirrhosis of liver, congestive heart failure, acute or chronic renal failure and nephrotic syndrome will be excluded. Children who were receiving drugs that alter plasma sodium levels, such as frusemide, hydrochlorothiazide, vasopressin or desmopressin and mannitol, will also be excluded.

Sample Size : Given the sparse and conflicting data, we took the incidence of hospital-acquired hyponatraemia among children to be 30%. Therefore, a sample of 72 patients would be needed in each group to demonstrate a 10% decrease in the incidence of hyponatraemia (defined as plasma sodium <130 mEq/L), with a power of 80% and alpha error of 0.05. In view of feasibility, it was decided a priori to enroll at least 50 patients in each treatment limb.

Outcome Measurement : At enrolment, 2 mL of venous blood will be taken for estimation of plasma sodium, potassium, chloride, blood sugar, urea and creatinine. Plasma sodium, potassium, chloride, blood sugar levels will be estimated every day thereafter. The study measurements will be carried out until the child received only i.v. maintenance fluid therapy or at the 72-h time-point following the initiation of the i.v. fluid therapy, whichever is earlier.