Resuscitation/original research
Rapid Fluid Resuscitation in Pediatrics: Testing the American College of Critical Care Medicine Guideline

Presented as an abstract at the 2006 Society of Critical Care Medicine Annual Congress, January 2006, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2007.06.482Get rights and content

Study objective

The 2002 American College of Critical Care Medicine (ACCM) guidelines for the resuscitation of pediatric septic shock suggest that 20 mL/kg of bolus intravenous fluid be given within 5 minutes. Of 3 commonly used, inexpensive methods of fluid delivery, we hypothesized that only use of a manual push-pull system will permit guideline adherence.

Methods

This prospective, interventional study was open to children in the Columbus Children’s Hospital Emergency Department who were ordered a 20 mL/kg nonemergent fluid bolus by their treating physician. Subjects were randomized to receive the fluid for 5 minutes by a pressure bag maintained at 300 mm Hg, by a manual push-pull system, or by gravity. Volume of fluid delivered, absolute rates of fluid delivery, and adherence to the ACCM guideline were recorded. Statistical analysis was done with both parametric and nonparametric methods.

Results

Sixty children were enrolled, with 57 included in data analysis. Median volumes of fluid delivered in the study period were 20.9 mL/kg (pressure bag), 20.2 mL/kg (push-pull), and 6.2 mL/kg (gravity) (P<.0001). The ACCM guideline was met in 58% of the pressure bag group, 68% of the push-pull group, and none of the gravity group. No children weighing greater than 40 kg met the guideline in any of the groups.

Conclusion

The ACCM guideline for rapid fluid resuscitation is feasible for many children, especially those weighing less than 40 kg. Contrary to our hypothesis, the use of a pressure bag and a manual push-pull system both appear to be acceptable methods of rapid fluid delivery. Administration of bolus fluid by gravity likely has a limited role in acute pediatric resuscitation.

Introduction

The administration of large volumes of resuscitative fluid early in the course of treatment has been clearly shown to have a beneficial impact on outcomes from pediatric septic shock.1 Rapid fluid administration has therefore become the recommended practice in resuscitation of pediatric septic shock.2, 3, 4, 5 In 2002, the American College of Critical Care Medicine (ACCM) published a seminal paper titled “Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Patients in Septic Shock,” which stressed the importance of rapid fluid resuscitation.6 These guidelines suggest that children with septic shock receive 20 mL/kg boluses of isotonic intravenous fluid, up to 60 mL/kg, within the first 15 minutes of resuscitation if shock persists, which equates to 20 mL/kg of isotonic intravenous fluid within 5 minutes.

In our experience, this goal is infrequently achieved. We have found that one of the chief reasons for noncompliance with this guideline is the belief of many practitioners that the administration of 20 mL/kg to a child within 5 minutes is technically unfeasible because of the patient’s size and the small gauge of intravenous catheters used in children.7 Although flow rates by gravity through pediatric catheters have been evaluated ex vivo,8 we are unaware of any data describing in vivo fluid administration rates in children.

We performed this prospective, randomized, interventional study to test the hypothesis that, among 3 simple, inexpensive, and commonly used methods of fluid delivery, only manual pushing of isotonic intravenous fluid can achieve compliance with the ACCM guideline of 20 mL/kg within 5 minutes in children.

Section snippets

Setting

This study was carried out in the emergency department (ED) of Columbus Children’s Hospital, a large pediatric referral center with greater than 70,000 ED visits per year. This study was approved by the institutional review board at Columbus Children’s Hospital, and parental written informed consent (and patient assent for children ≥9 years of age) was obtained before enrollment.

Selection of Participants

We performed this study in relatively healthy children receiving a nonemergent isotonic intravenous fluid bolus. This

Results

Sixty subjects were enrolled between September 2005 and April 2006 (20 per group) (Figure 2). Three subjects were excluded from analysis (1 in each group) because of protocol violation (improper caliber of T-connector). Data from the remaining 57 subjects (19 per group) were analyzed. The demographics of the study population and their outcomes are shown in the Table. There were no statistically significant differences in age, weight, or intravenous catheter gauge among treatment groups. One

Limitations

Our subjects received a maximum of 20 mL/kg of isotonic intravenous fluid in the course of this study. The effect of a larger volume of fluid on operator fatigue and vein patency is unclear.

Also, infants younger than 1 year were not represented in our cohort, nor were 24-gauge intravenous catheters or catheters placed more distally in the extremity. However, we found that successful adherence to the ACCM guideline was easier in the smaller children. In fact, smaller intravenous catheter gauge

Discussion

In 1991, Carcillo et al1 reported that mortality from pediatric septic shock was dramatically reduced in children who received large volumes of fluid resuscitation within the first hour of presentation. The median volume of fluid given in the first hour to this patient population was 60 mL/kg, with no increase in incidence of cardiogenic pulmonary edema or cerebral edema. Since then, several studies have reinforced the positive impact of early, aggressive fluid resuscitation in pediatric septic

References (10)

  • J.A. Carcillo et al.

    Role of early fluid resuscitation in pediatric septic shock

    JAMA

    (1991)
  • L.M. Bell

    Textbook of Pediatric Emergency Medicine

  • A.L. Zaritsky et al.

    Pediatric Advanced Life Support Provider Manual

    (2002)
  • M.M. Parker et al.

    Pediatric considerations

    Crit Care Med

    (2004)
  • A. Kirby et al.

    Improved outcomes associated with early resuscitation in septic shock: do we need to resuscitate the patient or the physician?

    Pediatrics

    (2003)
There are more references available in the full text version of this article.

Cited by (48)

  • A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid administration in emergency situations: A randomised crossover design

    2022, Australian Critical Care
    Citation Excerpt :

    Thus, from these results, using the HTS makes fluid resuscitation faster because of the low resistance when filling the syringe. The findings from this study comparing the effectiveness of using a pressure bag and push-and-pull technique are consistent with those from another study.12 Comparing the use of push-and-pull technique and the use of pressure bags, our study revealed that the use of a pressure bag resulted in a slightly faster infusion speed than the push-and-pull technique because of a continuous pressure applied.

  • Emergency Department Management of Pediatric Shock

    2018, Emergency Medicine Clinics of North America
    Citation Excerpt :

    In 1 trial, fluid administration rates were equivalent in children using a pressure bag versus push/pull system, and both were faster than gravity or an IV infusion pump. Investigators have shown that 20 mL/kg of fluid can be delivered in 5 minutes or less via pressure bag or push methods.28 Although placement of a central venous line (CVL) is common in resuscitation in adults, this is unnecessary in children, at least in the initial stages.

  • Pediatric Sepsis

    2017, Emergency Medicine Clinics of North America
  • Equipment

    2016, Smith's Anesthesia for Infants and Children, Ninth Edition
  • Pediatric Shock

    2015, Journal of Emergency Nursing
    Citation Excerpt :

    Techniques to rapidly deliver intravenous fluid include applying pressure directly to the bag of fluid with an inflatable device, delivering aliquots of fluid using a large syringe that is refilled through a 3-way stopcock attached to the bag (the “push-pull” method), or use of rapid infusion pumps designed to deliver high volumes of warmed fluids or blood. Gravity alone is insufficient to deliver 20 mL/kg over 5 to 10 minutes (as demonstrated by Stoner et al14 in a randomized trial that compared the rate at which fluid could be delivered to 57 children requiring fluid resuscitation using gravity, an inflatable pressure bag, or a “push-pull” method). Patients with compensated hypovolemic or distributive shock should receive 20 mL/kg per bolus of isotonic crystalloid, such as normal saline solution or Ringer’s lactate solution, over 5 to 20 minutes.

  • Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios

    2014, Resuscitation
    Citation Excerpt :

    Rapid administration of intravenous fluid is important in treating a hypovolemic paediatric patient.34 Participants in the scenarios were often observed to administer fluid boluses via an infusion pump when a quicker alternative would be to utilise a syringe and three way tap or a blood pump infusion set.34 It is important, when teaching fluid resuscitation to clarify what is meant by the term ‘bolus’; not just the type of fluid but also the volume to be infused, the route of infusion and exactly how the fluid will be delivered to the patient.

View all citing articles on Scopus

Supervising editor: Kathy N. Shaw, MD, MSCE

Author contributions: MJS and MWH conceived of the study. MJS, DGG, DMC, and MWH designed the study. MJS and DGG recruited subjects and collected data. MJS, MWH, and DMC performed data analysis. MJS and MWH drafted the article, with substantial contributions to its revision from DGG and DMC. SAF performed additional statistical analyses and provided substantial contributions to the article revision. MWH takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded in part by NICHD K12HD43372-03, NHLBI K08HL085525-01.

Publication dates: Available online August 30, 2007.

Reprints not available from the authors.

View full text