Resuscitation/original researchRapid Fluid Resuscitation in Pediatrics: Testing the American College of Critical Care Medicine Guideline
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)
- et al.
Role of early fluid resuscitation in pediatric septic shock
JAMA
(1991) Textbook of Pediatric Emergency Medicine
- et al.
Pediatric Advanced Life Support Provider Manual
(2002) - et al.
Pediatric considerations
Crit Care Med
(2004) - et al.
Improved outcomes associated with early resuscitation in septic shock: do we need to resuscitate the patient or the physician?
Pediatrics
(2003)
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 CareCitation 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 AmericaCitation 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 AmericaEquipment
2016, Smith's Anesthesia for Infants and Children, Ninth EditionPediatric Shock
2015, Journal of Emergency NursingCitation 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, ResuscitationCitation 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.
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.