Suitable intravenous fluid for preventing dysnatremia in children with gastroenteritis; a randomized clinical trial

Balanced crystalloid solutions versus 0.9% saline for treating acute diarrhoea and severe dehydration in children

BACKGROUND

Although acute diarrhoea is a self-limiting disease, dehydration may occur in some children. Dehydration is the consequence of an increased loss of water and electrolytes (sodium, chloride, potassium, and bicarbonate) in liquid stools. When these losses are high and not replaced adequately, severe dehydration appears. Severe dehydration is corrected with intravenous solutions. The most frequently used solution for this purpose is 0.9% saline. Balanced solutions (e.g. Ringer's lactate) are alternatives to 0.9% saline and have been associated with fewer days of hospitalization and better biochemical outcomes. Available guidelines provide conflicting recommendations. It is unclear whether 0.9% saline or balanced intravenous fluids are most effective for rehydrating children with severe dehydration due to diarrhoea.

OBJECTIVES

To evaluate the benefits and harms of balanced solutions for the rapid rehydration of children with severe dehydration due to acute diarrhoea, in terms of time in hospital and mortality compared to 0.9% saline.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 4 May 2022.

SELECTION CRITERIA

We included randomized controlled trials in children with severe dehydration due to acute diarrhoea comparing balanced solutions, such as Ringer's lactate or Plasma-Lyte with 0.9% saline solution, for rapid rehydration.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. time in hospital and 2.

MORTALITY

Our secondary outcomes were 3. need for additional fluids, 4. total amount of fluids received, 5. time to resolution of metabolic acidosis, 6. change in and the final values of biochemical measures (pH, bicarbonate, sodium, chloride, potassium, and creatinine), 7. incidence of acute kidney injury, and 8.

ADVERSE EVENTS

We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Characteristics of the included studies We included five studies with 465 children. Data for meta-analysis were available from 441 children. Four studies were conducted in low- and middle-income countries and one study in two high-income countries. Four studies evaluated Ringer's lactate, and one study evaluated Plasma-Lyte. Two studies reported the time in hospital, and only one study reported mortality as an outcome. Four studies reported final pH and five studies reported bicarbonate levels. Adverse events reported were hyponatremia and hypokalaemia in two studies each. Risk of bias All studies had at least one domain at high or unclear risk of bias. The risk of bias assessment informed the GRADE assessments. Primary outcomes Compared to 0.9% saline, the balanced solutions likely result in a slight reduction of the time in hospital (mean difference (MD) -0.35 days, 95% confidence interval (CI) -0.60 to -0.10; 2 studies; moderate-certainty evidence). However, the evidence is very uncertain about the effect of the balanced solutions on mortality during hospitalization in severely dehydrated children (risk ratio (RR) 0.33, 95% CI 0.02 to 7.39; 1 study, 22 children; very low-certainty evidence). Secondary outcomes Balanced solutions probably produce a higher increase in blood pH (MD 0.06, 95% CI 0.03 to 0.09; 4 studies, 366 children; low-certainty evidence) and bicarbonate levels (MD 2.44 mEq/L, 95% CI 0.92 to 3.97; 443 children, four studies; low-certainty evidence). Furthermore, balanced solutions likely reduces the risk of hypokalaemia after the intravenous correction (RR 0.54, 95% CI 0.31 to 0.96; 2 studies, 147 children; moderate-certainty evidence). Nonetheless, the evidence suggests that balanced solutions may result in no difference in the need for additional intravenous fluids after the initial correction; in the amount of fluids administered; or in the mean change of sodium, chloride, potassium, and creatinine levels.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of balanced solutions on mortality during hospitalization in severely dehydrated children. However, balanced solutions likely result in a slight reduction of the time in the hospital compared to 0.9% saline. Also, balanced solutions likely reduce the risk of hypokalaemia after intravenous correction. Furthermore, the evidence suggests that balanced solutions compared to 0.9% saline probably produce no changes in the need for additional intravenous fluids or in other biochemical measures such as sodium, chloride, potassium, and creatinine levels. Last, there may be no difference between balanced solutions and 0.9% saline in the incidence of hyponatraemia.

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.

Comparison of acid-base and electrolyte changes following administration of 6% hydroxyethyl starch 130/0.42 in a saline and a polyionic solution in anaesthetized dogs

OBJECTIVE

To evaluate the effects of a 6% hydroxyethyl starch (130/0.42) in either a buffered, electrolyte-balanced (HES-BAL) or saline (HES-SAL) carrier solution on electrolyte concentrations and acid-base parameters in healthy anaesthetized dogs.

STUDY DESIGN

Prospective randomised clinical study.

ANIMALS

A group of 40 client-owned dogs undergoing general anaesthesia for elective surgical procedures or diagnostic imaging.

METHODS

During anaesthesia, dogs were intravenously administered 15 mL kg^-1 of either HES-SAL (n = 20) or HES-BAL (n = 20) over 30-40 minutes. Jugular blood samples were analysed before (T₀) and 5 minutes (T₅), 1 hour (T₆₀) and 3 hours (T₁₈₀) after fluid administration. Sodium, potassium, chloride, ionised calcium, phosphate, albumin, pH, venous pCO₂, base excess (BE), bicarbonate and anion gap were determined and strong ion difference (SID) and total quantity of weak nonvolatile acids were calculated for each time point.

RESULTS

Chloride was significantly increased at T₅, T₆₀ and T₁₈₀ compared with T₀ after HES-SAL, and was significantly greater after HES-SAL than after HES-BAL at T₅ (p = 0.042). Ionised calcium was significantly decreased at T₅ compared with T₀ after HES-SAL, and was significantly lower after HES-SAL than after HES-BAL at T₅ (p < 0.001). Bicarbonate was significantly lower after HES-SAL than after HES-BAL at T₅ (p = 0.004) and T₆₀ (p = 0.032). BE was significantly lower after HES-SAL than after HES-BAL at T₅ (p < 0.001) and T₆₀ (p = 0.007). SID was significantly decreased after HES-SAL at T₅ and T₆₀ compared with T₀, and was significantly lower after HES-SAL than after HES-BAL at T₅ (p = 0.027). Mean electrolyte and acid-base parameters remained within or marginally outside of reference intervals.

CONCLUSIONS AND CLINICAL RELEVANCE

Changes in both groups were minor and short-lived with either fluid in healthy individuals, but might become clinically relevant with higher fluid doses or in critically ill dogs.