At What Point Is the Accumulated Evidence Sufficient to Change Maintenance Intravenous Fluid Prescribing Practice in Children? How About Yesterday?

Abstract

It is intriguing and somewhat disturbing that despite intravenous fluids (IVFs) being the most commonly prescribed therapy in hospitalized children, there still seems to be such a wide variation in the approach to choosing what type of intravenous (IV) maintenance fluid to use 1,2 and the required monitoring that goes along with it. In this issue of Hospital Pediatrics, Rooholamini et al 3 have attempted to address the discrepancy between evidence and practice through a quality improvement project using a standardized pathway to guide the choice of maintenance IVF. Their multidisciplinary approach included creating an evidence-based clinical pathway synthesizing the current consensus with regards to indications of when to start and discontinue IVFs and especially with regards to the optimal tonicity of the IVFs prescribed. They also included standardized monitoring for dysnatremia and signs of fluid overload. I would recommend readers electronically access the clinical pathway described by Romero et al 4 because it is well designed with many good principles prominently highlighted (eg, "do not use 1/4 NS for maintenance fluids," and "pay attention to weight fluctuations 63%") and presents the latest evidence in a pragmatic, algorithmic fashion. Those with increased antidiuretic hormone (ADH) secretion risk factors are recommended to receive 0.9% saline, whereas the rest are given 0.45% saline. Some guidance on total IVF maintenance calculation is also given. In the section on monitoring, they have recommended that all children receiving .75% of their maintenance by IVF have their sodium (Na) checked within 24 hours of initiation, but only those on hypotonic fluids require routine daily checks if getting .75% maintenance IVF. Their approach has tried to accommodate perceived gaps and areas of continuing controversy in the evidence (eg, potential adverse effects of isotonic fluids and frequency of Na monitoring). The most relevant and generalizable of their objectives were the following: Did the pathway implementation change the frequency of hypotonic fluid prescription, and were there any associated changes in the rate of severe dysnatremia? Did the pathway implantation improve appropriate clinical and laboratory monitoring for patients on maintenance IVF? For almost 50 years, the standard practice was prescription of hypotonic IVF (0.2% saline) for maintenance requirements based on seminal work published by Holliday and Segar 5 in 1957. At the turn of this century,