Factors affecting pediatric isotonic fluid resuscitation efficiency: a randomized controlled trial evaluating the impact of syringe size

Abstract

BackgroundGoal-directed therapy guidelines for pediatric septic shock resuscitation recommend fluid delivery at speeds in excess of that possible through use of regular fluid infusion pumps. In our experience, syringes are commonly used by health care providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid resuscitation scenario. At present, it is unclear which syringe size health care providers should use when performing fluid resuscitation to achieve maximal fluid resuscitation efficiency. The objective of this study was therefore to determine if an optimal syringe size exists for conducting manual pediatric fluid resuscitation.MethodsThis 48-participant parallel group randomized controlled trial included 4 study arms (10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from McMaster Children’s Hospital, Hamilton, Canada blinded to the purpose of the trial. Consenting participants were randomized using a third party technique. Following a standardization procedure, participants administered 900 mL (60 mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided syringes of the allocated size in rapid sequence. Primary outcome was total time to administer the 900 mL and this data was collected through video review by two blinded outcome assessors. Sample size was predetermined based upon a primary outcome analysis using one-way ANOVA.Results12 participants were randomized to each group (n=48) and all completed trial protocol to analysis. Analysis was conducted according to intention to treat principles. A significant difference in fluid resuscitation time (in seconds) was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20 mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI 413; 497] (p<0.001).ConclusionsThe syringe size used when performing manual pediatric fluid resuscitation has a significant impact on fluid resuscitation speed, in a setting where fluid filled syringes are continuously available. Greatest efficiency was achieved with 30 or 60 mL syringes.Trial registrationClinicalTrials.gov, NCT01494116

Evaluating the test re-test reliability and inter-subject variability of health care provider manual fluid resuscitation performance

“…To control for a potential learning effect, we employed a standardization procedure. The possibility of provider fatigability certainly was a concern due to findings from our previous work in which HCPs reported increasing fatigue with performance of manual fluid resuscitation using syringes [ 11 ]. For this reason, we designed our protocol to include a washout period between each trial.…”

“…Two blinded outcome assessors independently viewed and extracted fluid administration time data from the trial video-recordings using a previously employed standard procedure [ 11 ]. The outcome assessors only had access to the study ID number associated with each video-recording and were not aware of any other data collected.…”

Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting

“…Although previous research has separately evaluated these two techniques,19 20 their relative efficiency in the hands of typical healthcare providers has not been studied.…”

Simulated fluid resuscitation for toddlers and young children: effect of syringe size and hand fatigue

“…In a study conducted by Harvey et al . using ‘Disconnect–Reconnect’ manual infusion technique, the 60‐ml syringe was more efficient as discussed above. However, this study did not take into consideration the role of hand fatigue in efficiency of a syringe size during fluid resuscitation.…”

“…This optimum balance between infusion pressure generated by a syringe and frequency of injection may be tilted toward 60‐ml syringe, as shown in a study by Harvey et al . when they used ‘Disconnect–Reconnect’ manual infusion technique for simulated fluid resuscitation. This can be explained because the time it takes to ‘Disconnect and Reconnect’ a syringe is longer than simply turning the knob of the 3‐way stop cock and pulling the fluid in the smaller syringes (5 ml, 10 ml, and 20 ml).…”