Ep 114 - The past, present and future of IV Fluids in Paediatric Practice with Steve Playfor

The Evolution of IV Fluid Therapy: A Critical Review Welcome to St Emlyn's blog. Today, we explore the evolving landscape of intravenous (IV) fluid therapy in pediatric care. I'm Simon Carly, and I had the privilege of discussing this topic with Dr. Steve Playful at the Royal Manchester Children's Hospital. We delved into the historical context, current practices, and future directions of IV fluid therapy. Here's a comprehensive review of our discussion. Historical Context of IV Fluids in Pediatrics The use of IV fluids in pediatrics has undergone significant changes over the years. Approximately 20 years ago, the standard practice involved administering hypotonic fluids to children. This practice was rooted in research from the 1950s that misjudged children's electrolyte and fluid requirements, leading to widespread use of solutions like 0.18% saline with 5% glucose. However, this approach had its drawbacks. While individual practitioners might not have frequently observed issues, numerous instances of iatrogenic hyponatremia leading to cerebral edema and death highlighted the risks. This spurred a reevaluation of IV fluid therapy practices in pediatrics. Transition from Hypotonic to Isotonic Solutions By the late 1990s, concerns about the dangers of hypotonic solutions grew. In 2006, the National Patient Safety Agency in the UK formed a group to address these concerns. They concluded that most children could safely receive half-normal saline as maintenance fluid, except in high-risk situations, marking a significant shift from previous practices. The pediatric community started adopting isotonic solutions, such as normal saline. However, normal saline (0.9% sodium chloride) presents its own issues. Despite its name, it is not truly "normal" as its sodium content is slightly higher than plasma levels, and its chloride content is about 60% higher. Moreover, the pH of normal saline is around 5.5, far from physiological levels. Emergence of Balanced Solutions Balanced solutions have emerged as a promising alternative to both hypotonic and isotonic solutions. Designed to more closely mimic the body's natural plasma, solutions like Ringer's lactate and Plasma-Lyte have gained popularity in the UK. These balanced solutions are buffered with substances like acetate or gluconate to maintain a more physiological pH. Plasma-Lyte, for instance, is available with and without dextrose, making it versatile for different clinical scenarios. These solutions are typically better tolerated and associated with fewer complications compared to normal saline. The Debate: Saline vs. Balanced Solutions The debate over the optimal type of IV fluid for pediatric patients continues. Recent studies, including large international trials, suggest balanced solutions are associated with fewer complications than normal saline. These complications include hyperchloremia, which can lead to acute kidney injury and other adverse outcomes. Despite these findings, normal saline remains the most commonly administered IV fluid worldwide. This persistence is largely due to tradition and established practices. Changing these deeply ingrained habits requires substantial evidence and updated clinical guidelines. Key Studies and Evidence Several studies highlight the benefits of balanced solutions over normal saline. Research indicates that balanced solutions result in less acidosis and fewer chloride level shifts without demonstrated harm. However, not all studies show significant differences. The SPLIT trial, for instance, did not find a marked difference between the two fluid types, though this study had limitations, including uncontrolled pre-enrollment fluid administration and varying severities of illness among patients. Future Directions in IV Fluid Therapy As we look ahead, several areas of interest in IV fluid therapy emerge. One key question is which balanced solution is optimal for pediatric patients. Current options include fluids buffered wit