37 Choice of maintenance intravenous fluids: A survey of Canadian paediatric residents

While hypotonic fluids were the standard of care for maintenance intravenous (IV) therapy in paediatrics for many years, evidence suggests an association with hyponatremia, an iatrogenic complication that can result in morbidity and mortality. Recent literature and guidelines support use of isotonic solutions for infants and children in most clinical contexts, as there is likely non-physiologic secretion of antidiuretic hormone (ADH) in hospitalized patients. Current IV fluid prescribing practices in Canada are unknown. It is unclear whether clinical practice reflects guidelines and emerging literature related to the risk of hyponatremia with hypotonic IV fluids. Furthermore, choice of maintenance IV fluids for neonates and the routine addition of potassium to maintenance fluids - topics not addressed in existing guidelines - have never been studied. We sought to explore Canadian paediatric residents’ choice of maintenance IV fluids, particularly with reference to fluid tonicity in a variety of age groups (including neonates). Secondary objectives were to determine (1) what dextrose concentration residents would prescribe for neonates/young infants, and (2) whether residents routinely add potassium chloride to maintenance fluids. A link to an ethics board-approved, internet-based survey was emailed to trainees in the 17 paediatric residency programs across Canada, via the Canadian Paediatric Program Directors, in the spring of 2018. Data were collected and managed using REDCap electronic data capture tools. The survey instrument, available in both English and French, included questions related to demographic and training information, followed by a series of questions eliciting IV fluid choice in a variety of clinical scenarios (hyperbilirubinemia, bronchiolitis, seizures, appendicitis, viral gastroenteritis, and respiratory distress) and patient ages (7 days, 6 weeks, 5 months and 12 years). As an exploratory question, participants were asked whether they routinely add potassium chloride to maintenance IV fluids when a child is nil per os (NPO), has a serum potassium within normal limits and normal urine output. Percentages were used to summarize categorical data. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. Survey responses were submitted by 147 residents (22% response rate). Tonicity: Isotonic IV fluids were selected by >75% in all clinical scenarios involving infants and children assuming normal electrolytes at baseline (Figure). Very hypotonic solutions (0.2% NaCl and ‘2/3-1/3’) were rarely chosen. In scenarios describing hypernatremia – a 12-year-old and a 5-month-old with gastroenteritis – approximately half of participants continued to opt for isotonic fluids (56.5% and 46.9%, respectively). In neonates, the majority of participants chose to use hypotonic solutions, but a substantial proportion opted for isotonic fluids (Figure); senior residents were more likely than junior residents to select hypotonic fluids (p=0.002 for bronchiolitis and p=0.003 for hyperbilirubinemia). Dextrose: In clinical scenarios involving 6-week-old infants, the vast majority of participants opted to include a dextrose concentration of 5% in maintenance IV fluids (>85%). In scenarios describing 7-day-old neonates, the majority selected 10% dextrose, although approximately one third continued to select 5% dextrose. Potassium: The majority of participants (62.6%) routinely add 20 mmol/L of potassium chloride to maintenance IV fluids when a child is NPO while 33.1% do not typically include potassium chloride. Residents who selected “other” (5.4%) and provided an explanation of their potassium prescribing practice identified duration of NPO and underlying disease process as being important in their decision-making. Results suggest a predominance of isotonic and 5% dextrose fluid use, even when a hypotonic solution might be appropriate (i.e., hypernatremia). There was more variability (1) amongst neonates and (2) in terms of routine addition of potassium chloride; these findings likely reflect a relative paucity of guidance and gaps in existing guidelines. Trainees should be encouraged to select IV fluids thoughtfully based on existing guidelines (when applicable) and careful consideration of physiologic factors affecting fluid and electrolyte status.

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