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QUESTION 1: Do balanced fluids have benefits over 0.9% sodium chloride?
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  • Published on:
    Response to Dr Smith - balanced fluids
    • Ashish Patel, Dr Department of Paediatric Nephrology, Birmingham Woman’s and Children’s NHS Foundation Trust, Birmingham B15 2TG, UK
    • Other Contributors:
      • Sally-Ann Hulton, Dr

    Dear Sir/ Editor,

    Dr Smith makes relevant and interesting points regarding the terminology used for fluids, which can be used for both “resuscitation” purposes and “maintenance” therapy, and we thank him for his interest and response.

    The purpose of this clinical question was to review the current evidence for paediatric patients in relation to “ balanced fluids”, a term emerging in the medical literature. NICE recommends using any isotonic crystalloid, which covers a wide range of sodium concentration from 130 to 154mmol/L (reference 1 in the article).

    The loss of electrolytes, either from the gut or as a result of renal impairment, needs regular clinical review. We observe that repeated bicarbonate measurements are not regularly undertaken after initial assessment or following admission and it is important to remind trainees to consider these losses, hence our recommendation of daily monitoring of electrolytes. By following this approach, appropriate individualised adjustments can be made to the fluid prescription of patients as necessary.

    Our conclusion from this question highlighted that research needs to be undertaken in the paediatric population of bicarbonate/ lactate containing fluids to determine whether this may affect acute kidney injury and other specific clinical outcomes. We agree attention to detail is always necessary when caring for infants and children receiving intrav...

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    Conflict of Interest:
    None declared.
  • Published on:
    Resuscitation or maintenance?
    • Graham C Smith, Consultant Paediatric Nephrologist Children's Kidney Centre, University Hospital of Wales, Cardiff

    Having just read this article I am concerned about the terminology used as I am not sure it truly reflects the clinical problem posed. The article refers to "maintenance" fluids but the question asked relates more to “resuscitation” fluids.

    It is important to be clear as to the aim of treatment in the individual patient when prescribing fluids rather than just following a guideline. The paper debates the relative merits of 0.9% sodium chloride and balanced fluids as “maintenance” fluids. To my mind “maintenance” fluids are administered to patients who have a replete extracellular fluid (ECF) volume. If ECF volume is low then “resuscitation” fluids are required. “Maintenance” and “resuscitation” fluids have different roles and therefore might be expected to have different characteristics.

    As the article refers to “maintenance” fluids I will deal with these first. This fluid is needed to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It should be differentiated in turn from "replacement" fluid which is the fluid given on top of the "maintenance" fluid when patients have fluid losses in excess of those normally anticipated. This includes diarrhoea, vomiting and fluid from surgical drains. The fluid used for "replacement" needs to match the composition and volume of the fluid being lost. Once "resuscitation" and "replacement" fluid...

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    Conflict of Interest:
    None declared.