Aim Bolus administration of 0.9% sodium chloride solution has been associated with hyperchloraemia, acidosis, acute kidney injury and increased mortality. Such adverse effects are believed to be less likely with balanced electrolyte solutions, such as Plasma- Lyte 148 or Hartmann’s solution. Despite existing evidence, 0.9% sodium chloride solution remains a popular choice for intravenous fluid boluses in paediatrics. This project aims to establish current practice of fluid bolus administration in paediatric patients, and to collect testimony from prescribers to help understand why decisions to prescribe specific fluids were made.

Method Paediatric patients in critical care areas (PICU and PHDU), the Emergency Department (PED) and in general ward areas who had been administered intravenous fluid boluses were identified using a pragmatic data collection technique and the dose, type of fluid, indication and patient’s weight were recorded. Where possible, the prescriber was identified and asked to be interviewed. Prescribers were asked what factors had affected their decision to prescribe the type and dose of fluid administered.

Results More than 30 individual episodes of intravenous fluid bolus administration were identified. Most fluid boluses were administered in PICU and PHDU, where balanced electrolyte solutions, specifically Plasma-Lyte 148, were the most popular choice. On general paediatric wards and in PED, 0.9% sodium chloride solution remained the most commonly administered fluid bolus solution. While some prescribers were able to give confident explanations of the factors involved in fluid selection, others referred to clinical guidelines. Individual prescribers described how their prescribing practice would vary according to the clinical setting; with senior clinicians and nursing staff being less accepting of balanced electrolyte solutions in general ward areas. Significant lack of knowledge of intravenous fluid physiology was demonstrated by some prescribers.

Conclusion Our findings demonstrate an increase in the administration of balanced electrolyte solutions, such as Plasma-Lyte 148, as fluid boluses; this is in keeping with other international surveys of fluid administration.^1,2 Similarly, we have also found significant differences in fluid bolus administration practice across different clinical areas as demonstrated by Jonsson and Perner in 2017.

We have demonstrated the importance of on-going multi-disciplinary educational efforts in continuing the evolution of intravenous fluid bolus administration practice to reflect current best practice.

References

1. Hammond NE, Taylor C, Finfer S, et al. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study. PLoS One2017;12:e0176292.

2. Jonsson AB, Perner A. Changes from 2012 to 2015 in intravenous fluid solutions issued to hospital departments. Acta Anaesthesiol Scand2017;61:532–538.