Rubbing salt in the wound

M Hatherill

doi:10.1136/adc.2003.045047

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Rubbing salt in the wound

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Author's Reply: Rubbing Salt in the Wound
Mark Hatherill
Published on: 22 March 2016
Should routine maintenance intravenous fluids be used?
John C Furness
Published on: 22 March 2016

Published on: 22 March 2016
Author's Reply: Rubbing Salt in the Wound
- Mark Hatherill, Paediatric Intensivist
Dear Editor
Furness and Saravasiddhi make a valid point in emphasizing that intravenous maintenance fluid should not be routine [1]. However, there are common situations in which enteral feeding, whether oral, nasogastric, or nasojejunal, is either impossible or inadvisable [2]. These may include the immediate pre- or post-operative period, major trauma, severe vomiting, and respiratory or central nervous system i...
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Dear Editor
Furness and Saravasiddhi make a valid point in emphasizing that intravenous maintenance fluid should not be routine [1]. However, there are common situations in which enteral feeding, whether oral, nasogastric, or nasojejunal, is either impossible or inadvisable [2]. These may include the immediate pre- or post-operative period, major trauma, severe vomiting, and respiratory or central nervous system infections in which concern over airway protection or respiratory effort raises the possibility of endotracheal intubation.
Unfortunately, these are among the conditions associated with nonosmotic antidiuretic hormone release and hyponatraemia in children [3]. More recent data support the hypothesis that hospital-acquired hyponatraemia is associated with administration of very large volumes of intravenous fluid [4].Therefore, if enteral feeding is not possible in children at risk of hyponatraemia, it may be advisable to limit intravenous maintenance fluid to two thirds of the traditional recommendation.
References
(1) Furness JC, Saravasiddhi S. Should routine maintenance intravenous fluids be used? ADC 2004URL direct link to eLetter
(2) Sporik R. Why block a small hole? The adverse effects of nasogastric tubes. Arch Dis Child 1994;71:393-394.
(3) Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or permanent brain damage in healthy children. BMJ 1992;304:1218-1222.
(4) Hoorn EJ,Geary D,Robb M, Halperin ML,Bohn D. Acute hyponatremia related to intravenous fluid administration in hospitalised children: An observational study. Pediatrics 2004;113:1279-1284.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Should routine maintenance intravenous fluids be used?
- John C Furness, Consultant Paediatrician
- Other Contributors:
  Sateesh Saravasiddhi
Dear Editor
We were interested to read the challenging leading articles in the May issue of ADC, “Research in general paediatrics,” [1] and, “What routine intravenous maintenance fluids should be used? “ [2]
We wondered if the papers were a deliberate challenge to a trial of isotonic versus hypotonic intravenous maintenance fluids in DGHs? On further consideration we felt that this may not be the corre...
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Dear Editor
We were interested to read the challenging leading articles in the May issue of ADC, “Research in general paediatrics,” [1] and, “What routine intravenous maintenance fluids should be used? “ [2]
We wondered if the papers were a deliberate challenge to a trial of isotonic versus hypotonic intravenous maintenance fluids in DGHs? On further consideration we felt that this may not be the correct question.
Both papers in the debate [3,4] explain the complicated physiological processes involved in controlling fluid balance in health and disease. They also make the valuable point that different diseases will have different effects on water and electrolyte balance. There is increasing evidence to support early enteral nutrition even in ventilated children using nasogastric feeds.[5]
Nasogastric feeding has the advantage in children with normal gastrointestinal, renal and endocrine function that water and electrolyte balance will be controlled by intrinsic physiological mechanisms. This seems easier and safer than relying on imperfect human brains.
We suggest that the debate should be: “When should intravenous maintenance fluids be used?” and would dare to suggest that the increased use of enteral fluids should make the answer, “Not routinely.”
We would be interested in what our colleagues think.
References
1. Sammons HM, McIntyre J, Choonara I. Research in general paediatrics Arch. Dis. Child. 2004; 89: 408-410
2. Mann NP. What routine intravenous maintenance fluids should be used? Arch. Dis. Child. 2004; 89(5):411
3. Taylor D, Durward A. Pouring salt on troubled waters Arch. Dis. Child. 2004;89: 411-414
4. Hatherill M. Rubbing salt in the wound Arch. Dis. Child. 2004; 89(5):414-418
5. Chellis MJ, Sanders SV, Webster H, Dean JM, Jackson D. Early enteral feeding in the pediatric intensive care unit. J Parenter Enteral Nutr. 1996;20(1):71-3
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Conflict of Interest:
None declared.
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