Choose best way to rapidly fluid resuscitate children

Guidelines can be met in two ways

If a child is in septic shock, there is no question that they require rapid fluid resuscitation, with 20mL/kg of bolus intravenous (IV) fluid given within five minutes, according to guidelines from the American College of Critical Care Medicine (ACCM).1 But what is the best method to do this?

Of three commonly used, inexpensive methods of fluid delivery, researchers at Nationwide Children's Hospital in Columbus, OH, expected that only use of a manual push-pull system would allow for compliance with the guidelines.2 However, the researchers found that the use of a pressure bag and a manual push-pull system both appear to be acceptable methods of rapid fluid delivery.

"There was a lot of dispute out there as to whether the guidelines could be met, but in fact, we showed they can," says Michael J. Stoner, MD, one of the study's authors and a pediatric ED physician at Nationwide Children's.

There is frequent noncompliance with the guidelines, due to a misconception that that the administration of 20 mL/kg to a child within five minutes is technically unfeasible because of the patient's size and the small caliber of IV catheters used in children, he explains.

For 57 children, researchers rapidly gave IV fluid up to 20 mL/kg or five minutes, whichever came first, by a pressure bag maintained at 300 mmHg, by a manual push-pull system or by gravity. The ACCM guideline was met in 58% of the pressure bag group, 68% of the push-pull group, and none of the gravity group. No children weighing greater than 40 kg met the guideline in any of the groups.

"Even though the study shows that appropriate ways of delivering fluid to a shocky child include either a syringe or a pressure bag, it's really difficult to quantify fluid with a pressure bag," notes Stoner. "I personally think that using a syringe is the best way to account for the fluid. The biggest consideration is it takes a second person, which might be difficult if you are short staffed."

A regular standard pump is inadequate, says Stoner. "You might be tempted to put the child on a pump because you want to account for every drop, but the pump doesn't cut it," he says. It would take too long to fluid resuscitate any child in septic shock weighing over four kilograms, he explains. "If your patient is in respiratory distress, taking a half-hour to give them oxygen would not be appropriate," he says. "Taking that long to get somebody in septic shock enough fluid also isn't appropriate. Standard pumps just aren't quick enough."

Rapid fluid delivery isn't appropriate for every dehydrated pediatric patient, cautions Stoner. "This is just to remind people of another option for the child who is really sick and shocky, who needs to get fluid resuscitated quickly," he says.

Also, if you are using pressure bags, there is a risk of giving too much fluid to a pediatric patient, says Stoner. "If you are in an adult mindset and giving boluses by the liter, the pressure bag is great," he says. "But a lot of times that is too much fluid for a child, and smaller volumes are difficult to judge with the pressure bag."

Know early signs of septic shock

If there is any indication to think "this might be shock," act on your instincts and put a plan in motion, advises Michelle Clark, RN, assistant manager of nursing for the ED at Children's Healthcare of Atlanta.

Children have an excellent compensatory mechanism to keep themselves hemodynamically stable and keep their vital organs oxygenated and perfused, explains Clark. "They increase their heart and respiratory rates," she says. "Their arteries dilate, but the venules remain constricted, and they may have a normal blood pressure early in sepsis."

While their blood pressure may look normal, look for widening pulse pressures, says Clark. "The heart is continually pumping faster than normal, but eventually the cardiac output will decrease," she says.

Septic children usually present with fever, although neonates may be hypothermic, notes Clark. "Sometimes this phase is missed until the patient becomes unstable and is noticed in retrospect," she says. If you fail to recognize the subtle clues in the beginning stages, the child may advance to decompensated shock, warns Clark.

Signs and symptoms of cold shock include a change in mental status with much decreased responsiveness, decreased urine output, edema, metabolic acidosis, hypotension, poor perfusion with decreased peripheral pulses, hypoglycemia, and eventually disseminated intravascular coagulopathy, says Clark. "Irreversible shock occurs when damage to vital organs cannot be reversed," she says. "These children may be initially resuscitated, but die secondary to multisystem organ failure."

Early treatment for septic shock includes volume expanders, antibiotics to fight the underlying infection, increased oxygen delivery, and decreased oxygen demand by reducing fevers and keeping the child calm, says Clark.

Although it doesn't occur in every case, some children get more hemodynamically unstable after their first dose of antibiotics, notes Clark. "This may be associated with the introduction of antibiotics which release endotoxins from the bacteria, or the child may just be getting worse," she says. "Again, this is treated with volume expanders and sometimes an additional antibiotic."

References

1. Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30:1,365-1,378.

2. Stoner MJ, Goodman DG, Cohen DM, et al. Rapid fluid resuscitation in pediatrics: Testing the American College of Critical Care Medicine Guideline. Ann Emerg Med 2007; 50:601-607.

Sources

For more information on caring for pediatric septic shock patients, contact:

  • Michelle Clark, RN, Assistant Manager of Nursing, Emergency Department, Children's Healthcare of Atlanta, Atlanta. Phone: (404) 785-6788. E-mail: michelle.clark@choa.org.
  • Michael J. Stoner, MD, Emergency Department, Nationwide Children's Hospital, Columbus, OH. Phone: (614) 722-4385. Fax: (614) 722-4380. E-mail: michael.stoner@nationwidechildrens.org.