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Abstract Body

There is no clear consensus on intravenous maintenance fluid therapy (IV-MFT) prescribing in acutely and critically ill children and practices vary a lot among health care professionals, as shown in a recent international survey published by Morice et al. (2022). ESPNIC metabolism endocrinology and nutrition section conducted a systematic review and metanalysis to answer five main questions about IV-MFT: i) the indications for use ii) the role of isotonic fluid iii) the role of balanced solutions iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) the optimal amount of fluid. This project was conducted by a multidisciplinary expert group following the SIGN grading method to produce guidelines.

Five databases were searched for studies that answered these five questions, in acutely and critically children, published until November 2020. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds.

56 studies met the inclusion criteria, and 16 recommendations could be produced. Outcome reporting was inconsistent among studies. Consensus within the expert group was high, but recommendations generated were based on a heterogeneous level of evidence

Main recommendations are to favor enteral/oral hydration whenever possible, to use balanced isotonic solutions providing glucose, to restrict IV-MFT infusion volumes (compared to Holliday and Segar formula) in most hospitalized children and to regularly monitor plasma serum glucose, electrolyte levels and fluid balance.

Background and Aims

Red-blood cells (RBC) transfusions are common in PICU and have been identified as an independent morbimortality risk factor. Although a restrictive transfusion practice is currently recommended, an overuse of RBC is not uncommon. The aim is to compare RBC transfusion practices before and after the implementation of a transfusion protocol with a transfusion score in a third level PICU.

Methods

Pre- vs. post-interventional study. Data was collected prospectively and all children admitted to the unit during the two study periods were included. During the preintervention phase (twelve months, 2019), clinicians prescribed transfusions based on their clinical judgement without local protocols or other indications. During 2020, an anemia management and transfusion protocol was developed and implemented in the Unit. The protocol includes a transfusion score created from a predictive model after analyzing preintervention transfusions. Transfusion data was then collected in the postintervention phase (twelve months, 2021).

Results

During 2019, 351 patients were admitted vs 352 patients in 2021. 65% of patients presented anemia during admission in the first period vs 60% in the second period. 249 RBC transfusions were indicated to 68 patients (19.4% of admitted patients) in 2019. After implementing the transfusion protocol and score, the number of RBC transfusions dropped to 173 (-30.5%, p<0.05), with a reduction in the percentage of transfused patients to 13% (p<0,05). Preintervention global transfusion hemoglobin threshold was 8.6 g/dl, which dropped to 7.6 g/dl (p<0.001) after the implementation of the protocol.

Conclusions

Implementing a transfusion protocol and score seems effective to reduce RBC transfusions and hemoglobin threshold.

Background and Aims

The risks of intravenous potassium administration increase with the concentrated, short timespan infusions used in acute correction of hypokalaemia. The effect of such corrections on serum potassium concentration is unknown in children. We aimed to define the increment achieved in children following infusion of 0.4 mmol/kg potassium chloride over one hour. Secondary outcomes included whether pre-infusion age, weight, sex, Na⁺, K⁺, HCO₃^-, Mg²⁺, glucose, pH; diagnostic category, and time of sampling post-infusion affected potassium increment.

Methods

All potassium chloride infusions administered over 56 months on a tertiary Paediatric Intensive Care unit were included. Only acute corrections at 0.4 mmol/kg over one hour were included. Serum electrolyte measurement was by blood gas and laboratory analyses.

Results

135 patients with 369 individual infusions (220 in males, 149 in females) were analysed. Mean age, weight and pre-infusion K⁺ were 4.79 years, 16.9kg, and 2.71 (±0.33) mmol/L respectively. The mean potassium increment was 0.38 (SD ±0.36) mmol/L, (95% CI, 0.34 to 0.41), giving an increment/dose ratio of 0.95. 14 (3.8%) infusions incremented >1mmol/L, 6 (1.6%) >1.2mmol/L, and 3 (0.81%) >1.5mmol/L. The maximum post-infusion serum potassium was 4.60 mmol/L. Potassium increment was not affected by pre-infusion age, weight, sex, Na⁺, K⁺, HCO₃^-, Mg²⁺, glucose, pH, or diagnostic category. Increment was maintained at least 3 hours post infusion.

Conclusions

Infusing 0.4 mmol/kg of potassium chloride over one hour raises serum potassium by 0.38 mmol/L, the effect lasting at least 3 hours. There were no instances of post-infusion hyperkalaemia. Increment was not affected by any other measured factors.