2019 surveillance of intravenous fluid therapy in children and young people in hospital (NICE guideline NG29)
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We will not update the guideline on intravenous fluid therapy in children and young people in hospital.
We found new evidence covering 2 sections of the guideline: fluid resuscitation, and routine maintenance. This evidence was considered alongside topic expert feedback.
Topic experts involved with the current surveillance review queried whether there is a role for balanced crystalloids (particularly for resuscitation) and noted they were being used more widely in practice. The original guideline committee noted a lack of evidence to recommend one isotonic crystalloid over another for fluid resuscitation, and therefore chose not to specify which isotonic fluid to use. For maintenance fluids, the committee found no studies comparing isotonic solutions (including sodium chloride or balanced crystalloids) directly against each, so did not consider it appropriate to specify a particular isotonic fluid. New evidence was identified which suggested that balanced crystalloids could have some benefits over 0.9% sodium chloride for both fluid resuscitation and fluid maintenance. However, the evidence was from 2 single trials in specific conditions and did not include outcomes deemed critical by the original guideline committee. A third trial identified showed that balanced crystalloids had no benefit over 0.9% sodium chloride for resuscitation, but were more costly. Overall, we did not find sufficient new evidence to support an update of the guideline in this area at this point in time.
When developing the original guideline, the committee noted that current practice for fluid resuscitation was to administer a bolus over less than 10 minutes and they found no evidence to suggest this should change. New evidence on resuscitation found by the current surveillance review suggested a fluid bolus over 15–20 minutes had some benefits versus a bolus over 5–10 minutes, though these benefits were for outcomes not deemed critical or important by the original guideline. As the study also found no effect on outcomes of death, length of stay, or resolution of shock that were deemed critical or important by the original guideline, we decided there was currently no impact on the guideline. We identified another study that found no benefit of rapid rehydration over 3–6 hours versus slower rehydration over 8 hours, which is unlikely to affect the guideline as it does not recommend either of these strategies.
Evidence examined by the original guideline committee included the FEAST trial in African children (which found that fluid boluses increased mortality versus no bolus), but the committee disregarded it because it was not directly applicable to the UK clinical setting. Instead, the committee based their recommendation on current practice for fluid resuscitation to administer a 20 ml/kg bolus, having found no evidence to suggest this should change. Topic experts involved with the current surveillance review questioned whether a 20 ml/kg fluid resuscitation bolus volume was still correct or if a smaller volume should be used. New evidence in this area found by the current surveillance review included a Cochrane review suggesting that liberal fluid therapy for resuscitation might increase mortality versus conservative therapy. But the results were based predominantly on the FEAST trial, and so had the same limitations already identified by the original committee. We also identified a UK trial that found no benefit of a 10 ml/kg versus a 20 ml/kg bolus, and another trial that found no difference between a rehydration strategy with or without boluses. Overall, we found no new evidence to support an update of the guideline in this area at this time.
New evidence for other aspects of intravenous fluid therapy was identified:
hypertonic (>0.9%) versus isotonic (0.9%) sodium chloride for resuscitation
standard versus restricted volumes for routine fluid maintenance
liberal versus restricted intraoperative maintenance infusion
balanced crystalloid versus 0.45% sodium chloride for maintenance infusion
isotonic (0.9%) versus hypotonic (<0.9%) sodium chloride for maintenance infusion
3.3% versus 5% dextrose for maintenance infusion.
However, the evidence examining these therapies did not indicate a need to update the guideline because results were either: consistent with existing recommendations, of limited relevance to the guideline, from single trials, or based on outcomes not deemed to be critical or important by the original guideline committee.
For further details and a summary of all evidence identified in surveillance, see the summary of evidence from surveillance.