Recommendations for research
The guideline committee has made the following recommendations for research. The committee's full set of research recommendations is detailed in the full guideline.
What is the incidence of complications during, and as a consequence of, IV fluid therapy in children and young people?
Every day, children and young people are prescribed IV fluid therapy for a variety of reasons. However, there is little evidence on IV fluids in children and young people, and the limited evidence available is of very poor quality.
Complications of IV fluid therapy can lead to mortality and significant morbidity for the patient. This, in turn, represents a cost burden for the NHS in terms of critical care admissions, prolonged inpatient stays or the potential need for long‑term follow‑up and care by medical and allied healthcare professionals.
What is the most appropriate glucose concentration in IV fluids for children and young people of different ages?
In recent years, the use of glucose‑containing hypotonic IV fluids in children and young people has been questioned, because of the risk of hyponatraemia. Many children and young people are now prescribed non‑glucose‑containing isotonic IV fluids for maintenance. However, there are several groups of children and young people, in particular, neonates and some children in the perioperative period (for example, those who underwent prolonged fasting preoperatively, and those who had central blocks during anaesthesia), who may benefit from glucose‑containing IV solutions to prevent hypoglycaemia. A blanket prescription of 5 or 10% glucose solution for all may result in hyperglycaemia in some children and young people. However, the use of IV fluids containing lower concentrations of glucose may be sufficient to prevent hypoglycaemia and also avoid unnecessary hyperglycaemia. This may have a clinical application across all age groups, including neonates.
For children and young people receiving IV fluids, does the use of a standardised national fluid balance chart reduce the rate of complications arising as a result of prescription and/or administration errors?
The National Confidential Enquiry into Perioperative Deaths reports in 1999 and 2009 identified problems in fluid management in patients in the UK. A lack of consistency in prescribing and recording IV fluids may contribute to this. A lack of familiarity of 'mobile' medical and nursing staff with fluid balance charts in different hospital settings may further increase the likelihood of prescription and administration errors.
A prospective cohort of children and young people receiving IV fluids, prescribed and documented on a standardised national fluid balance chart, or a case–control study comparing the use of a standardised national fluid balance chart with non‑standard 'local' fluid balance charts is needed to assess the clinical and cost effectiveness of using a standardised national fluid balance chart. Outcomes should include complications of IV fluid therapy (hypovolaemia, hypervolaemia, electrolyte abnormalities, neurological complications and hypoglycaemia) and incidence of prescription errors. If using a standardised national fluid balance chart resulted in better fluid prescription and clinical outcomes in children and young people, this could potentially lead to significant cost savings for the NHS.
Does ensuring that all hospital healthcare professionals involved in prescribing and delivering IV fluids for children and young people are appropriately trained in the principles of fluid prescribing and IV fluid therapy‑related complications lead to a reduction in IV fluid‑related complications and associated healthcare costs?
Assessing patients' IV fluid needs, as well as prescribing and delivering IV fluids, are essential daily tasks on most paediatric wards. These are complex responsibilities that entail careful clinical assessment, good understanding of the physiology of fluid homeostasis both in health and disease, and appropriate supervision and training. There is currently no standard training provided for healthcare professionals working in the UK. Any teaching at both undergraduate and postgraduate level is currently delivered ad hoc, and in many cases may be limited. If fluid management in hospitalised children and young people is to improve, standardised training is likely to be needed. Any educational interventions made would need to be evaluated to assess whether practice had subsequently improved.