Acceptability and feasibility Sublingual administration of sugar in treatment of hypoglycaemia

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12. Evidence for recommendations on the choice of intravenous fluids

12.1 Choice of intravenous fluids for resuscitation and maintenance in

children a Resuscitation: Children severely dehydrated or with signs of shock should be resuscitated using isotonic intravenous IV solutions such as sodium chloride 0.9 or ringers lactate. Strong recommendation, low quality evidence b Intravenous maintenance luid: For children who require intravenous IV luids for maintenance, options include ringers lactate solution with 5 dextrose, sodium chloride 0.45 with glucose 5, sodium chloride 0.45 with glucose 2.5, or 0.9 sodium chloride with glucose 5. Strong recommendation, low quality evidence c Low sodium-containing IV solutions such as sodium chloride 0.18 with glucose 4, or 5 glucose in water, should not be used as there is an increased risk of hyponatraemia. Strong recommendation, low quality evidence here is evidence that there is a greater level of risk of hyponatraemia associated with the use of very low sodium-containing solutions in paediatric patients in comparison to luids where the sodium content is 75–150mmolL. he panel also emphasized that IV maintenance luids should contain glucose to avoid hypoglycaemia and starvation ketosis. Enteral feeding should be used in sick children, as it provides nutrition and avoids complications associated with IV luids. If oral nutrition is not tolerated, nasogastric tube feeding should be considered.

12.1.1 Evidence and summary of findings

here is evidence of a greater level of risk of hyponatraemia associated with the use of hypotonic solutions: the odds of developing hyponatraemia following hypotonic solutions are 17.2 times greater than with isotonic luids. Within the range of hypo- tonic solutions available, the use of sodium chloride 0.18 with glucose 4 presents an even greater risk. he panel identiied a systematic review published in 2006 that sought to compare outcomes for children receiving hypotonic versus isotonic luid therapy [Choong, 2006]. he review included six studies: two controlled trials of children 1-12 years, 80 n = 60 and adolescent females 12–18 years, n = 12 undergoing elective procedures; one trial of children with gastroenteritis and dehydration 6 months–14 years, n = 104; one case-control study of children treated for iatrogenic hyponatraemia mean age 7 years, n = 148; one cohort study of children undergoing scoliosis repair 6–16 years, n = 24; and one retrospective chart review of children undergoing craniofacial surgery 2 months–15 years, n = 56. Hypotonic solutions used in the studies ranged from 0.16–0.45 sodium chloride. Only three studies reported on morbidity and mortality. Wilkinson et al [1992], reported seizures in 2 out of 26 patients receiving hypotonic luids OR 6.22; 95 CI 0.29 to 135.8. Hoorn et al [2004] reported nausea and vomiting more commonly in patients with hospital acquired hyponatraemia p = 0.008 but numbers were too small to evaluate these outcomes with suicient power. Meta-analysis of the efect on serum sodium showed that hypotonic maintenance solutions signiicantly increased the risk of developing hyponatraemia OR 17.22; 95 CI 8.67 to 34.2. Mean plasma sodium in patients following hypotonic solutions was signiicantly lower OR -3.39 mmoll; 95 CI -5.35 to -1.43, than those who received isotonic solutions. In children receiving hypotonic solutions, the mean plasma sodium decreased signiicantly more ater luid administration OR -5.37 mmoll; 95 CI -8.79 to -1.94. hree studies reported a decrease in plasma sodium despite the infusion of isotonic or near-isotonic maintenance luids, but none reported on the risk of hypernatraemia with these luids.

12.1.2 Benefits and risks

In two institutions in the UK where there were incidents of hyponatraemia due to use of hypotonic luids, no further cases of iatrogenic hyponatraemia have been reported since the solution was removed from the ward stock. here is growing awareness of the dangers associated with use of hypotonic solutions and there have been various statements and changes in the national guidelines discouraging their use in children. In 2003, the Royal College of Anaesthetists issued a statement advising against the use of hypotonic luids. In 2007, the UK National Patient Safety Agency NPSA issued an alert advice to health-care organizations of how to minimize the risks associated with administering intravenous infusions to children. Risks All sick children are potentially at risk of hyponatraemia, especially those with pulmonary and central nervous system infections, and post operative surgical cases. he use of hypotonic luids may be harmful and cause water overload with possible severe hyponatraemia and other complications. Among children who develop symptomatic hyponatraemia, the incidence of permanent brain damage in adulthood is signiicantly increased [Chung 1986].