A 5 Year Old Dehydrated Boy Needs Fluid Resustication

A 5-year-old boy presents to the paediatric surgery department with a 24-hour history of abdominal pain. His history and examination findings are consistent with a diagnosis of acute appendicitis. He is dehydrated with an estimated fluid deficit of 15%.
Which of the following is the most appropriate resuscitation fluid?

A:  Packed red blood cells
B:  5% dextrose and 0.45% sodium chloride
C:  10% dextrose and 0.18% sodium chloride
D:  0.9% sodium chloride
E:  3% sodium chloride

Answer And Explanation:
D:  0.9% sodium chloride

The most appropriate choice of fluid is 0.9% sodium chloride. This remains within the extracellular compartment. In the past, fluid prescribers have been advised to limit the sodium load in children, but the National Patient Safety Agency issued an alert in 2007 highlighting the dangers of hyponatraemia in children resulting from the administration of large volumes of hypotonic fluids, e.g. 0.18% and 0.45% sodium chloride. There is an argument for using these as maintenance fluids in some groups
of patients.

Packed red cells may be necessary but with only a 15% fluid deficit, the risks outweigh the benefits in this case.

Whilst there has been some interest in using hypertonic saline for fluid resuscitation, there is not enough evidence for it to have become an established practice especially in the paediatric population.
The British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) published in 2009, contain 28 recommendations for assessment of fluid requirements, perioperative fluid and nutrition management. They recommend that although 4%/0.18% dextrose/saline and 5% dextrose are important sources of free water for maintenance, these should be used with caution in children because of the risk of dangerous hyponatraemia with excessive amounts, and that with some provisos they are not appropriate for replacement therapy.