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A 10-year-old girl comes to the ED with a fever, cough, and left flank pain. Her vitals are: temp 103.4, HR 137, BP 83/44. You suspect sepsis and know the clock is ticking to treat her quickly. Orders are placed to obtain blood cultures and administer broad-spectrum antibiotics and a fluid bolus of 20 ml/kg. In your mind, this is the standard of care to give this child the best chance of survival and recovery. But have you ever considered how that fluid bolus will be administered? When you think of a fluid bolus, what are you envisioning? Does it really matter what method is used to give the fluid? What are the options?  This 3-part series will discuss some of the most commonly used fluid resuscitation techniques and highlight the often-overlooked risks associated with two of the most commonly used fluid resuscitation methods: push-pull and disconnect-reconnect.

American College of Critical Care Medicine and Pediatric Advance Life Support (PALS) guidelines specify that 20 ml/kg of crystalloid fluid be administered within 5 minutes of the recognition of septic shock or hypotension, and up to 60 ml/kg in the first 15 minutes of care.  Both guidelines advise that 20 mL/kg fluid boluses be given until tissue perfusion is restored, with careful reassessment after each bolus to ensure there are no signs of volume overload.  When cardiogenic shock is suspected, smaller bolus volumes are recommended, with careful monitoring for rales and hepatomegaly or objective evidence of volume overload by bedside ultrasound.¹

Many studies have documented improvement in mortality, length of stay, disability, and cost ^3-14  when we provide resuscitation according to published guidelines, yet the literature also reveals that we often are not able to achieve these guidelines.^2,14-17  A number of recent studies have questioned the universal use of rapid fluid resuscitation in sepsis, though these were conducted in developing countries where the patient population and available medical resources are quite different from ours.^18-21   There is little debate that in children with decompensated shock from conditions such as hypovolemia, sepsis, hemorrhage, and anaphylaxis, rapid restoration of intravascular volume is required to correct hypotension and reverse shock.^2,22 In fact, PALS guidelines specifically note that “early recognition and rapid intervention are critical to halting the progression from compensated shock to hypotensive shock to cardiopulmonary failure and cardiac arrest.”²  When we encounter these patients, we want the fluid administered as quickly, efficiently, and safely as possible. Unfortunately, we often spend time discussing the amount and type of fluid, but we may not think as much about the administration technique.

There are five fluid administration techniques commonly used in pediatric emergency care: infusion pumps, gravity drip, pressure bags, rapid infusers, and syringe techniques (push-pull and disconnect-reconnect). Each has practical concerns for rapid fluid resuscitation:

INFUSION PUMP

• Commonly has a maximum infusion rate of 999 mL/hr
• Max rate is too slow deliver a bolus within the recommended guidelines for any patient who weighs over 4.2kg.

GRAVITY DRIP

• Rate is also too slow to administer a bolus within guidelines. In a 2007 study, 0 of 19 patients received guideline-concordant fluid resuscitation when gravity feed was used²³
• Difficult to give precise amounts of fluid. Unlike adults, weight-based fluid resuscitation in pediatric patients is rarely rounded to the nearest liter bag and clinicians are unable to stop fluid at a precise volume by looking at a bag

PRESSURE BAG

• Quicker than gravity feed or pump, but too slow to achieve recommended guidelines
• Difficult to give precise amounts of fluid due to the pressure cuff covering the bag

RAPID INFUSERS

• Expensive and may not be readily accessible
• Requires someone dedicated to the rapid infuser during resuscitation
• Requires training and staff comfortable with using equipment

SYRINGE TECHNIQUES (PUSH-PULL and DISCONNECT-RECONNECT)

The disconnect-reconnect and push-pull techniques are probably the most common ways of administering fluid boluses in pediatrics.   The disconnect-reconnect method often requires two people, one to prepare multiple fluid-filled syringes and the other to administer the fluid to the patient. The push-pull method uses a syringe attached to a liter fluid bag with a 3-way stopcock to draw fluid into syringe then deliver it to the patient using repetitive strokes of the syringe. Though these methods are commonly used, few studies have considered their safety or efficacy. Part 2 and part 3 of this series will summarize some of the literature evaluating these techniques and explore the pros and cons of using syringe techniques for fluid administration.

This is the first of a three-part series on fluid resuscitation methods.