Isotonic maintenance fluid: Practice Gap discussion at Update Course 2018

So here's another kind of interesting, AKA pancreatitis type question. A 15-year-old male has an elective total abdominal colectomy, and end ileostomy for medically refractor refractory ulcerative colitis. The surgery resident unfortunately is called to a code, and you are writing the postoperative orders. The best choice for maintenance fluids, a simple little question about IV fluids, uh, the choices are D5/4 normal saline, D5/4 normal with potassium. Uh, half normal saline, half normal saline with potassium, or normal saline with potassium. We put that pole up I think we're working on it. Come on. At the very, the very, not the PDC, but the PCAP committee, the very first meeting we Brought forth a question on the correct IV fluids for someone with pyloric stenosis, and John Waldhausen said this should take about 5 minutes because that's a pretty simple, straightforward thing. And about an hour and a half later we decided we wouldn't use a question on the fluids for pyloric stenosis. So there's 3 components, the D5, it's assumed we always use D5. Yes. Outside of infancy, yeah, outside of the newborn, is there some evidence for that? I'm just hyatrogenic hyponatremia is one of the biggest problems in our hospitals, and it all, I mean, it all comes back from what we've learned about ADH and so on and so forth, and, and not needing to use, um, uh, normal saline, but in fact, um. If you look, kids, not just kids, but get hyponatremic because we give them half normal saline, and, and that's, that's one of those dogmas lore, you know, from our lore that that really needs to be overcome, and the data on this are so clear. Well, you're going to go over it, but, but the data are pretty strong. So it's another thing like the pancreatitis where a lot of us were taught don't ever feed these patients, it's going to make them worse, and this one certainly I think if I'd ordered this on someone when I was an intern, I wouldn't have. Gotten patted on the back for it, but the correct answer is, as, as Ron said, D5 normal saline with 20 mil equivalents of potassium. So there have been, there is, there is indeed a lot of data on this, uh, and it's, I think, didn't March see the American Academy of Pediatrics is coming out with a consensus statement as well, but. But basically, uh, there is a problem with uh with hyponatremia in hospitalized kids because they get less than isotonic solution, hypotonic fluids, uh, and they get cerebral edema and other complications related to it. And so, uh, in that scenario, the correct answer is to give them an isotonic fluid. So again, this is, we need a headline here because this is a big change. So, um, to reiterate it. I think we were all taught that you resuscitate them with resuscitative isotonic fluid and then convert them over to hypotonic, and the big change here is you keep them on isotonic fluid. That's the big change because you're gonna get hyponatremia. David, um, and I talked that that all of you have said that the key to this PDC concept is to push this out at every venue possible. So, so this was presented at ABSA. And I think there are most people, and Matt, you may remember better than me, most people got that wrong. I think most people said it would give hypotonic. Here it looks like 48%, I can't see my choices. Oh here, 48% said the correct answer. So that's actually pretty good. I thought that was a high number. That's a high number. We're moving the ball, correct. But that's, you got to start somewhere and considering you're asking us to make a radical change from what we were all taught. In a very short period of time, the question is, will that number change the next 3 times we present it? So, uh, I think this was a great, a great. And we could tweet that out. No more hype. Is there ever a role in normal, uh, normal electrolyted children? Is there ever a role for, for hypotonic fluids? We just erase it from our pixis and get rid of it. Well, you know how we came up with hypotonic fluid in the first place. It wasn't based on the evidence. It was some scientist literally 100 years ago doing the math based on what are the theoretical losses of sodium and chloride, and the equations came out to these numbers. It wasn't based on anything real, so I don't, I think the answer what about babies. Well, babies are different because their kidney function is immature when they're first born, so the, the amount of electrolytes you give them will change over the first couple of days of life, and they probably should have D10 rather than D5 because of lower. I think we have a question on that and the correct answer in the first day of life in a term newborn is to give them D10 and no saline, yeah, D10W probably for for a newborn D10W. Well, no, no salt, yeah, yeah. The, the, uh. The other, I don't want to, I don't want to push it anymore, but in adults that where this is where this literature reached the came out in adults, critical care and stuff much earlier, they're probably going to shift from normal saline to ringers as their normal tonic solution, and my guess is the same thing will happen in kids. We've gotten a couple of comments. Kevin Moriarty and some others have just said D5LR, correct? Yeah, so I think, I think that's, now there's, I don't think in kids there's literature on that yet, but my suspicion is. That that that we'll move over to that, that's a more physiologic, not just normatonic. Solution. OK, good. next me.