(834) Outcomes After the 2018 American Academy of Pediatrics Guideline on Intravenous Fluids in Children

Introduction: In 2018, the American Academy of Pediatrics issued practice guidance calling for the use of only isotonic fluids in pediatric patients requiring maintenance intravenous fluids (IVF). This recommendation was in response to data showing an increased hyponatremia risk and associated adverse outcomes in children treated with hypotonic fluids. We studied institutional response to the guideline and its effect on outcomes.

Methods: We compared IVF ordering practices for two years before and after publication of the 2018 American Academy of Pediatrics Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Subjects were included if they were between the ages of 1 month to 17 years, not admitted to an ICU, had orders for IVF and did not have disease states or medications affecting sodium/chloride metabolism. Data were collected from retrospective chart review and included IVF sodium concentration, IVF rate, and occurrences of hyponatremia, hyperchloremia, hyperchloremic metabolic acidosis, acute kidney injury (AKI), and sodium related adverse events.

Results: There were 501 subjects who met study criteria. The frequency of hypotonic IVF use dropped from 86% before publication of the guideline to 20% after. The mean sodium/chloride load increased from 5.6 mEq/kg/day to 10.3 mEq/kg/day. In 317 subjects with follow-up laboratory results, hyperchloremia (>110 mEq/L) occurred in 18.9% of subjects after publication compared to 8.9% before. The rate of hyponatremia or hyperchloremic metabolic acidosis was not significantly different between the two groups . AKI or sodium related adverse events did not occur in either group.

Conclusions: There was a significant decrease in institutional use of hypotonic IVF in the following publication of the AAP guideline, with a corresponding increase in sodium and chloride loads. The rate of hyponatremia did not decrease but rates of hyperchloremia doubled. Although there were no significant increases in non-gapped metabolic acidosis or AKI in the current trial, concern remains due to studies showing worsened outcomes associated with high chloride loads. Perhaps a more individualized approach to IVF ordering, supported by appropriate laboratory monitoring, could result in a more balanced risk profile.