Factors affecting pediatric isotonic fluid resuscitation efficiency: a randomized controlled trial evaluating the impact of syringe size

Abstract

Background: Goal-directed therapy guidelines for pediatric septic shock resuscitation recommend fluid delivery at speeds in excess of that possible through use of regular fluid infusion pumps. In our experience, syringes are commonly used by health care providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid resuscitation scenario. At present, it is unclear which syringe size health care providers should use when performing fluid resuscitation to achieve maximal fluid resuscitation efficiency. The objective of this study was therefore to determine if an optimal syringe size exists for conducting manual pediatric fluid resuscitation.

Methods: This 48-participant parallel group randomized controlled trial included 4 study arms (10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from McMaster Children's Hospital, Hamilton, Canada blinded to the purpose of the trial. Consenting participants were randomized using a third party technique. Following a standardization procedure, participants administered 900 mL (60 mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided syringes of the allocated size in rapid sequence. Primary outcome was total time to administer the 900 mL and this data was collected through video review by two blinded outcome assessors. Sample size was predetermined based upon a primary outcome analysis using one-way ANOVA.

Results: 12 participants were randomized to each group (n=48) and all completed trial protocol to analysis. Analysis was conducted according to intention to treat principles. A significant difference in fluid resuscitation time (in seconds) was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20 mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI 413; 497] (p<0.001).

Conclusions: The syringe size used when performing manual pediatric fluid resuscitation has a significant impact on fluid resuscitation speed, in a setting where fluid filled syringes are continuously available. Greatest efficiency was achieved with 30 or 60 mL syringes.

Trial registration: ClinicalTrials.gov, NCT01494116.

Figures

Figure 1

The ‘disconnect-reconnect’ technique for rapid fluid resuscitation. This method involves (1) connecting a fluid filled syringe to the IV extension tubing, (2) administering the fluid manually, and then (3) disconnecting the empty syringe, thus allowing for connection of another ready syringe that has been filled with fluid by an assistant, and repeating until fluid delivery is completed.

Figure 2

The Pediatric Fast Fluid Trial flow diagram. No participants were excluded from initial 48 subject recruitment. All subjects completed protocol to analysis. Initial allocation called for 1:1:1:1 syringe size distribution, however one subject was mistakenly allocated to participate in the 30 mL group from the 60 mL group. This same subject was analysed as per protocol in the 60 mL group after per protocol analysis showed no change in primary outcome.

Figure 3

Preferred techniques of rapid fluid resuscitation as reported by participants. The majority of respondents reported preference for the ‘disconnect-reconnect’ technique of fluid bolusing. The next most commonly cited preference was the ‘push-pull’ technique, and 8/48 participants reported preference for a regular infusion pump – an unacceptable means of delivering a fluid bolus in a resuscitation scenario. Legend: gray, Pressure bag; red, Disconnect-Reconnect technique; green, Push-Pull technique; violet, Regular infusion pump; blue, Don’t know/no answer; orange, More than one preferred technique.

Figure 4

Mean fluid bolus times by syringe size with 95% confidence intervals (primary outcome analysis). Significant difference between 10 mL and 30/60 mL syringe size groups is clearly demonstrated. There is a notable trend of superiority between of the 30/60 mL groups over the 20 mL group, but this did not achieve significance. This trend provides empirical validity to PALS recommendations suggesting use of 35–60 mL syringes for optimal fluid resuscitation [1].

Figure 5

A Fluid infusion time by syringe size group. In the GLM analysis an interaction was found between syringe size group and bolus number that precluded comment on the impact of bolus number on fluid infusion time. This outcome was intended to determine whether progressive fatigue objectively occurred among providers with repeated fluid bolus administration. A: blue, First 20 mL/kg normal saline bolus; green, Second 20 mL/kg normal saline bolus; red, Third 20 mL/kg normal saline bolus. B Fluid infusion time by bolus number. This figure assists with understanding why the interaction between syringe size and bolus number is occurring. It appears that the 10 mL syringe size group “speeds up” in terms of the time to administer sequential 20 mL/kg fluid boluses while the larger syringe size groups appear to “slow down”. The 10 mL group likely “sped up” because providers became more efficient at rapidly disconnecting and reconnecting syringes. B: blue, 10 mL syringe group; green, 20 mL syringe group; red, 30 mL syringe group; violet, 60 mL syringe group.

Figure 6

Mean fatigue score with 95% confidence interval by syringe size group and bolus number. Increased fatigue scores correlated significantly with bolus number in each syringe group by GLM analysis. This provides a subjective basis for our recommendation to consider provider changes during a fluid resuscitation. Legend: ●First 20 mL/kg normal saline bolus; ▲Second 20 mL/kg normal saline bolus; ■Third 20 mL/kg normal saline bolus.