Archives of disease in childhood
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Multicenter Study
Paediatric acute asthma management in Australia and New Zealand: practice patterns in the context of clinical practice guidelines.
To compare clinical practice guideline (CPG) recommendations and reported physician management of acute paediatric asthma in the 11 largest paediatric emergency departments, all of which have CPGs, in Australia (n = 9) and New Zealand (n = 2). All 11 sites participate in the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network. ⋯ CPG recommendations and reported physician practice for mild to moderate paediatric asthma management were broadly similar across PREDICT sites and consistent with national guidelines. Practice was highly variable for severe to critical asthma and probably reflects limitations of available evidence. Areas of controversy, in particular the comparative efficacy of intravenous bronchodilators, would benefit from multi-centre trials. Collaborative development of CPGs should be considered.
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Review
Will changing maintenance intravenous fluid from 0.18% to 0.45% saline do more harm than good?
The recommended change in maintenance intravenous fluid in children from 0.18% to 0.45% saline might cause more children to develop hypernatraemia than it would prevent children from developing hyponatraemia, and thus could do more harm than good. There is no simple formula that will guarantee to prevent either hyponatraemia or hypernatraemia in all children, and it is impossible to decide on a safe fluid regimen merely by knowing the plasma sodium concentration and estimating the degree of dehydration, as is often done. Changing which fluid is used for routine maintenance therapy will not compensate for using a too-simple approach to fluid replacement. ⋯ A vital part of that assessment includes measuring the urinary volume, sodium and creatinine, and using them to calculate the fractional excretion of water and sodium. This enables fluid replacement to be decided using a logical approach in which plasma sodium measurements are just used for fine-tuning. Also, 0.18% saline provides a more physiological standard replacement than 0.45% saline, equivalent to normal oral intakes, and should remain the basic maintenance fluid.
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Multicenter Study
Hyponatraemia and hypokalaemia during intravenous fluid administration.
Hospital-acquired hyponatraemia is associated with excessive volumes of hypotonic intravenous fluids and can cause death or permanent neurological deficit. ⋯ Intravenous fluids should be used with caution as regards the tonicity and volume administered, and with appropriate monitoring of serum electrolytes.