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Introduction: The efficacy and safety of the Rapid Intravenous Rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice. Objective: To prepare a document with evidence-based recommendations about RIR in paediatric population. Methods: The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of “relevant outcomes”; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security). Results: 16 recommendations were set up, from which we can highlight as the main ones: 1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation, moderate evidence). 2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong, high). 3) Isotonic fluids are recommended (strong, high), suggesting saline fluid as the first option (light, low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong, moderate). 4) A rhythm of 20cc/kg/h is recommended (strong, high) during 1−4 h (strong, moderate). Conclusions: This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting. Resumen: Introducción: Existe consenso en cuanto a la eficacia y seguridad de las pautas de rehidratación intravenosa rápida (RIR) en niños con deshidratación secundaria a gastroenteritis aguda (GEA), pero también una gran variabilidad en su uso en la práctica clínica. Objetivo: elaborar un documento de recomendaciones sobre la RIR en población pediátrica basadas en la evidencia científica. Metodología: Se diseñó un proyecto basado en metodología GRADE, siguiendo el siguiente esquema de trabajo: Formación del Grupo de Trabajo; formulación de preguntas de investigación y definición de “desenlaces de interés”; puntuación y selección de ítems; revisión bibliográfica; evaluación y síntesis de la evidencia (GRADE); revisión, discusión y formulación de recomendaciones. Se incluyeron 10 preguntas clínicas y 15 desenlaces de interés (7 de eficacia y 8 de seguridad). Resultados: Se establecieron 16 recomendaciones, destacando como principales: 1) La RIR es segura en niños con deshidratación leve-moderada secundaria a GEA, salvo contraindicación expresa o comorbilidad aguda grave (recomendación fuerte, evidencia moderada); 2)Se recomienda su uso en este contexto cuando la rehidratación oral haya fracasado o esté contraindicada (fuerte, alta); 3)Se recomienda utilizar sueros isotónicos (fuerte, alta), sugiriendo como primera opción el suero fisiológico (débil, baja), añadiendo glucosa (2,5%) en pacientes con glucemia normal y cetosis (fuerte, moderada). 4)Se recomienda un ritmo de infusión de 20 mL/kg/hora (fuerte, alta), durante una a cuatro horas (fuerte, moderada). Conclusiones: En este documento se establecen recomendaciones de consenso, basadas en la evidencia científica disponible, que podrían contribuir a homogeneizar el uso de la RIR en nuestro medio.

Introduction: Isotonic fluids, in most cases, are the safest way to dispense fluids intravenously. The aim of this study was to determine the prescription of maintenance intravenous fluids and to study possible associated factors. Material and method: A descriptive, cross-sectional, multi-centre study was performed. A questionnaire was sent nationwide to several healthcare providers via an online survey, sent by email through different Medical Scientific Societies, and the Official Spanish Medical Association, between December 2016 and December 2017. Results: A total of 487 questionnaires were received, of which 456 were submitted by paediatricians. More than one quarter (28.95%) (95% CI; 24.77–33.13) of the paediatricians usually dispense hypotonic fluids and 81.14% (95% CI; 77.54–84.74) prescribe infusion rates based on the Holliday and Segar protocol. The general profile of paediatricians who prescribe hypotonic fluids intravenously in Spain are medical residents, paediatricians working in paediatric non-intensive care units, in private hospitals, and those who recognise that no consensus exists among their direct work colleagues regarding this subject. Conclusions: More than twenty-five per cent of all paediatricians in our country continue to use hypotonic fluids as maintenance intravenous fluid therapy. There might be several potential factors associated to this. These kind of studies provide evidence of the great difficulties in transferring scientific knowledge to clinical practice. Resumen: Introducción: Los fluidos isotónicos, en la mayoría de los casos, constituyen la forma más segura de administración de líquidos por vía intravenosa. Los objetivos de nuestro trabajo han sido describir las prácticas de prescripción de los fluidos intravenosos de mantenimiento y estudiar los posibles factores asociados. Material y método: Estudio transversal, descriptivo, multicéntrico de ámbito nacional, mediante encuesta on-line, difundida a través de sociedades científicas médicas y la Organización Médica Colegial, entre diciembre de 2016 y diciembre de 2017. Resultados: Un total de 487 encuestas fueron recibidas, 456 de pediatras. El 28,95% (IC 95%: 24,77-33,13) de ellos prescribían habitualmente fluidos hipotónicos y el 81,14% (IC 95%: 77,54-84,74) se basaba en la regla de Holliday y Segar para calcular el volumen total a infundir. El perfil del pediatra en España que utiliza fluidos hipotónicos intravenosos es el de médico residente de pediatría, pediatra que trabaja en áreas diferentes a las unidades de cuidados intensivos pediátricos, en hospitales privados, y aquellos que reconocen que no existe un consenso al respecto en su grupo de trabajo. Conclusiones: Más de una cuarta parte de los pediatras en nuestro país sigue utilizando los fluidos hipotónicos como fluidoterapia intravenosa de mantenimiento. Diferentes factores podrían estar asociados a este hecho. Estos estudios son prueba de las grandes dificultades existentes para trasladar el conocimiento a la práctica.

OBJETIVOS: Avaliar se o uso de soluções salinas hipotônicas como fluidoterapia de manutenção em crianças hospitalizadas aumenta o risco de hiponatremia, se a administração de fluidos isotônicos é capaz de proteger contra a hiponatremia adquirida e se as soluções isotônicas aumentam os riscos de efeitos deletérios como hipernatremia ou sobrecarga hídrica. FONTES DOS DADOS: Realizou-se uma pesquisa bibliográfica nas bases de dados PubMed (01/01/1969 a 13/07/2011), Embase (1989 a 2011) e Cochrane Library (1989 a 2011). Adicionalmente, referências foram incluídas dos estudos selecionados. SÍNTESE DOS DADOS: Crianças hospitalizadas têm riscos potenciais para hiponatremia, e o uso de soluções salinas hipotônicas é o principal fator de risco para esse agravo. As soluções salinas isotônicas têm mostrado efeito protetor para hiponatremia e, até o momento, sem efeitos deletérios significativos, como sobrecarga hídrica, hipernatremia ou flebites. CONCLUSÕES: As evidências indicam que a tradicional recomendação de Holliday & Segar quanto à fluidoterapia de manutenção para crianças doentes e hospitalizadas merece ser reconsiderada em virtude das evidências sobre os efeitos adversos dela advindos, assim como dos melhores resultados obtidos com o emprego das soluções isotônicas.

OBJETIVO: Examinar as necessidades hídricas (água livre de eletrólitos) a serem consideradas quando da administração de fluidos de manutenção na criança em estado grave. Analisamos algumas das dificuldades na estimativa desses requisitos, e discutimos as controvérsias a respeito das recomendações tradicionais. FONTES DOS DADOS: MEDLINE (1966-2007),Embase (1980-2007), e Cochrane Library, usando os termos: “fluidoterapia”, “solução hipotônica”, “isotônica”, e sinônimos ou termos relacionados. SÍNTESE DOS DADOS: A solução de manutenção e regime de fluido ideais permanecem um ponto de controvérsia em pediatria. As recomendações tradicionais para fluidos de manutenção são cada vez mais criticadas por não se aplicarem consistentemente à doença aguda, onde o gasto de energia e a necessidade de eletrólitos se desviam significantemente das estimativas originais. Apresentamos uma estrutura fisiologicamente fundamentada para a prescrição de fluidos de manutenção, com o objetivo de manter a tonicidade em equilíbrio, e administrar o volume mínimo de fluidos de manutenção necessário para manter a hemodinâmica. Discutimos também as indicações para soluções isotônicas e hipotônicas. CONCLUSÕES: As prescrições de fluidos de manutenção devem ser individualizadas. Não existe uma solução endovenosa única e ideal para todas as crianças durante todas as fases da doença, mas há evidências suficientes para sugerir que a escolha empírica mais segura é uma solução isotônica. As soluções hipotônicas devem ser consideradas apenas se o objetivo é alcançar um equilíbrio positivo de água livre. As crianças em estado grave podem necessitar de uma redução de até 40-50% dos volumes de manutenção atualmente recomendados. Todos os pacientes que receberem fluidos endovenosos devem ser monitorados bem de perto, com pesagem diária, equilíbrio dos fluidos, controle dos parâmetros bioquímicos e clínicos, a fim de melhor orientar esta terapia.OBJECTIVE: To examine electrolyte-free water requirements that should be considered when administering maintenance fluids in a critically ill child. We examine some of the difficulties in estimating these requirements, and discuss the controversies with respect to the traditional recommendations. SOURCES: MEDLINE (1966-2007), Embase (1980-2007), and the Cochrane Library, using the terms: “fluid therapy”, “hypotonic”, “isotonic solution”, and synonyms or related terms. SUMMARY OF THE FINDINGS: The ideal maintenance solution and fluid regimen remains a topic of heated debate in pediatrics. The traditional recommendations for maintenance fluids are increasingly criticized as they do not consistently apply in acute illness, where energy expenditure and electrolyte requirements deviate significantly from the original estimates. A physiologically based framework for prescribing maintenance fluids is presented, with the objective of maintaining tonicity balance, and infusing the minimum volume of maintenance fluid required to maintain hemodynamics. Indications for isotonic and hypotonic solutions are discussed. CONCLUSIONS: Maintenance fluid prescriptions should be individualized. No single intravenous solution is ideal for every child during all phases of illness, but there is evidence to suggest that the safest empirical choice is an isotonic solution. Hypotonic solutions should only be considered if the goal is to achieve a positive free-water balance. Critically ill children may require a reduction by as much as 40-50% of the currently recommended maintenance volumes. All patients receiving intravenous fluids should be monitored closely with daily weights, fluid balances, biochemical and clinical parameters in order to best guide this therapy.

Introduction: The efficacy and safety of the Rapid Intravenous Rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice., Objective: To prepare a document with evidence-based recommendations about RIR in paediatric population., Methods: The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of "relevant outcomes"; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security)., Results: 16 recommendations were set up, from which we can highlight as the main ones: 1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation, moderate evidence). 2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong, high). 3) Isotonic fluids are recommended (strong, high), suggesting saline fluid as the first option (light, low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong, moderate). 4) A rhythm of 20cc/kg/h is recommended (strong, high) during 1-4 h (strong, moderate)., Conclusions: This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting., (Copyright © 2021 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: The efficacy and safety of the rapid intravenous rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice., Objective: To prepare a document with evidence-based recommendations about RIR in paediatric population., Methods: The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of «relevant outcomes»; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security)., Results: Sixteen recommendations were set up, from which we can highlight as the main ones: (1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation and moderate evidence). (2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong and high). (3) Isotonic fluids are recommended (strong and high), suggesting saline fluid as the first option (light and low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong and moderate). (4) A rhythm of 20 cc/kg/h is recommended (strong and high) during 1-4 h (strong and moderate)., Conclusions: This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting., (Copyright © 2021 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Isotonic fluids, in most cases, are the safest way to dispense fluids intravenously. The aim of this study was to determine the prescription of maintenance intravenous fluids and to study possible associated factors., Material and Method: A descriptive, cross-sectional, multi-centre study was performed. A questionnaire was sent nationwide to several healthcare providers via an on-line survey, sent by email through different Medical Scientific Societies, and the Official Spanish Medical Association, between December 2016 and December 2017., Results: A total of 487 questionnaires were received, of which 456 were submitted by paediatricians. More than one quarter (28.95%) (95% CI; 24.77-33.13) of the paediatricians usually dispense hypotonic fluids and 81.14% (95% CI; 77.54-84.74) prescribe infusion rates based on the Holliday and Segar protocol. The general profile of paediatricians who prescribe hypotonic fluids intravenously in Spain are medical residents, paediatricians working in paediatric non-intensive care units, in private hospitals, and those who recognise that no consensus exists among their direct work colleagues regarding this subject., Conclusions: More than twenty-five per cent of all paediatricians in our country continue to use hypotonic fluids as maintenance intravenous fluid therapy. There might be several potential factors associated to this. These kind of studies provide evidence of the great difficulties in transferring scientific knowledge to clinical practice., (Copyright © 2019 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)