2. Introduction
• Intravenous (IV) fluid therapy is necessary to meet the water, electrolyte
and energy requirements of hospitalised patients when oral intake is not
possible or indicated.
• Although the recommended dextrose concentration for maintenance fluid
therapy has traditionally been 5% (10% in newborns)
• it may be preferable to use lower dextrose concentrations to prevent the
development of hyperglycaemia and its potential harmful effects in critical
patients.
• There is evidence in the paediatric literature of an association between
hypoglycaemia or hyperglycaemia and increased morbidity and mortality in
critical patients, which has also been described in adults.
3. Clinical Question
• In patients who undergone surgery, will receiving IV fluids with
different glucose concentration have different plasma glucose levels
• P – patients aged 6 months to 14 years weighing 6 or more kg that had under-
gone elective surgery
• I – patients receiving Iv fluids with glucose
• C – patients receiving IV fluids with 3.3% dextrose concentration vs saline
with 5% glucose
• O –there is no statistical difference between the two groups
• M – single-centre, prospective, open-label phase IV randomised controlled
trial
•
4. Relevance
Clinical Scenario Objectives
In patients who undergone surgery, will
receiving IV fluids with different glucose
concentration have different plasma
glucose levels
P – patients aged 6 months to 14
years weighing 6 or more kg that
had under-gone elective surgery
I – patients receiving Iv fluids with
glucose
C – patients receiving IV fluids with
3.3% dextrose concentration vs
saline with 5% glucose
O –there is no statistical difference
between the two groups
M – single-centre, prospective,
open-label phase IV randomised
controlled trial
To compare plasma glucose levels and incidence of hyperglycaemia in
the postoperative period after general surgery using fluids with different
glucose
5. Methods
A randomised, open-label, non-
blind, clinical trial was conducted
on patients admitted to Paediatric
Intensive Care Unit after elective
surgery.
• The inclusion criteria
• were from 6 months to 14 years
of age, with a weight greater than
6 kg, onset glucose level > 60
mg/dL, and a signed informed
consent, with no oral intake and
maintenance intravenous fluid
therapy using fluids with 3.3% or
5% glucose.
6. • Exclusion criteria
• Refusal of concent
• Patients that required changes in treatment, treatment for acute
hypoglycaemia (glycaemia < 60 mg/dL) or whose consent for participation
was withdrawn during the study were excluded from the final analysis.
7. • Plasma glucose levels were measured before surgery, on admission,
and 8, 24, and 48 h, with the mean glucose levels and incidence of
hyperglycaemia (glucose level > 150 mg/dL) in both groups being
compared.
• the hypotonic (HT) group, which received 2/3 dex-trose in 1/3 saline
(51 mEq of chloride, 51 mEq of sodium and 33 g of dextrose per litre
of solution), and the isotonic (IT) group, which received 5% dextrose
in 0.9% saline (154 mEq of chloride, 154 mEq of sodium and 50 g of
dextrose per litre of solution). We calculated fluid requirements by
the Holliday- Segar method
• During surgery, patients received isotonic fluids without dextrose.
8. Validity
• 1.2 Was the assignment of patients to treatments randomized?
•Yes
• We used the Epidat 3 software to allo-cate patients randomly to one of two treatment
groups, on a 1:1 ratio
9. Validity
1.3 Were the groups similar at the start of the
trial? YES
• patients aged 6 months to 14 years weighing 6 or more kg that had
under-gone elective surgery and in whom postoperative oral and/or
enteral fasting with maintenance IV fluid therapy was pre-scribed for
a minimum of 6 h.
10. Validity
1.4 Aside from the experimental treatment were
the groups treated equally? YES
• Same monitoring, induction technique, anesthetic protocol, and
postoperative analgesia were standardized.
• We calculated fluid requirements by the Holliday- Segar method
• recording of plasma glucose levels at admission and at 8, 24 and 48 h.
• During surgery, patients received isotonic fluids without dextrose.
• plasma glucose levels were measured in the hospital’s laboratory using a
Cobas ISE analyser
11. Methods
• The primary outcome was the plasma glucose level (in mg/dL).
• The secondary outcome was the incidence of hyperglycaemia. We
defined hyperglycaemia as a plasma glucose level of more than 150
mg/dL
• Patients that had a plasma glucose level of less than 60 mg/dL at any
point in the study were treated with IV dextrose and excluded from
the analysis.
12. Validity
1.4 Were the patients, their clinicians and study
personnel blind to treatment? NO
• The study did not use any blinding
13. Validity
1.5 Were all patients who entered the trial properly
accounted for and attributed at its conclusion? YES
• There was no note that any patient during the study who were
included was removed from the study
18. Discussion
• Hyperglycaemia is one of the most frequent metabolicchanges in
hospitalised patients. Stress states such as inflam-mation, shock,
hypoxia, major burns or polytrauma and systemic inflammatory
response syndrome. With release of positive mediators of
inflammation and neurohormones with the purpose of ensuring an
adequate supply of energy and oxygen to the tissues.
19. • Hyperglycaemia is not free of complications. It can delay wound
healing, increase the risk of infection, impair white blood cell function
or cause osmotic diuresis that may result in secondary dehydration or
electrolyte imbalances.
• hyperglycaemia can damage the brain. In the presence of ischaemia
or hypoxia, cerebral blood flow decreases, causing lactic acidosis and
changes in neural function that may even result in cell death.
20. • We ought to highlight the increase in glucose levelsobserved between
the preoperative period and the postop-erative period, the latter
recorded at the time of admissionto the PICU in both groups. The
mean glucose level rosefrom 92.6 ± 26.8 mg/dL before surgery to
125.1 ± 50 mg/dL after
• Thus, we may conclude that administration of fluids witha 3.3%
dextrose concentration achieves plasma glucose lev-els similar to
those obtained in patients that receive salinewith 5% glucose, with a
similar incidence of hyperglycaemia,so that use of the lower
concentration could be equallyefficacious in maintaining glucose
levels within the targetrange.
21. Can the result be applied to my patient care?
• Patients undergoing elective surgeries
• ASA 1 – 2
• Patients undergoing anesthesia
• Patients receiving iv fluids
23. Are the likely treatment worth the potential
harm and benefits? YES
24. Resolution of the Scenario
• The article was valid and reliable
• the researchers conclude that administration of fluids witha 3.3%
dextrose concentration achieves plasma glucose levels similar to
those obtained in patients that receive saline with 5% glucose, with a
similar incidence of hyperglycaemia, so that use of the lower
concentration could be equally efficacious in maintaining glucose
levels within the targetrange.
Notas do Editor
Effect of single dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study
Shorten
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hypnosis was monitored using a Narcotrend monitor
Neuromuscular transmission was measured by an accelerometer using a commercial device incorporating a pulse generator and a piezoelectric motion sensor placed at the tip of the thumb
Skin temperature over the thumb was monitored and maintained above 32°C.
The ulnar nerve was stimulated supramaximally at the wrist with train-of-four stimuli (60 mA for 200 μs) at 15-s intervals and the acceleration of the thumb was measured.
We have summarised quanti-tative variables using the mean and standard deviation, andqualitative variable using absolute frequencies and percent-ages.
To assess associations between two variables, we builtcontingency tables and used the chi square test, the Yateschi square test or the Fisher exact test (for 2 × 2 tables withsmall cell sizes) as applicable. To assess whether the changesthat occurred in certain variables at different time points inthe followup differed between groups, we used the Studentt test after verifying the random sampling, independence,normality and homogeneity of variance assumptions.
If theassumption of homogeneity of variance was not met (Levenetest), we used the Student t test with the Welch correction.If the assumption of normality was not met (Shapiro---Wilktest), we used the Mann---Whitney U test. When the normal-ity assumption was not met, we calculated 95% confidenceintervals for significant differences between means. Wedefined statistical significance as a p-value of less than 0.05.
Score mo ng validity
ResultsThe final analysis included 130 patients: 60 in the HT groupand 70 in the IT group. There were no differences in thebaseline characteristics of patients in these groups, save inbody weight - table 1
Table 2
The mean glucose levels were higher in the IT group com-pared to the HT group throughout the study, except at 24 h,where the mean was higher in the HT group, although thedifferences between groups were not statistically significant
In the IT group, the mean plasma glucose level peaked at8 h from initiation of IV fluid therapy at 273 mg/dL, while inthe HT group, the mean peaked at 368 mg/dL at 24 h.The lowest plasma glucose level in the study occurredin a patient in the HT group at 8 h from admission, with a HT group (n = 60) IT group (n = 70) PAge (months) 56 ± 48.3 71.2 ± 50 .082Sex, n (%)0.721Male 29 (48.3) 37 (52.9)Female 31 (51.7) 33 (47.1)Peso (kg) 18.2 ± 11 23.7 ± 15 .034Duration ofsurgery (min)255 ± 145 283 ± 136 .266Type of surgery, n (%)Neurosurgery 17 (28) 16 (22.8)Trauma14 (23)19 (27)Tumourresection9 (15) 14 (20)Maxillofacial/ENT9 (15) 12 (17)Respiratorysystem7 (11.6) 5 (7)Gastrointestinal 3 (5)3 (4)Other 1 (1.6)1 (1.4)
In the IT group, the mean plasma glucose level peaked at8 h from initiation of IV fluid therapy at 273 mg/dL, while inthe HT group, the mean peaked at 368 mg/dL at 24 h.The lowest plasma glucose level in the study occurredin a patient in the HT group at 8 h from admission, with a value of 61 mg/dL.
The minimum level in the IT group alsooccurred at this time point, with a value of 67 mg/dL.We found no significant differences between the IT andthe HT groups in the frequency of hyperglycaemia at anypoint of the study.
At 8 h, 26% of patients in the HT groups had plasma glu-cose levels of 150 mg/dL or higher compared to 21.3% ofpatients in the IT group (P < .63).
At 24 h, 20% of patients in the HT group and 22.7% ofpatients in the IT group had hyperglycaemia (P < .8).
At 48 h, we observed plasma glucose levels of 150 mg/dLor higher in 19% of patients in the HT group versus 23.1% inthe IT group (P < .78).
This could be explained by the rise in plasma glucose associ-ated with the hypermetabolic stress response produced bysurgery,
