Boluses of Ringer's in Surgical Kids (BRiSK Study)

NCT ID: NCT05285371

Last Updated: 2024-09-19

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

EARLY_PHASE1

Total Enrollment

70 participants

Study Classification

INTERVENTIONAL

Study Start Date

2022-02-22

Study Completion Date

2024-08-01

Brief Summary

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Traditional protocols for intravenous fluid administration in children who have undergone a major abdominal or thoracic operation are based on a landmark paper published in 1957 by Holliday and Segar. The basic tenets include: (1) Continuous intravenous fluid administration; (2) Total fluid volume based on the "4:2:1" rule; (3) Use of hypotonic electrolyte solutions, most commonly 0.45% sodium chloride (NaCl) + 20 milliequivalents per liter (mEq/L) potassium chloride (KCl); and (4) Inclusion of 5% dextrose to increase the osmolarity of the infusate and to help prevent ketosis and acidemia.

Detailed Description

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Recent studies have questioned the validity of each of these tenets. Maintenance rate as defined by Holliday \& Segar is postulated to be in excess of pediatric patients' post-surgical fluid needs. The investigators propose a novel protocol for the administration of IV fluids to children after major abdominal or thoracic surgery that includes: (1) Intermittent boluses; (2) Total volume administered in 24 hours closer to 2/3 of the traditional maintenance fluid requirements; and (3) Use of a balanced salt solution (Lactated Ringer).

Conditions

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Dehydration in Children Fluid Therapy

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Study participants will be randomized into one of two groups - Continuous (CONT) or Bolus (BOL).

CONT group will receive traditional continuous D50.45% NaCl + 20 mEq/L KCl solution at 2/3 maintenance rate.

BOL group will receive intravenous boluses of Lactated Ringer\'s at 2/3-maintenance rate.
Primary Study Purpose

TREATMENT

Blinding Strategy

NONE

Study Groups

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CONT Group

CONT group will receive standard traditional intravenous fluid of D50.45% NaCl + 20 mEq/L KCl at 2/3 maintenance rate.

Group Type PLACEBO_COMPARATOR

Urinalysis (UA)

Intervention Type DIAGNOSTIC_TEST

Urinalysis will be performed twice daily starting on Postoperative Day 0.

Complete Metabolic Panel (CMP)

Intervention Type DIAGNOSTIC_TEST

A CMP will be performed on Postoperative Day 2 and Postoperative Day 4.

Glucose Stick Test (d-Stick)

Intervention Type DIAGNOSTIC_TEST

A d-Stick will be performed twice daily except on Postoperative Day 2 and Postoperative Day 4 as the CMP includes serum glucose levels.

Medical Chart Review

Intervention Type OTHER

A medical chart review will be performed for all subjects enrolled.

BOL Group

BOL group will receive intravenous boluses of Lactated Ringer's three times daily at 2/3 maintenance rate.

Group Type EXPERIMENTAL

Urinalysis (UA)

Intervention Type DIAGNOSTIC_TEST

Urinalysis will be performed twice daily starting on Postoperative Day 0.

Complete Metabolic Panel (CMP)

Intervention Type DIAGNOSTIC_TEST

A CMP will be performed on Postoperative Day 2 and Postoperative Day 4.

Glucose Stick Test (d-Stick)

Intervention Type DIAGNOSTIC_TEST

A d-Stick will be performed twice daily except on Postoperative Day 2 and Postoperative Day 4 as the CMP includes serum glucose levels.

Medical Chart Review

Intervention Type OTHER

A medical chart review will be performed for all subjects enrolled.

Interventions

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Urinalysis (UA)

Urinalysis will be performed twice daily starting on Postoperative Day 0.

Intervention Type DIAGNOSTIC_TEST

Complete Metabolic Panel (CMP)

A CMP will be performed on Postoperative Day 2 and Postoperative Day 4.

Intervention Type DIAGNOSTIC_TEST

Glucose Stick Test (d-Stick)

A d-Stick will be performed twice daily except on Postoperative Day 2 and Postoperative Day 4 as the CMP includes serum glucose levels.

Intervention Type DIAGNOSTIC_TEST

Medical Chart Review

A medical chart review will be performed for all subjects enrolled.

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

1. Males or females age 12 months to 21 years.
2. Weight \>= 8 kg.
3. Patients with an uncomplicated abdominal or thoracic surgical procedure in which the expected postoperative length of stay is anticipated to be at least 2-5 days.
4. Patients admitted to a regular bed following surgery.
5. Patients who will be inpatient for approximately 4-8 days postoperatively.
6. Parental/guardian permission (informed consent).

Exclusion Criteria

1. Patients with a history of diabetes, seizures, hyperglycemia, and hypoglycemia.
2. Patients prescribed insulin.
3. Patients receiving parenteral nutrition.
4. Patients with excessive GI losses (small bowel obstruction, severe diarrhea, large-volume ascites or drainage).
5. Complicated surgery that requires an ICU or ICU transfer immediately after surgery.
6. Patients with any form of hypersensitivity to the study fluids.
7. Laboratory abnormalities that indicate clinically significant hematologic, hepatobiliary, or renal disease:

* Serum Sodium \<130 or \>145 mmol/L
* Serum Potassium \<3.0 or \>5.0 mEq/L
* Serum Chloride \<90 or \>110 mEq/L
* Serum Creatinine ≥ 1.6 mg/dL
* Serum Glucose \<60 or \>180 mg/dL
* Alanine Aminotransferase \>200 U/L
* Total Bilirubin \>12.0 mg/dL
8. Pregnant or lactating females.
9. Parents/guardians or subjects who, in the opinion of the Investigator, may be non-compliant with study schedules or procedures.
Minimum Eligible Age

1 Year

Maximum Eligible Age

21 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

Yes

Sponsors

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Children's Hospital of Philadelphia

OTHER

Sponsor Role lead

Responsible Party

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Responsibility Role SPONSOR

Principal Investigators

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Peter Mattei, MD

Role: PRINCIPAL_INVESTIGATOR

Children's Hospital of Philadelphia

Locations

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Children's Hospital of Philadelphia

Philadelphia, Pennsylvania, United States

Site Status

Countries

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United States

References

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Reference Type BACKGROUND
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Rooholamini SN, Clifton H, Haaland W, McGrath C, Vora SB, Crowell CS, Romero H, Foti J. Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids. Hosp Pediatr. 2017 Dec;7(12):703-709. doi: 10.1542/hpeds.2017-0099.

Reference Type BACKGROUND
PMID: 29162640 (View on PubMed)

Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL. Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. J Pediatr. 2010 Feb;156(2):313-9.e1-2. doi: 10.1016/j.jpeds.2009.07.059. Epub 2009 Oct 9.

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Bagri NK, Saurabh VK, Basu S, Kumar A. Isotonic versus Hypotonic Intravenous Maintenance Fluids in Children: A Randomized Controlled Trial. Indian J Pediatr. 2019 Nov;86(11):1011-1016. doi: 10.1007/s12098-019-03011-5. Epub 2019 Jul 6.

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Friedman JN, Beck CE, DeGroot J, Geary DF, Sklansky DJ, Freedman SB. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015 May;169(5):445-51. doi: 10.1001/jamapediatrics.2014.3809.

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Reference Type BACKGROUND
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Abdessalam S. Hypotonic versus isotonic maintenance fluid administration in the pediatric surgical patient. Semin Pediatr Surg. 2019 Feb;28(1):43-46. doi: 10.1053/j.sempedsurg.2019.01.007. Epub 2019 Jan 23.

Reference Type BACKGROUND
PMID: 30824133 (View on PubMed)

McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A, Dorofaeff T. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database Syst Rev. 2014 Dec 18;2014(12):CD009457. doi: 10.1002/14651858.CD009457.pub2.

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Easley D, Tillman E. Hospital-acquired hyponatremia in pediatric patients: a review of the literature. J Pediatr Pharmacol Ther. 2013 Apr;18(2):105-11. doi: 10.5863/1551-6776-18.2.105.

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Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: a case for using isotonic saline. Pediatrics. 2003 Feb;111(2):227-30. doi: 10.1542/peds.111.2.227.

Reference Type BACKGROUND
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Malbrain MLNG, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, De Laet I, Minini A, Wong A, Ince C, Muckart D, Mythen M, Caironi P, Van Regenmortel N. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann Intensive Care. 2020 May 24;10(1):64. doi: 10.1186/s13613-020-00679-3.

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Bampoe S, Odor PM, Dushianthan A, Bennett-Guerrero E, Cro S, Gan TJ, Grocott MP, James MF, Mythen MG, O'Malley CM, Roche AM, Rowan K, Burdett E. Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures. Cochrane Database Syst Rev. 2017 Sep 21;9(9):CD004089. doi: 10.1002/14651858.CD004089.pub3.

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Chin KJ, Macachor J, Ong KC, Ong BC. A comparison of 5% dextrose in 0.9% normal saline versus non-dextrose-containing crystalloids as the initial intravenous replacement fluid in elective surgery. Anaesth Intensive Care. 2006 Oct;34(5):613-7. doi: 10.1177/0310057X0603400511.

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Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27.

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Maheshwari K, Turan A, Makarova N, Ma C, Esa WAS, Ruetzler K, Barsoum S, Kuhel AG, Ritchey MR, Higuera-Rueda C, Kopyeva T, Stocchi L, Essber H, Cohen B, Suleiman I, Bajracharya GR, Chelnick D, Mascha EJ, Kurz A, Sessler DI. Saline versus Lactated Ringer's Solution: The Saline or Lactated Ringer's (SOLAR) Trial. Anesthesiology. 2020 Apr;132(4):614-624. doi: 10.1097/ALN.0000000000003130.

Reference Type BACKGROUND
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Farrell PR, Farrell LM, Hornung L, Abu-El-Haija M. Use of Lactated Ringers Solution Compared With Normal Saline Is Associated With Shorter Length of Stay in Pediatric Acute Pancreatitis. Pancreas. 2020 Mar;49(3):375-380. doi: 10.1097/MPA.0000000000001498.

Reference Type BACKGROUND
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Other Identifiers

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21-019180

Identifier Type: -

Identifier Source: org_study_id

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