Research Article of International Journal of Pediatric Research and Reviews
The Use of a Rapid Fluid Infusion System in Children
Sai Surapa Raju, MD1; Judy Fuller, RN2; Stacy L. Gaither, MSN, RN1; Hui-Chien Kuo, MS3; Inmaculada Aban, PhD3; Nancy M. Tofil, MD, MEd1
1University of Alabama at Birmingham, Department of Pediatrics
2Children’s Hospital of Alabama, Emergency Department
3University of Alabama at Birmingham, Pediatric Research Office
Fluid resuscitation is the cornerstone of treatment for pediatric shock caused by conditions such as sepsis, dehydration, trauma, and anaphylaxis. Children presenting to the Emergency Department (ED) in shock have a high risk of mortality, and each hour of delay in shock reversal doubles the odds of death1,2. Pediatric Advanced Life Support (PALS) guidelines emphasize the importance of providing rapid fluid resuscitation to prevent the progression to hypotensive or refractory shock3. PALS and other septic shock guidelines recommend that patients receive a 20 mL/kg bolus of crystalloid immediately upon recognition of hypovolemic or distributive shock, with 20 mL/kg to be delivered within 5 minutes and up to 60 mL/kg within the first 15-60 minutes3-6. Studies based on these guidelines show that earlier fluid delivery directed at reversal of shock reversal leads to decreased morbidity7-9, mortality2,7,9-12, and hospital length of stay (LOS)9,11-13. Unfortunately, timely fluid delivery is often not achieved due to the technical challenges of obtaining adequate vascular access and delivering fluid boluses quickly in patients with shock or hypotension11,14-16.
Current methods of fluid bolus delivery in the pediatric emergency care setting include infusion pumps, gravity drip, pressure bags, rapid infusers, and the push-pull syringe technique17,18. Each of these methods are limited by speed, ease of use, or safety concerns. Infusion pumps provide a maximum rate of 999 mL per hour, which for a 25kg child would provide a 60 mL/kg bolus in 90 minutes. In most patients, infusion pumps are therefore too slow to provide adequate fluid resuscitation. Gravity drip rates are unpredictable and inadequate for the treatment of shock and hypotension. For example, up to 50 minutes are required for one liter of fluid to flow through a 22G intravenous (IV) line, and up to 200 minutes via the intraosseous (IO) route19-22. A pressure cuff may speed flow modestly, but requires constant re-inflation, makes volume of infusion difficult to track, and carries the risk of inadvertent air embolism3,20,22-25. Rapid infusers can deliver fluids very quickly but are expensive, require frequent training, are not readily available in many emergency care settings, and importantly do not provide adequate flow with the small gauge IV or intraosseous (IO) access typical of pediatric resuscitation19,26.
Due to the limitations of these common fluid delivery methods, pediatric emergency providers commonly use a syringe and 3-way stopcock to repeatedly draw fluid from the container of crystalloid and then deliver to the patient. This technique is referred to as the “push-pull” method and is recommended in the PALS guidelines3. An alternate technique involves disconnecting and reconnecting multiple pre-filled 60mL syringes, which often requires two providers18. Both methods may be associated with increased risk of nosocomial infection due to the difficulty of maintaining syringe sterility27-31.
The LifeFlow® infuser (410 Medical, Inc; Durham, NC) is a new manually operated device for rapid fluid bolus delivery that overcomes some of these common barriers. The device is currently FDA-cleared for infusion of crystalloid and colloid fluids, and is in use at our center for emergency resuscitation. Using common IV gauges LifeFlow can deliver fluid 2 to 4 times faster than standard techniques, and allows providers to observe a clinical response immediately by improvements in vital signs, mental status and skin perfusion29,32-34. This study describes the use of the LifeFlow device in a busy academic children’s hospital ED with 74,000 patient visits per year.
Keywords: Rapid Fluid Infusion System, Children
How to cite this article:
Sai Surapa Raju, Judy Fuller; Stacy L. Gaither, Hui-Chien Kuo, Inmaculada Aban, Nancy M. Tofil. The Use of a Rapid Fluid Infusion System in Children. International Journal of Pediatric Research and Reviews, 2020, 3:26. DOI:10.28933/ijoprr-2020-07-2105
1. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003;112(4):793-799. doi: 10.1542/peds.112.4.793
2. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics. 2009;124(2): 500-508. doi:10.1542/peds.2008-1967
3. American Heart Association. Pediatric Avanced Life Support (PALS) Provider Manual. (Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds.). Dallas, TX: American Heart Association; 2016.
4. Davis AL, Carcillo JA, Aneja RK, et al. American college of critical care medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med. 2017;45(6):1061-1093. doi:10.1097/CCM.00 0000 0000002425
5. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020;46(Suppl 1):10-67. doi:10.1007/ s00134-019-05878-6
6. American Academy of Pediatrics (AAP). APLS: The Pediatric Emergency Medicine Resource. 5th ed. (Fuchs S, Yamamato L, eds.). Jones & Bartlett Learning; 2011.
7. Balamuth F, Weiss SL, Fitzgerald JC, et al. Protocolized treatment is associated with decreased organ dysfunction in pediatric severe sepsis. Pediatr Crit Care Med. 2016;17(9):817-822. doi:10.1097/ PCC.0000000000000858
8. Oliveira CF, Nogueira de Sá FR, Oliveira DSF, et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008;24(12):810-815. doi:10.1097 /PEC.0b013e31818e9f3a
9. Lane RD, Funai T, Reeder R, Larsen GY. High reliability pediatric septic shock quality improvement initiative and decreasing mortality. Pediatrics. 2016;138(4). doi:10.1542/peds.2015-4153
10. Leisman D, Wie B, Doerfler M, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med. 2016;68(3):298-311. doi:10.1016/ j.annemergmed.2016.02.044
11. Paul R, Neuman MI, Monuteaux MC, Melendez E. Adherence to PALS sepsis guidelines and hospital length of stay. Pediatrics. 2012;130(2):e273-80. doi:10.1542/peds.2012-0094
12 Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011;127(6):e1585-92. doi:10.1542/ peds.2010-3513
13 Akcan Arikan A, Williams EA, Graf JM, Kennedy CE, Patel B, Cruz AT. Resuscitation bundle in pediatric shock decreases acute kidney injury and improves outcomes. J Pediatr. 2015;167(6):1301-5.e1. doi:10.1016/j.jpeds.2015.08.044
14. Paul R, Melendez E, Stack A, Capraro A, Monuteaux M, Neuman MI. Improving adherence to PALS septic shock guidelines. Pediatrics. 2014;133(5):e1358-66.doi:10.1542/peds.2013-3871
15. Moresco BL, Woosley C, Sauter M, Bhalala U. Poor Compliance with Sepsis Guidelines in a Tertiary Care Children’s Hospital Emergency Room. Front Pediatr. 2018;6:53. doi:10.3389/fped .2018.00053
16. Gatewood MO, Wemple M, Greco S, Kritek PA, Durvasula R. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf. 2015;24(12):787-795. doi:10.1136/bmjqs-2014-003552
17. Stoner MJ, Goodman DG, Cohen DM, Fernandez SA, Hall MW. Rapid fluid resuscitation in pediatrics: testing the American College of Critical Care Medicine guideline. Ann Emerg Med. 2007;50(5):601-607. doi:10.1016/j.annemergmed .2007.06.482
18. Cole ET, Harvey G, Urbanski S, Foster G, Thabane L, Parker MJ. Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting. BMJ Open. 2014;4(7): e005028. doi:10.1136/bmjopen-2014-005028
19. Auten JD, Mclean JB, Kemp JD, et al. A pilot study of four intraosseous blood transfusion strategies. J Spec Oper Med. 2018;18(3):50-56.
20.Kamata M, Walia H, Hakim M, Tumin D, Tobias JD. An in vitro assessment of the efficacy of various IV cannulas for the rapid IV fluid administration. Pediatr Crit Care Med. 2017;18(5):e224-e228. doi:10.1097/PCC.0000000000001151
21. Tintinalli JE, Stapczynski JS. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: Mcgraw-hill; 2011:2120.
22. Philip BK, Philip JH. Characterization of flow in intravenous catheters. IEEE Trans Biomed Eng. 1986;33(5):529-3l. doi:10.1109/TBME. 1986.325 743
23. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011;28(3):201-202. doi:10.1136/emj. 2009 .083485
24. Fibel KH, Barnes RP, Kinderknecht JJ. Pressurized intravenous fluid administration in the professional football player: A unique setting for venous air embolism. Clin J Sport Med. 2015;25(4):e67-9. doi:10.1097/J SM.000000000 0000150
25. Shamim F, Abbasi S. Fatal vascular air embolism during fluid resuscitation as a complication of pressure infuser bag. J Emerg Trauma Shock. 2016;9(1):46. doi:10.4103/0974-2700.161659
26. Belmont Instrument Corporation, ed. The Belmont® RAPID INFUSER, RI-2 Operator’s Manual. Billerica, MA; 2018.
27. Blogg CE, Ramsay MA, Jarvis JD. Infection hazard from syringes. Br J Anaesth. 1974;46(4):260-262. doi:10.1093/bja/46.4.260
28.Olivier LC, Kendoff D, Wolfhard U, Nast-Kolb D, Nazif Yazici M, Esche H. Modified syringe design prevents plunger-related contamination–results of contamination and flow-rate tests. J Hosp Infect. 2003;53(2):140-143. doi:10.1053/jhin.2002.1347
29. Spangler H, Piehl M, Lane A, Robertson G. Improving aseptic technique during the treatment of pediatric septic shock: A comparison of 2 rapid fluid delivery methods. J Infus Nurs. 2019;42(1):23-28. doi:10.1097/NAN. 000000 0000 000307
30. Robertson G, Hoff H, Spangler H, Piehl M. High Occurrence of Potential Contamination Risks Observed for Pediatric Patients Receiving Rapid Fluid Boluses with Single-use Syringes. Am J Infect Control. 2019;47(6):S5. doi:10.1016 /j.ajic. 2019.04.138
31. American Association of Nurse Anesthetists. AANA Safe Injection Guidelines for Syringe Use.Pdf. American Association of Nurse Anesthetists; 2014. https://www.aana.com/ docs/default-source/practice-aana-com-web-documents-(all)/safe-injection-guidelines-for-needle-and-syringe-use.pdf. Accessed December 17, 2019.
32. Piehl M, Smith-Ramsey C, Teeter WA. Improving fluid resuscitation in pediatric shock with LifeFlow®: a retrospective case series and review of the literature. Open Access Emerg Med. 2019;11:87-93. doi:10.2147/OAEM.S188110
33. Piehl M, Griffin A, Blaivas M. Case reports: rapid fluid delivery for hypotension via a novel device (LifeFlow®) leads to improved patient outcome. J Emerg Med Crit Care. 2019;5(1):1-3. doi:10.13188/ 2469-4045.1000019
34. Piehl M, Spangler H, Robertson G, Chenet K. A novel technique for improving fluid resuscitation in septic shock. Ann Emerg Med. 2017;70(4):S150. doi:10.1016/j.annemergmed.2017.07.353
35. Kaji AH, Schriger D, Green S. Looking Through the Retrospectoscope: Reducing Bias in Emergency Medicine Chart Review Studies. Ann Emerg Med.2014;64:292-298.doi:10.1016/j. annemergmed.2014.03.025
36.Piehl M, Smith-Ramsey C, Teeter WA. Improving fluid resuscitation in pediatric shock with LifeFlow®: a retrospective case series and review of the literature. Open Access Emerg Med. 2019;11:87-93. doi:10.2147/OAEM.S188110
37.Piehl M, Griffin A, Blaivas M. Case reports: rapid fluid delivery for hypotension via a novel device (LifeFlow®) leads to improved patient outcome. J Emerg Med Crit Care. 2019;5(1):1-3. doi:10.13188/2469-4045.1000019
38.Piehl M, Spangler H, Robertson G, Chenet K. A novel technique for improving fluid resuscitation in septic shock. Ann Emerg Med. 2017;70(4):S150. doi:10.1016/j.annemergmed.2017.07.353
39.Gillis HC, Walia H, Tumin D, Bhalla T, Tobias JD. Rapid fluid administration: an evaluation of two techniques. Med Devices (Auckl). 2018;11:331-336. doi:10.2147/MDER.S172340
40.Mendelson J. Emergency department management of pediatric shock. Emerg Med Clin North Am. 2018;36(2):427-440. doi:10.1016/ j.emc.2017.12.010
41. Hartman ME, Saeed MJ, Powell KN, Olsen MA. The comparative epidemiology of pediatric severe sepsis. J Intensive Care Med. 2019;34(6):472-479. doi:10.1177/0885066617735783
42. Balamuth F, Weiss SL, Neuman MI, et al. Pediatric severe sepsis in U.S. children’s hospitals. Pediatr Crit Care Med. 2014;15(9):798-805. doi:10.1097/ PCC.0000000000000225
43. Evans IVR, Phillips GS, Alpern ER, et al. Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis. JAMA. 2018;320(4):358-367. doi:10.1001/ jama.2018.9071
44. Prout AJ, Talisa VB, Carcillo JA, et al. Children with Chronic Disease Bear the Highest Burden of Pediatric Sepsis. J Pediatr. 2018;199:194-199.e1. doi:10.1016/j.jpeds.2018.03.056
45. O’Brien S, Nadel S, Almossawi O, Inwald DP. The impact of chronic health conditions on length of stay and mortality in a general PICU. Pediatr Crit Care Med. 2017;18(1):1-7. doi:10.1097/ PCC.000 0000000000976
46.Zimmerman JJ, Banks R, Berg RA, Zuppa A, et al. Trajectory of mortality and health-related quality of life morbidity following community-acquired pediatric septic shock. Crit Care Med 2020; 48:329-337. doi: 10.1097/CCM.0000000000004 123.