Supplemental intraoperative crystalloids for pediatric postoperative nausea and vomiting
A systematic review and meta-analysis
Pediatric Anesthesia
Submitted January 2023 by Dr Justin Skowno
Read by 284 Journal Watch subscribers
PONV is an unpleasant complication of anaesthesia and surgery that we should all be doing our best to minimise. This meta-analysis cobbles together the relatively meagre number of studies looking at the role of IV fluids in the reduction of PONV in paediatrics and gives a clear “YES” as the answer. Their paper follows a good methodological approach and is only held back by the studies available to them. They discuss things well, particularly the fact that
the studies didn’t use any anti-emetics, used mostly sevoflurane and nitrous oxide (emetogenic anaesthesia) and no TIVA was used. Thus, they may be fairly far from current state of the art.
However, the simple and safe use of a generous amount of IV fluid helps with PONV and post operative thirst and should be something we consider for all procedures. I’ve sometimes not wanted to “unnecessarily” give IV fluids for some shorter procedures to save on money and plastics, but I’ll reconsider this, whilst at the same time giving TIVA and anti-emetics as a routine.
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Point-of-care ultrasonography to predict fluid responsiveness in children
A systematic review and meta-analysis
Pediatric Anesthesia
Submitted January 2023 by Dr Justin Skowno
Read by 277 Journal Watch subscribers
All anaesthetists have given many fluid boluses, mostly to try and help their patients. Unfortunately, knowing whether that bolus actually achieved the goal you had hoped for is rather harder than it seems. This study assesses the current literature and focuses on POCUS to determine fluid responsiveness. It is a technically thorough paper, following current guidelines (PRISMA-DTA), and finds 25 papers on the topic with assessable, relevant data. They find that POCUS, specifically delta-Aortic Velocity peak and somewhat less so delta-IVC diameter, are valuable in diagnosing fluid responsiveness BUT they are operator dependent in terms of skills required to get the measurements and have high heterogeneity.
Commentary
Fluid responsiveness is such a core diagnostic concept in paediatric anaesthesia and critical care that we almost forget that, despite not having a nice gold standard device to help us, we are actively assessing this in our patients most of the time. We use our clinical skills and mental models influenced by Guyton, and supplement these with whichever devices we have at hand and are familiar with.
This field has steadily developed over the past 25-30yrs, and broadly follows findings in the adult world. However, the physiological variations present within our paediatric space are substantially larger than encountered in adults. The studies presented here investigate patients post cardiac surgery, neonates, adolescents, etc. with a very wide range of physiologies. As a result, it is harder to demonstrate consistent benefit or lack of benefit for a diagnostic test in this area in any one study. Dynamic indicators of fluid responsiveness in highly controlled situations (animal models with flow probes) are exceptionally accurate at picking it up – our challenge is the heterogeneity of practice noted.
This paper adds to the field and is a good read for those interested in the detail. It is specifically useful for anyone interested in cardiovascular physiology and POCUS.
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