|Year : 2022 | Volume
| Issue : 2 | Page : 79-85
Comparison the effects of using two methods of fluid therapy with normal saline or 5% dextrose in half amount of normal saline solution on blood glucose and plasma electrolytes during and after neonatal surgeries: A randomized controlled trial
Hamidreza Shatabi, Negin Khavarian Moghadam, Amir Shafa, Mohamadreza Habibzade
Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||03-Nov-2021|
|Date of Decision||09-Dec-2021|
|Date of Acceptance||26-Dec-2021|
|Date of Web Publication||20-Apr-2022|
Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Nowadays, with or without sugar, balanced electrolyte solutions are used to prevent hyponatremia, hypoglycemia, and hyperglycemia for neonatal fluid therapy. Objectives: This study aimed to compare the effects of two types of fluid therapy with normal saline and 5% dextrose in half amount of normal saline (DW5% NaCl 0.45%) solution on plasma electrolytes and blood glucose during and after surgery in neonates. Methods: The research population consisted of 1-day to 30-day-old infants who were candidates for surgery under general anesthesia; 70 infants were selected and assigned by block randomization in two groups of 35. Patients in Group A received fluid therapy with normal saline 0.9% (10 cc/kg/h) and DW 5% NaCl 0.45% solution in Group B (10 cc/kg/h). Results: There was no significant difference in the mean value of bicarbonate level (HCO3), base excess and blood acidity (pH) in the study groups (P > 0.05). In Group A, there was no significant difference in sodium (Na) and mean arterial pressure (MAP) over time (P > 0.123), while in Group B, Na level decreased and MAP increased significantly (P < 0.05) with time. Blood sugar levels increased significantly in both groups over time, although this increase was greater in Group B. Conclusion: In general, the results of the study showed that both fluid therapy with normal saline and DW5% NaCl 0.45% solutions can be used in neonatal surgery, but based on the studied variables in this work, normal saline has a lower risk of hyperglycemia than DW5% NaCl 0.45% solution and therefore it is preferred.
Keywords: Blood sugar, fluid therapy, neonatal surgeries, neonates, plasma electrolytes
|How to cite this article:|
Shatabi H, Moghadam NK, Shafa A, Habibzade M. Comparison the effects of using two methods of fluid therapy with normal saline or 5% dextrose in half amount of normal saline solution on blood glucose and plasma electrolytes during and after neonatal surgeries: A randomized controlled trial. J Clin Neonatol 2022;11:79-85
|How to cite this URL:|
Shatabi H, Moghadam NK, Shafa A, Habibzade M. Comparison the effects of using two methods of fluid therapy with normal saline or 5% dextrose in half amount of normal saline solution on blood glucose and plasma electrolytes during and after neonatal surgeries: A randomized controlled trial. J Clin Neonatol [serial online] 2022 [cited 2022 Aug 9];11:79-85. Available from: https://www.jcnonweb.com/text.asp?2022/11/2/79/343419
| Introduction|| |
Pediatric and neonatal surgery has grown significantly in recent years, thanks to a greater understanding of pediatric physiology, improved pediatric anesthesia and neonatal intensive care, better cardiopulmonary care, and better nutrition and fluid therapy. During neonatal anesthesia, the optimal state is providing a normal physiological state (normovolemia, tissue perfusion, acid–base state, and normal metabolic function) for the infant. The most common complications following neonatal anesthesia are associated with nonsurgical complications including Hemodynamic problems, multiple organ dysfunction syndrome, and pulmonary insufficiency.,,
As we know, infants have a higher metabolic need than adults and therefore are at higher risk of hypoglycemia and lipolysis during surgery. On the other hand, during anesthesia, both oxygen consumption and metabolic need are reduced in the infants who lead to lower need for glucose during surgery.,,
Conventionally, in neonatal intensive care units (NICUs) to prevent hypoglycemia, serum is supplied with 10% dextrose serum, but during anesthesia, the use of this serum as a maintenance fluid may cause hyperglycemia in the infant due to reduction of the body's metabolic needs, which increases complications such as high blood osmolality and risk of cerebral hemorrhage as well as other complications.,,, On the other hand, the use of glucose serum alone increases the risk of hyponatremia. Therefore, it is highly recommended to use electrolyte balanced solutions with or without sugar to prevent hyponatremia, hypoglycemia, and hyperglycemia for neonatal fluid therapy.,,,,,
However, evaluation the effect of intravenous dextrose administration in 9% normal saline at the onset of anesthesia has been considered in some studies in adults, but attention to the effects of dextrose in infants and the importance and management of fluid therapy in neonatal surgeries in fewer studies have been considered as a clinical trial. Therefore, this study compares the effects of two types of fluid therapy with normal saline and 5% dextrose in half amount of normal saline (DW5% NaCl 0.45%) solution on plasma electrolytes and blood sugar (BS) levels during and after neonatal surgery.
| Methods|| |
The present study is a double-blind randomized controlled clinical trial. The study population includes all 1-day to 30-day old infants who are candidates for surgery under general anesthesia in the Surgery Department of Imam Hossein Hospital in Isfahan from December 2019 to June 2020.
From this population according to the sample size formula in comparison between the two groups, at a confidence level of 95%, test power of 80%, and taking into account the results of previous studies from standard deviation (SD) of plasma glucose in both groups with normal saline 9% and 5% dextrose – 0.9% saline equal to 0.82 and 2.48, respectively, and considering the error level of 1.20, the sample size in each group was 39.
Inclusion criteria include 1-day to 30-day old infants, candidates for general anesthesia with ASA I or II. In addition, infants with severe anomalies, prematurity, and low birth weight, as well as the infants who were candidates for major surgeries such as cardiovascular and lung surgery (requiring thoracic opening), extensive laparotomies, and open abdomen surgery (such as Hirschsprung and Omphalocele who needed to receive colloids during surgery) did not enter the study. The patients were excluded if the surgery was canceled or the surgery method and anesthesia induction were changed as well as occurrence of any disorders during surgery that required medical intervention.
After obtaining the ethical approval from the Medical Ethics Committee of Isfahan University of Medical Sciences (code: IR.MUI.REC.1398.183) and registration code of clinical trial (IRCT20200229046645N1) and filling the written consent by the patient's parents to participate in the study, 78 eligible infants were randomly selected. Envelopes were prepared with the labels of A and B and then parents were asked to choose one of them and patients were randomly divided into the two groups in this way.
It should be noted that in order to blinding the study, both liquid solutions containing normal saline and DW5% NaCl 0.45% were prepared by the pharmacist in the same container, volume, and color that were labeled with the codes of A and B. These solutions (serums) were then daily given to the anesthesiologist in the operating room as the patients (participants), care provider, and the data collector (assessing outcomes) were not aware of the type of intervention in each group and the study was double blind.
At the beginning of the study, demographic and clinical information including age, sex, type of operation, and weight was recorded. Then, preoperative vital signs (heart rate [HR], oxygen saturation of arterial blood [SpO2], mean arterial pressure [MAP], BS, serum electrolytes (serum potassium [K] and sodium [Na] levels) were measured and registered.
All patients underwent anesthesia by the same method (induction of anesthesia with thiopental sodium 5 mg/kg, atropine 0.01 mg/kg, fentanyl 2 μg/kg, and atracurium 0.5 mg/kg). Then, intubation with the appropriate size and anesthesia maintenance was done for all the patients following the oxygen, isoflurane, cardiac and respiratory monitoring. In Group A, patients underwent fluid therapy with normal saline 0.9% (10 cc/kg/h), and in Group B, they were received fluid therapy with DW5% NaCl 0.45% (10 cc/kg/h).
It should be noted that this protocol was only related to fluid therapy prescription in the operating room and after admission to NICU, the necessary treatments were performed according to the opinion of the neonatologist.
Primary outcome measures
Blood glucose levels were measured at baseline, end of surgery, and 2 h after (in NICU) with a glucometer. In addition, serum sodium and potassium levels were measured and recorded before admitting to the operation room, at the end of the operation, and 2 h after (in the NICU) by taking a blood sample. Serum BE, pH, and bicarbonate levels were also recorded after surgery (in the NICU) by sending an ABG sample.
Secondary outcome measures
In addition, as a secondary parameter, neonatal hemodynamic parameters including HR, SpO2, and MAP were recorded every 15 min during surgery.
The obtained data were finally entered into SPSS software (version 24; SPSS Inc., Chicago, Ill., USA). Data were presented by frequency (percentage) or mean ± SD. Repeated measures of ANOVA and independent sample t-test were used for inferential statistics. A significance level of <0.05 was considered in all analyzes.
| Results|| |
The samples were dropped from 78 to 70 (in the two groups of 35), out of 39 infants in each group, four cases from Group A (one due to bleeding and need for blood transfusion, three due to change of surgical method) and four cases from Group B (two due to need for colloidal injection, one due to bleeding and one person due to change of surgical method) were excluded from the study and the sample size in each group was reduced to 35 cases [Figure 1].
In Group A, there were 20 boys (57.1%) and 15 girls (62.9%) with the mean age of 20.14 ± 10.45 days and in Group B, there were 24 boys (68.6%) and 11 girls (31.4%) with the mean age of 15.83 ± 11.21 days. The two groups were not significantly different in terms of age, gender, and other baseline factors (P > 0.05) [Table 1].
On the other hand, the postoperative mean of ABG parameters (including pH, BE, and HCO3) was not significantly different between the two groups (P > 0.05) [Table 2].
|Table 2: Comparison of the mean of blood acidity, base excess, bicarbonate variables at the end of surgery in study groups|
Click here to view
Postoperative ABG changes are shown in [Table 3]. According to this table, significant changes in MAP were not significant in Group A over time (P = 0.123), but in Group B, these changes were significant so that the amount of MAP increased over time (P = 0.032). Furthermore, the interaction of time and group for MAP was significant (P = 0.004). In addition, HR in each Group A and B had a significant decrease over time (P < 0.001). In addition, the interaction of time and group was significant for HR (P < 0.001). In Group A, SpO2 also had a significant increase over time (P = 0.011), but changes in this factor were not significant in Group B (P = 0.052). Therefore, the interaction of time and group was not significant for SpO2 (P = 0.85).
|Table 3: Determination and comparison of mean arterial pressure, heart rate, and oxygen saturation of arterial blood in the studied groups during different times|
Click here to view
On the other hand, BS and K in each group of A and B had a significant increase over time (P < 0.05). However, the interaction of time and group was also significant for the BS parameter (P < 0.001) and nonsignificant for K parameter (P = 0.887).
In contrast, the mean level of Na in Group A did not change significantly over time (P = 0.437), although in Group B there a significant increase was observed (P < 0.001). The interaction of time and group was not significant for this parameter (P = 0.338) [Table 4].
|Table 4: Determination and comparison of blood sugar, sodium, and potassium in the study groups during different times|
Click here to view
| Discussion|| |
The present study was performed to compare the effect of two methods of fluid therapy with normal saline solution or (DW5% NaCl 0.45%) solution on BS and plasma electrolytes during and after neonatal surgery.
The results showed that in the two groups of normal saline solution or (DW5% NaCl 0.45%) solution, there was no significant difference between the variables of arterial blood gases (HCO3, PH, BE) and the results were in the normal or expected range.
In this study, in Group A, which received normal saline solution for fluid therapy, the mean of MAP and Na did not change significantly over time and remained around the normal range. But in the parameters of BS and SpO2 percentage, the amount of variables increased significantly over time and the level of BS was in the hyperglycemic range. The mean of HR and K parameters also decreased significantly over time and both of them were remained in the normal range.
In Group B that DW5% NaCl 0.45% solution was used for fluid therapy, MAP, BS, and HR parameters increased significantly over time. In the meantime, the BS parameter was in the significant hyperglycemic range and the other variables were in the normal range. However, the two parameters of Na and K decreased significantly over time, although both were remained in the normal range. However, in this group, the mean of SpO2 parameter did not change significantly over time and was in the normal range.
Comparing the above points, it seems that the most important complication during serotherapy with normal saline and 5% dextrose in half amount of normal saline (DW 5% NaCl 0.45%) solution is hyperglycemia, which was more severe in the group treated with DW 5% NaCl 0.45% solution. Therefore, based on the results of this study, both types of solutions can be used in neonatal surgery, but normal saline fluid has a lower risk of hyperglycemia than DW 5% NaCl 0.45% solution, and therefore, it is preferred.
Consistent with the present study, Ouchi et al. in an observational study compared isotonic and hypotonic solutions in pediatric surgery which showed elevated serum glucose levels in the group treated with both isotonic and hypotonic fluid, but it was more severe in the hypotonic fluid group. Serum potassium levels were not significantly different between the two groups; however, in the group treated with hypotonic fluids, serum sodium levels were significantly lower than serum sodium levels in the isotonic group.
Mierzewska-Schmidt in a study to compare the three methods of serotherapy in pediatric surgery revealed that hyperglycemia occurred in the patients undergoing therapy with 5% dextrose solution after surgery, which is similar to the results of this study. However, in the same group, patients also showed hyponatremia. In our study, although serum sodium levels decreased, but it did not reach to the hyponatremic range. Finally, in this study, the isotonic solution has been introduced as the preferred serotherapy method, which is consistent with the results of our study.
Furthermore, in the study of Bito et al., a decrease in serum sodium levels occurred in patients treated with hypotonic serum, and it was concluded that isotonic solution was generally better than hypotonic serum. However, it should be noted that in their study, the opposite result of increased level of serum sodium was seen in the patients treated with isotonic solution, which may be due to the small number of samples in that study or different times of serum sodium levels measurement.
In a study by Datta et al., on fluid therapy in infants with fluids containing dextrose, the use of isotonic solution contained 1% dextrose caused hyperglycemic rebound and acidosis in patients and the use of 10% dextrose solution of 0.20% saline did not cause hyperglycemia in patients. This finding contradicts our study as in the present study, acidosis and hyperglycemic rebound were not observed in the group receiving fluid therapy with isotonic solution, and clear hyperglycemia was observed in patients receiving fluid therapy with half saline/5% dextrose. The discrepancy is probably due to differences in the time of sampling as well as the percentage of dextrose solution.
In another study, 31% of patients in the normal saline group developed metabolic acidosis and patients in this group developed hyperkalemia during surgery (K > 6) and required treatment, which may be due to the difference in the amount of normal saline injected and surgery duration. Normal saline solution, which is a hyperchloric and hypertonic solution, can cause hyperchloremic metabolic acidosis when administered in high volumes, which, in turn, may theoretically cause potassium to shift out of the cell and cause some degrees of hyperkalemia in the patient.
In the study by Park (2012) on the factors related to metabolic acidosis after abdominal surgery, two important causes of hyperchloremia were reported as using high doses of normal saline and lactic acidosis. In this study, the length of stay in hospital in the acidosis group was significantly longer. Although this study had limitations such as being retrospective and lack of control over the fluid therapy, it presented a valuable result about the effect of hyperchloremia on acid and base.
Considering the above-mentioned materials, it seems that the preferred fluid for neonatal serum therapy during surgery is in accordance with the lower need of the patients for glucose, and on the other hand, it does not cause hyponatremia. Therefore, isotonic solution containing <10% dextrose is preferable.
It should be noted that our study has some limitations; for example, in the present study, the effects of neonatal fluid therapy methods were investigated during short-term surgeries, and due to the difficulty in long-term follow-up and also larger costs, long-term effects such as postoperative hyperglycemia have not been studied. Second, the levels of other serum electrolytes, including chloride, were not studied. In fact, chloride is one of the most important blood electrolytes that helps to maintain the balance between intracellular and extracellular fluids and serves to keep normal blood volume, blood pressure and pH that have not been investigated in this study due to some technical issues and financial limitations. Renal function, urine output, and fluid balance were not also considered in this study. Thus, it is suggested to do further studies with larger sample sizes and longer duration of surgeries and aim to evaluate more electrolyte parameters to re-evaluate this issue so that the results can be generalized to the community with more confidence.
| Conclusion|| |
According to the results of this study, both fluid therapy with normal saline and DW5% NaCl0.45% solutions can be used in neonatal surgery, but based on the variables studied in this work, normal saline solution has a lower risk of hyperglycemia than 5% dextrose/half saline solution, and therefore, this fluid therapy is preferred.
The authors would like to thank the Research Department of Isfahan University of Medical Sciences for facilitating this study with their financial and scientific support.
Financial support and sponsorship
This study was financially and scientifically supported by the Research Department of Isfahan University of Medical Sciences for facilitating this study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Escobar MA, Caty MG. Complications in neonatal surgery. Semin Pediatr Surg 2016;25:347-70.
Sümpelmann R, Becke K, Brenner S, Breschan C, Eich C, Höhne C, et al.
Perioperative intravenous fluid therapy in children: Guidelines from the Association of the Scientific Medical Societies in Germany. Paediatr Anaesth 2017;27:10-8.
Michelet D, Brasher C, Kaddour HB, Diallo T, Abdat R, Malbezin S, et al.
Postoperative complications following neonatal and infant surgery: Common events and predictive factors. Anaesth Crit Care Pain Med 2017;36:163-9.
Block RI, Magnotta VA, Bayman EO, Choi JY, Thomas JJ, Kimble KK. Are anesthesia and surgery during infancy associated with decreased white matter integrity and volume during childhood? Anesthesiology 2017;127:788-99.
Suehiro K, Okutani R, Ogawa S. Anesthetic considerations in 65 patients undergoing unilateral pneumonectomy: Problems related to fluid therapy and hemodynamic control. J Clin Anesth 2010;22:41-4.
Sümpelmann R, Mader T, Dennhardt N, Witt L, Eich C, Osthaus WA. A novel isotonic balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in neonates: Results of a prospective multicentre observational postauthorisation safety study (PASS). Paediatr Anaesth 2011;21:1114-8.
Bito K, Higuchi S, Omura A, Kaneda Y, Otaki R, Azuma S, et al.
Hypotonic versus isotonic electrolyte solution for perioperative fluid therapy in infants. Masui 2015;64:294-300.
Filston HC. Fluid and electrolyte management in the pediatric surgical patient. Surg Clin North Am 1992;72:1189-205.
Adenekan AT. Perioperative blood glucose in a paediatric daycase facility: Effects of fasting and maintenance fluid. Afr J Paediatr Surg 2014;11:317-22.
] [Full text]
Mierzewska-Schmidt M. Intraoperative fluid management in children –
A comparison of three fluid regimens. Anaesthesiol Intensive Ther 2015;47:125-30.
Datta PK, Pawar DK, Baidya DK, Maitra S, Aravindan A, Srinivas M, et al.
Dextrose-containing intraoperative fluid in neonates: A randomized controlled trial. Paediatr Anaesth 2016;26:599-607.
Ripolles J, Espinosa A, Martinez-Hurtado E, Abad-Gurumeta A, Casans-Frances R, Fernandez-Perez C, et al.
Intraoperative goal directed hemodynamic therapy in noncardiac surgery: A systematic review and meta-analysis. Braz J Anesthesiol 2016;66:513-28.
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;156:313-9.e1.
Suempelmann R, Mader T, Eich C, Witt L, Osthaus WA. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children: Results of a prospective multicentre observational post-authorization safety study (PASS). Pediatric Anesthesia 2010;20:977-81.
O'Brien F, Walker IA. Fluid homeostasis in the neonate. Paediatr Anaesth 2014;24:49-59.
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;34:613-7.
Disma N, Mameli L, Pistorio A, Davidson A, Barabino P, Locatelli BG, et al.
A novel balanced isotonic sodium solution vs normal saline during major surgery in children up to 36 months: A multicenter RCT. Paediatr Anaesth 2014;24:980-6.
Pigna A, De Rose R, Gentili A, Landuzzi V, Corticelli AS. Infusion constituents in pediatric anesthesia. Minerva Anestesiol 1996;62:137-41.
Gueli SL, Lerman J. Controversies in pediatric anesthesia: Sevoflurane and fluid management. Curr Opin Anaesthesiol 2013;26:310-7.
O'Malley CM, Frumento RJ, Bennett-Guerrero E. Intravenous fluid therapy in renal transplant recipients: Results of a US survey. Transplant Proc 2002;34:3142-5.
Nuraei N, Khajenouri R, Soleimani M, Dabbagh A. The effects of intraoperative normal saline versus lactated ringer solution on clinical outcomes and laboratory findings in renal transplant patients. Tehran Univ Med J 2010;68:243-9.
Park CM, Chun HK, Jeon K, Suh GY, Choi DW, Kim S. Factors related to post-operative metabolic acidosis following major abdominal surgery. ANZ J Surg 2014;84:574-80.
[Table 1], [Table 2], [Table 3], [Table 4]