1. In our study , exclusions were made for the
conditions that already have protocol-based management e.g.
hyponatraemia, hypernatremia, shock congestive heart failure). Some
of the conditions, were excluded to prevent sampling bias e.g.
(pre-existing diuretic use or edema). Therefore, results of our
study can be used for empirical fluid therapy in most sick children.
However, large randomized trials with multiple arms may determine
the appropriate empirical fluid therapy in remaining situations.
2. Energy expenditure in critically ill children
has been found to be as low as 50- 60 Kcal/Kg/day, by indirect
calorimetric measurements . Fluid requirement is much less in
critically ill children for a variety of reasons such as physical
immobility, the use of muscle relaxants and sedatives, mechanical
ventilation, and additional factors such as nonessential or
facultative metabolism. Moreover, fluid requirement is further
decreased because of inappropriate increase in arginine vasopressin
which impairs the kidneyís ability to excrete free water.
3. There is enough evidence to support high
incidence of hyponatremia with the use of 0.18% NaCl in 5% Dextrose
as maintenance fluid. Therefore, we agree that its use is no longer
justified in current pediatric practice.
Further studies with a larger sample size and an
additional control arm using standard volume isotonic fluids may
determine the overall benefit and safety of volume reduction and other
queries not addressed by our trial.