Fluid therapy in pediatric victims of the 2003 bam, Iran earthquake

On 26 December 2003, at 05:26 hours, an earthquake of magnitude
6.6 (Richter scale) caused a disaster in the Bam region of Southeastern
Iran, which had a population of approximately 102,000. In this study, the clinical
and laboratory features and therapeutic interventions in pediatric (three
months to 14 years) crush victims were analyzed. Determination of the type
and amount of fluid therapy for prevention of acute renal failure (ARF) was
the main aim of this study.
Methods: The clinical and laboratory data and therapeutic interventions provided
to 31 pediatric crush victims were collected. Early and vigorous fluid
resuscitation was immediately performed. Resuscitation of the children from
hypovolemic shock was initiated by interavenous (IV) administration of normal
saline until the signs and symptoms of shock disappeared. For victims with
crush injuries, an alkaline intravenous solution, up to 3 to 5 times more than
maintenance doses was provided. In this study, there were two groups with
decreasing severity of injury: (1) crush injury (CI), with or without ARF; and
(2) non-crush injury (Non-CI). According to the above mentioned classification,
there were 15 and 16 patients in group I and II, respectively.
Results: The mean time spent under the rubble was 2.2 ±2.5 hours and 0.5 ±0.5
hours in Groups I and II, respectively.Seventy-five percent of ARF patients (n = 8),
were admitted to the hospital the day of the earthquake (Day 0) and the day after
earthquake (Day 1). In non-ARF patients (n = 7), 85.7% of the victims were
admitted on Day 0 and Day 1. In Group II (ARF and non-ARF), all patients
were admitted within three days after the earthquake. Although ARF did not
develop in any of the children without CI, it was observed in eight of 15 patients
with CI. There was no significant difference between CI with ARF (n = 8) and
CI without ARF (n = 7) patients, in terms of the admission date, time of admission,
hospitalization duration, and time under the rubble (TUR). Admission
SGOTs were significantly different between these two groups. The ratio of the
amount of delivered IV fluid (DL) to expected (EX) was based on weight of children
was the only fluid therapy parameter in which there was a statistically significant
difference between ARF and non-ARF groups. It was 3.6 ±0.99 in ARF
and 4.8 ±0.74 in Nnon-ARF group (p = 0.01).
Conclusions: Early intravenous volume replacement may prevent both ARF and
dialysis need that may develop on the basis of rhabdomyolysis. In adults, six liters
or 12–14 liters of fluids for prophylaxis of ARF in crush syndrome,were suggested.
In children, it seems that DL/EX ratio (delivered to expected ratio) is the best
marker for evolution of IV fluid therapy in pediatric patients. In children with
crush injuries, DL/EX ratio of >4.8 was sufficient for the prevention of ARF