Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-227X/13/15/prepub Acknowledgements Authors are thankful to the HIAE’s ER staff for its support and to HIAE and HMMD for the support to the study development and publication.
Pediatric shock is a recognized medical emergency [1]. Aggressive fluid resuscitation is recognized as a critical component of early non-cardiogenic shock management [1-4]. The American College of Critical Care Medicine (ACCM) guidelines

for early goal-directed pediatric septic shock Inhibitors,research,lifescience,medical management recommend to, “Push boluses of 20 cc/kg isotonic saline or PR-171 clinical trial colloid up to & over 60 cc/kg until perfusion improves or unless rales or hepatomegaly develop” [4]. Clear pragmatic recommendations for health care providers (HCPs) as to how to achieve rapid fluid resuscitation are lacking in current guidelines. An important aspect limiting fluid flow is that the intravenous (IV) cannulas most commonly used in pediatric patients have a small radius Inhibitors,research,lifescience,medical relative to those used in adults [5]. In adult patients, options for rapid fluid resuscitation include rapid infuser devices and pressure bag support [6-8]. While these modalities are available for use in pediatric

resuscitation, in our experience, syringes are most commonly used for this purpose, likely due to their relative availability Inhibitors,research,lifescience,medical and health care providers’ comfort using them. A randomized controlled trial by Stoner et al. determined that manual syringe and pressure bag methods were an equivalent means of delivering fluid rapidly in an emergency department setting [9].

However, in this study only 58% of children resuscitated in the pressure bag and 68% in the syringe group met the ACCM benchmarks. In the clinical setting, we have observed Inhibitors,research,lifescience,medical and health care providers have endorsed two different manual syringe techniques used for the purpose of rapid isotonic fluid resuscitation for children in shock: 1) the ‘disconnect-reconnect’ technique and 2) the ‘push-pull’ technique [10]. When initiating manual Inhibitors,research,lifescience,medical fluid resuscitation using syringes, a health care provider must make a decision regarding what syringe size to use. A larger syringe has a larger radius relative to a given IV catheter. To create the STK38 same pressure gradient (which is proportional to flow rate) across an IV catheter, a health care provider must apply a comparatively greater force to the plunger when a larger syringe size is used, as dictated by the formula. F = ΔP(πr2). Where the force applied is constant, a slower fluid flow rate results when a larger radius syringe is used. When using the ‘disconnect-reconnect’ technique (Figure 1) to perform manual fluid resuscitation, one must also consider that total fluid administration time is actually the sum of the “fluid push time” plus the “syringe swap time”, as time is required to disconnect and replace empty syringes with new fluid filled ones.