Perioperative fluid therapy in children

Abstract

Editor—Cunliffe and Potter's1Cunliffe M Potter F Four and a fifth and all that.Br J Anaesth. 2006; 97: 274-277Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar editorial raises important questions about the prescription of i.v. fluids to the perioperative paediatric population. The survey by Way and colleagues2Way C Dhamrait R Wade A Walker I Perioperative fluid therapy in children: a survey of current prescribing practice.Br J Anaesth. 2006; 97: 371-379Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar confirms the lack of guidelines for fluid prescribing, and the potential risk of hyponatraemia in this group of patients. We would like to share the results of our recent work on this topic. The paediatric intensive care unit at the Royal Children's Hospital in Brisbane, Australia admits 600 patients a year including approximately 30 children who undergo spinal instrumentation surgery. In 2003, a clinical pathway was introduced to standardize the care of postoperative paediatric patients undergoing spinal instrumentation. In July 2004 the standard i.v. fluid regimen was changed from dextrose 3.0% and sodium chloride 0.3% (Cohort 1) at two-thirds ‘maintenance’ rate to dextrose 5% and Hartmann's solution (Cohort 2) at full ‘maintenance’ rate. The hourly full maintenance rate was defined as 4 ml kg−1 h−1 for the first 10 kg; 2 ml kg−1 for the next 5 kg, and 1 ml kg−1 for each kilogram thereafter.3Holliday M Segar W The maintenance need for water in parenteral fluid therapy.Pediatrics. 1957; 19: 823-832Crossref PubMed Google Scholar All other aspects of the postoperative clinical care remained the same as per the clinical pathway. The administration of postoperative fluid boluses was at the discretion of the treating doctor. We conducted a retrospective study to compare the incidence of postoperative hyponatraemia in the two cohorts of children undergoing spinal instrumentation surgery who had received the two different i.v. fluid regimens. The two groups were equivalent for age, gender, underlying diagnosis, operative procedure and amount of bolus fluid received (Table 1). The main results are shown in Table 2.Table 1Patients. NS, not significant3% Dextrose/ 1/3 NaCl (n=30)5% Dextrose/ Hartmann's (n=29)P-valueNumber of males (%)15.0 (50)9 (31)NSMean weight (kg)33.339.6NSMean age (yr)11.411.8NSMean no. of segments instrumented8.89.3NS Open table in a new tab Table 2Clinical and laboratory results. *Mean (sd). sd, standard deviation. NS, not significant3% Dextrose/ 1/3 NaCl (n=30)5% Dextrose/ Hartmann's (n=29)P-valueInitial serum Na (mmol litre−1)*140.7 (2.4)140.1 (2.5)NSSerum Na at 12–16 h (mmol litre−1)*135.5 (2.5)137.6 (2.8)NSFall in serum Na (mmol litre−1)5.22.20.00Follow-up serum Na <135 mmol litre−1; n (%)11 (37)5 (17)0.08Patients receiving additional fluid boluses; n (%)18 (60)19 (66)NSMean number of additional boluses given5.24.0NSMean total fluid bolus volume (ml kg−1)2417NS Open table in a new tab We conclude that the change in postoperative fluid regimen from dextrose 3% and sodium chloride 0.3% at two-thirds maintenance rate to dextrose 5% and Hartmann's at full maintenance rate reduced the proportion of patients with postoperative hyponatraemia and the fall in serum sodium at 12–16 h after operation. However, in our 2 yr study there were no patients in either cohort with clinically significant hyponatraemia. We are not aware of good quality clinical trials to guide the management of paediatric perioperative fluid therapy. We are currently enrolling patients in a randomized control trial to further investigate perioperative fluid management in children.