Perioperative fluid therapy in children
Editor—Cunliffe and Potter's1 editorial raises important questions about the prescription of i.v. fluids to the perioperative paediatric population. The survey by Way and colleagues2 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.3 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.
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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.
Brisbane, Australia
*E-mail: Mark_Coulthard{at}health.qld.gov.au
References
1 Cunliffe M and Potter F. Four and a fifth and all that. Br J Anaesth 2006; 97:274–7
2 Way C, Dhamrait R, Wade A, Walker I. Perioperative fluid therapy in children: a survey of current prescribing practice. Br J Anaesth 2006; 97:371–9
3 Holliday M and Segar W. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957; 19:823–32
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