Recently, several European Associations of Paediatric Anaesthetists changed their recommendations for intraoperative fluid therapy from hypotonic solutions with 5% glucose to isotonic solutions with 1–2.5% glucose.1,2 However, currently, such solutions are not commercially available in many European countries. As a consequence, paediatric anaesthetists tend to use suboptimal intravenous fluid strategies that may lead to serious morbidity and even mortality because of iatrogenic hyponatraemia, hyperglycaemia or medical errors.3–5 To address this issue, the German Scientific Working Group for Paediatric Anaesthesia suggests a European consensus statement on the composition of an appropriate intraoperative solution for infusion in children in order to facilitate the granting of a European marketing authorisation for such a solution, thereby improving the safety and effectiveness of intraoperative fluid therapy in children.
Maintenance fluid therapy in children has for half a century been based on Holliday and Segar's recommendations suggesting the use of hypotonic fluids with 5% glucose added. In recent years, many studies and case reports have shown that the routine use of such fluids may lead to serious hyponatraemia or hyperglycaemia and may occasionally result in permanent neurological damage or death.6–11 The two main factors for the development of perioperative hyponatraemia are first the stress-induced secretion of antidiuretic hormone leading to an impaired ability to excrete free water and second the administration of hypotonic solutions as a source of free water.12–14 Hyponatraemia leads to an influx of water into the brain, primarily through glial cell swelling, initially largely preserving neuronal cell volume. This process will ultimately lead to cerebral oedema, brain stem herniation and death. Prepubescent children are a high-risk group for a poor outcome associated with hyponatraemic encephalopathy because of the presence of a high brain size to cranial vault ratio and reduced Na-K-ATPase activity compared to the adult brain.15
Infants also are at increased risk of perioperative lipolysis and hypoglycaemia due to a higher metabolic rate compared to adults. If hypoglycaemia does occur, this will induce a stress response as well as alter cerebral blood flow and metabolism.16 Permanent neurodevelopmental impairment can result if hypoglycaemia goes unrecognised and untreated. However, intraoperative administration of 5% glucose solutions for prevention of hypoglycaemia will often result in hyperglycaemia due to stress-induced insulin resistance.17 Hyperglycaemia may also be detrimental to the brain due to an accumulation of lactate, a decrease in intracellular pH and subsequently compromised cellular function in the context of global or focal cerebral ischaemia.18 Last, the administration of glucose-free solutions increases the risk of lipolysis with the release of ketone bodies and free fatty acids.19,20 Against the above mentioned background, the use of isotonic fluids with lower glucose concentrations (i.e. 1–2.5%) represents a well accepted compromise between avoiding hypoglycaemia/lipolysis and hyperglycaemia in children.3,21–24 Unfortunately, a European marketing authorisation of such a solution is currently missing and nationally approved solutions or solutions produced by local pharmacies are only available in a few European countries:
France: Polyionique B66 (Central Pharmacy, Paris, France).
Switzerland: Ringer-Laktat mit Glucose 1%/Ringer-Laktat mit Glucose 2% (Laboratorium Bichsel, Interlaken, Switzerland).
Belgium: Hartmann's solution with Glucose 2.5% (Baxter, Lessines, Belgium).
Austria: ELO-PAED balanced mit 1% Glucose (Fresenius Kabi Austria, Graz, Austria).
Germany: Elektrolyt- Infusionslösung 148 mit Glucose 1 PÄD (Serumwerk Bernburg AG, Bernburg, Germany).
An appropriate solution for intraoperative infusion in children should have an osmolarity and sodium content close to the physiologic range in order to avoid hyponatraemia, an addition of 1–2.5% glucose in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions (i.e. acetate, lactate or malate) as bicarbonate precursors to avoid acid–base balance disturbances (i.e. hyperchloraemic acidosis). The intraoperative infusion of isotonic solutions containing 1–2.5% glucose in children is considered well established use in Europe. The granting of a European marketing authorisation for such a solution is highly recommended and will improve the safety and effectiveness of perioperative fluid therapy in children.
The authors reported no conflicts of interest.
List of Consensus supporters is as follows (in alphabetical order):
Dr Karin Becke, Consultant Paediatric Anaesthetist, Cnopfsche Kinderklinik, Nürnberg, Germany.
Professor Dr Pervin Bozkurt, Consultant Paediatric Anaesthetist, Medical Faculty Istanbul University Cerrahpaşa, Istanbul, Turkey.
Dr Peter Crean MB, FRCA, Consultant Paediatric Anaesthetist, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom.
Professor Dr Claude Ecoffey, Consultant Paediatric Anaesthetist, Hôpital Pontchaillou, Université de Rennes, Rennes, France.
Professor Dr Franz Frei, Consultant Paediatric Anaesthetist, Basler Kinderspital, Universitäts-Kinderkliniken und Polikliniken, Basel, Switzerland.
Dr Ignacio Galvez, Consultant Paediatric Anaesthetist, Hospital Materno-Infantil, Hospital Universitario Son Dureta, Mallorca, Spain.
Dr Andreas Gerber, Consultant Paediatric Anaesthetist, Universitäts Kinderkliniken, Zürich, Switzerland.
Dr Tom G. Hansen, Consultant Paediatric Anaesthetist, Odense University Hospital, Odense, Denmark.
Dr Martin Jöhr, Consultant Paediatric Anaesthetist, Kantonsspital, Luzern, Switzerland.
Professor Dr Franz- Josef Kretz, Consultant Paediatric Anaesthetist, Olga-Hospital, Stuttgart, Germany.
Professor Dr Per-Arne Lönnqvist, Consultant Paediatric Anaesthetist, Astrid Lindgrens Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
Professor Dr Peter Marhofer, Consultant Paediatric Anaesthetist, Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria.
Dr Neil Morton, Consultant Paediatric Anaesthetist, Yorkill Children's Hospital, Glasgow, United Kingdom.
Professor Dr Isabelle Murat, Consultant Paediatric Anaesthetist, Hôpital d’Enfant Armand Trousseau, Paris, France.
Professor Dr Krister Nilsson, Consultant Paediatric Anaesthetist, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
PD Dr Claudia Philippi-Höhne, Consultant Paediatric Anaesthetist, Universitätsklinik, Leipzig, Germany.
Dr Francisco Reinoso-Barbero, Consultant Paediatric Anaesthetist, Hospital Universitario La Paz, Madrid, Spain.
Dr Kerstin Sandström, Consultant Paediatric Anaesthetist, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
Professor Univ. Belg. Dr Ehrenfried Schindler, Consultant Paediatric Anaesthetist, Kinderklinik Sankt Augustin, Sankt Augustin, Germany.
Professor Dr Jochen M. Strauss, Consultant Paediatric Anaesthetist, Helios Klinikum, Berlin, Germany.
Professor Dr Robert Sümpelmann, Consultant Paediatric Anaesthetist, Kinderklinik Medizinische Hochschule Hannover, Hannover, Germany.
Professor Dr Elly Vermeulen, Consultant Paediatric Anaesthetist, Division of Perioperative and Emergency Care, University Medical Center, Utrecht, Netherlands.
Professor Dr Francis Veyckemans, Consultant Paediatric Anaesthetist, Cliniques Universitaires St Luc, Brussels, Belgium.
Dr Isabeau Walker, Consultant Paediatric Anaesthetist, Great Ormond Street Hospital, London, United Kingdom.
PD Dr Frank Weber, Consultant Paediatric Anaesthetist, Sophia Children's Hospital Erasmus University, Rotterdam, Netherlands.
Professor Dr Markus Weiss, Consultant Paediatric Anaesthetist, Universitäts Kinderkliniken, Zürich, Switzerland.
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