Remembering the classics: European consensus on IV fluids
Francis Veyckemans MD
Generations of pediatric medical, surgical and anesthesia residents have been taught that IV fluid administration rate and composition should be based on the Holliday and Segar recommendations from 1957.1 Everly since, most pediatric patients receive either D5 0.45NS or D5 0.2NS (usually with potassium) as a “maintenance” fluid, with rates following the 4-2-1 rule. On the other hand, based on the teachings of the late Dr. Fritz Berry, pediatric anesthesiologists were taught to NEVER use hypotonic IV fluids perioperatively. Why? Because of the very real risk of hyponatremia in surgical patients in whom non-osmotic stimuli like pain, surgery, trauma, sepsis, lung disease, etc. may result in increased anti-diuretic hormone (ADH) activity which would only exaggerate the hyponatremia risk. And of course, the rate of fluid administration in the OR is necessarily not based on “4-2-1 maintenance” anyway because of bleeding and insensible losses and NPO deficits. Using hyponatremic fluids as a replacement fluids further set up the patient for hyponatremia.
But what about the sugar content of these fluids? And which patients needed sugar in their IV fluids perioperatively? Dr. Monica Hoagland of the Children’s Hospital Colorad gave an outstanding lecture on perioperative glucose management in her recent lecture at the annual meeting of the Society for Pediatric Anesthesia in Austin. Her slides are still available on line at the SPA website.
(https://www2.pedsanesthesia.org/meetings/2023winter/guide/program/files/2023-TX-1679049769-637.pdf).
I asked one of the giants of pediatric anesthesia, Dr. Francis Veyckmans, to describe the European consensus paper2 on this topic and to give us the background story of how it came about. For those who don’t know him, Dr. Veyckemans is a staff anesthesiologist at the Hôpital Jeanne de Flandre, the Mother-Child hospital of the CHU of Lille in France. He is a prolific writer and speaker and an editor of the European Journal of Anaesthesiology and the Journal Pediatric Anesthesia. We are so fortunate to have him as a guest writer for the PAAD. Myron Yaster MD
Original article
Sümpelmann, R., Becke, K., Crean, P., Jöhr, M., Lönnqvist, P. A., Strauss, J. M., & Veyckemans, F. European consensus statement for intraoperative fluid therapy in children. European Journal of Anaesthesiology 2011;28:637–639. PMID: 21654319
Today’s PAAD2 was the result of a meeting of 26 paediatric anaesthesiologists organized in September 2010 during the 2nd Congress of the European Society for Paediatric Anaesthesiology in Berlin by the German Scientific Working Group for Paediatric Anaesthesia. The goal of this meeting was to achieve an expert consensus to facilitate the granting of an European marketing authorisation for an ideal IV maintenance solution to be used during pediatric anesthesia. At that time, 5% Glucose in 0.45 or 0.2 N Saline was often used as a standard maintenance fluid. Dr. Fritz Berry had already recommended 5% glucose in lactated Ringer’s or 0.9% NaCl since the 1980’s.3 Other solutions like lactated Ringer’s 2 or 2.5% glucose were available in some hospitals and countries. Pediatric anesthesia was (and still is) a small commercial market and none of the major companies wanted to embark upon the administrative duties and costs for obtaining the EU approval for a new IV solution.
The main statements were the results of previous research by R Sümpelmann4 in Germany and I Murat’s team5 in France : 1) the solution should be isotonic to prevent the occurrence of hyponatremia due to excessive administration of free water ; 2) its electrolytic content should be balanced (close to the plasma) to avoid hyperchloremic acidosis as when only 0.9% Saline is used ; 3) it should contain enough glucose to avoid both hypo- and hyperglycema, as well as increased lipolysis in infants when no glucose is administered, a 1% glucose seemed to be the best concentration ; 4) it should contain metabolic anions (like acetate,lactate or malate) as bicarbonate precursors to avoid acid–base balance disturbances. Acetate was finally chosen because its metabolization is faster and more independent of liver function than lactate. This was all achieved in a balanced electrolytic solution containing 1% glucose and acetate called Elektrolyt-Infusionslösung 148 mit Glucose 1 PÄD made by Serumwerk Bernburg AG in Germany. It was also shown to be safe in neonates, pending regular monitoring of blood glucose.4
The solution was quickly commercialized in Germany but it took more than 7 years to make it available in other European countries. Other similar solution have become available since then.6 The use of these « ideal » solutions is however not (yet ?) widespread in Europe : their moderate increased cost is probably an obstacle. Moreover the systematic use of a glucose-containing solution remains unusual or controversial despite the recent findings of Riegger et al : in a retrospective study, they reported a 3.9% incidence of intraoperative hypoglycemia (blood glucose < 60 mg/dl or 3.3 mmol/l) in the 26,142 patients in whom intraoperative blood glucose had been measured.7
This historical report is a nice opportunity to remind that IV fluids are a medication, and that their composition and volume administered should be known and monitored.
PS from Myron : To the best of my knowledge these commercial low glucose containing solutions are not available in the United States. However, they can be made by your pharmacy or by yourselves when patients who require glucose come to the OR. Let me know how you handle this in your practice and I will post in a reader response.
References
1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. May 1957;19(5):823-32.
2. Sümpelmann R, Becke K, Crean P, et al. European consensus statement for intraoperative fluid therapy in children. European journal of anaesthesiology. Sep 2011;28(9):637-9. doi:10.1097/EJA.0b013e3283446bb8
3. Berry FA. Intraoperative fluid therapy in pediatrics. ContempAnesthPract. 1983 1983;6:85-99. Not in File.
4. Sümpelmann R, Mader T, Dennhardt N, Witt L, Eich C, Osthaus WA. A novel isotonic balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in neonates: results of a prospective multicentre observational postauthorisation safety study (PASS). Paediatric anaesthesia. Nov 2011;21(11):1114-8. doi:10.1111/j.1460-9592.2011.03610.x
5. Berleur MP, Dahan A, Murat I, Hazebroucq G. Perioperative infusions in paediatric patients: rationale for using Ringer-lactate solution with low dextrose concentration. Journal of clinical pharmacy and therapeutics. Feb 2003;28(1):31-40. doi:10.1046/j.1365-2710.2003.00456.x
6. Disma N, Mameli L, Pistorio A, et al. A novel balanced isotonic sodium solution vs normal saline during major surgery in children up to 36 months: a multicenter RCT. Paediatric anaesthesia. Sep 2014;24(9):980-6. doi:10.1111/pan.12439
7. Riegger LQ, Leis AM, Golmirzaie KH, Malviya S. Risk Factors for Intraoperative Hypoglycemia in Children: A Multicenter Retrospective Cohort Study. Anesthesia and analgesia. Apr 1 2021;132(4):1075-1083. doi:10.1213/ane.0000000000004979