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Perioperative fluid administration in children: is there consensus?

Everywhere pediatric anesthesia is performed intravenous fluid administration for children undergoing surgery is a foundational component of the practice. Even though intravenous fluid administration is such a key aspect of our specialty, there is variation in practice among anesthesiologists and institutions. In 2006, the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) published recommendations for perioperative infusion therapy in neonates, infants, and toddlers. These guidelines were revised in 2016 because of recent studies finding unintended adverse effects of certain intravenous solutions and blood transfusion, as well as the availability of 1% glucose in balanced electrolyte solutions from manufacturers that could replace lactated ringers in many European countries. In this issue of pediatric anesthesia, Dr. S€ umpelmann and colleagues summarized the new Guidelines from the Association of the Scientific Medical Societies in Germany along with the evidence for shaping the guidelines concerning perioperative infusion therapy in children (1). In 2014, the Chinese Society of Anesthesia published guidelines for intravenous fluid administration to children as well (2). As with the German guidelines, the Chinese guidelines were developed from consensus and evidence across scientific literature. There are similarities and differences between the German and Chinese guidelines. We would like to compare and contrast the Chinese and German guidelines and consider reasons for the differences between them. In China, approximately 1 million children receive perioperative fluid therapy for anesthesia and surgery annually. We believe there is opportunity to improve the practice by making such comparisons and investigating the differences. There is no doubt that perioperative fasting time for children should be as short as possible in order to reduce the perioperative complications (3). The Chinese NPO guidelines for children recommend that the fasting times should be 8 h for solid foods, 6 h for infant formula, 4 h for breast milk, and 2 h for clear fluids. Unfortunately, many cases exceed the recommended fasting time for clear fluids due to uncertainties, such as surgical waiting time, incorrect scheduling, and misunderstanding of guidelines by guardians. In China, the guidelines recommend establishing IV access and administering IV solutions before anesthesia induction in young infants who fast longer than these durations. Another minor difference with the German guidelines is the necessity of intravenous fluid therapy. In the German guidelines, short duration cases (<1 h) with short fasting times after the neonatal period do not necessarily require intravenous fluid. In Chinese guidelines, healthy children undergoing short duration and elective cases often do not require intravenous fluid but those who receive procedures lasting 1 h or longer or who experience dehydration due to long fasting times or any other reasons, are recommended to receive intravenous fluid. In terms of postoperative fasting time, the German guidelines indicate that it is beneficial for recovery to drink and eat as soon as possible. In China, there are still a number of hospitals that follow rules requiring 2–6 h of postoperative fasting because of concerns about PONV and aspiration. There is a possibility that the shortage of medical and nursing staff may be a reason for the concern which limits the early postoperative recovery in China relative to other developed nations. Appropriate intravenous solutions are essential to maintain normal physiological function in pediatric surgical patients. For background infusion, there is controversy over the choice of solution with or without glucose, particularly in neonates and younger infants, who are more likely experience hypoglycemia or hyperosmolar hyperglycemic coma (4). The German guidelines recommend an intraoperative background infusion of a balanced electrolyte solution with 1–2.5% glucose, initiated at a rate of 10 ml kg 1 h , with subsequent adjustment to the actual requirement. However, for shorter surgeries (<1 h), a background infusion containing glucose is not necessarily required in children beyond neonatal age with short preoperative and postoperative fasting time. Similar in China, the balanced electrolyte solution without glucose is the initial choice except in certain populations. For neonates, failure to thrive infants, and any child undergoing long duration surgery, a balanced electrolyte solution with 1–2.5% glucose is the recommended initial infusion, and the glucose concentration is adjusted thereafter in relation to blood glucose levels, which are checked regularly. In premature infants, neonates with sepsis, newborns of a diabetic mother, and children administrated with TPN, the 2.5–5% glucose solution is recommended initially and the blood sugar level should be measured and adjusted regularly. The single injection of hypertonic