Liquidos

Pediatric Anesthesiology
Section Editor: Peter J. Davis

Review Article

Perioperative Crystalloid and Colloid Fluid Management
in Children: Where Are We and How Did We Get Here?
Ann G. Bailey, MD*†
Peggy P. McNaull, MD*†
Edmund Jooste, MBCHB, DA‡
Jay B. Tuchman, MD‡

It has been more than 50 yr since the landmark article in which Holliday and Segar
(Pediatrics 1957;19:823–32)proposed the rate and composition of parenteral
maintenance fluids for hospitalized children. Much of our practice of fluid
administration in the perioperative period is based on this article. The glucose,
electrolyte, and intravascular volume requirements of the pediatric surgical patient
may be quite different than the original population described, and consequently,
use of traditional hypotonicfluids proposed by Holliday and Segar may cause
complications, such as hyperglycemia and hyponatremia, in the postoperative
surgical patient. There is significant controversy regarding the choice of isotonic
versus hypotonic fluids in the postoperative period. We discuss the origins of
perioperative fluid management in children, review the current options for crystalloid
fluid management, andpresent information on colloid use in pediatric patients.
(Anesth Analg 2010;110:375–90)

F

luid management of the pediatric surgical patient
presents challenges to both the anesthesia and surgical
teams. Typically, the intraoperative management is
the responsibility of the anesthesiologist, whereas
postoperative orders are written by the surgeons. Both
groups rely on formulas andconcepts once thought to
be certain, but these are presently being examined and
challenged, especially in the pediatric literature. The
purpose of this review is to outline the history supporting current fluid management strategies and to
discuss the effect of recent controversies on future
practice decisions.

CRYSTALLOIDS
The “4-2-1 Rule”
Fluid therapy for the ill child was first describedin
the early 20th century. In 1918, Blackfan and Maxcy1
reported instilling 0.8% isotonic saline intraperitoneally to successfully treat infants with diarrheal dehydration. Karelitz and Schick, in 1931, administered a
continuous IV solution of 5% dextrose combined with
From the Departments of *Anesthesiology, and †Pediatrics,
University of North Carolina, Chapel Hill, North Carolina; and‡Department of Anesthesiology, Children’s Hospital of Pittsburgh
of UPMC, Pittsburgh, Pennsylvania.
Accepted for publication June 19, 2009.
Reprints will not be available from the author.
Address correspondence to Ann G. Bailey, MD, Department of
Anesthesiology, CB# 7010, 223 Burnett-Womack, Chapel Hill, NC
27599-7010. Address e-mail to abailey@aims.unc.edu.
Copyright © 2010 InternationalAnesthesia Research Society
DOI: 10.1213/ANE.0b013e3181b6b3b5

Vol. 110, No. 2, February 2010

either isotonic saline or lactated Ringer’s solution (LR)
to “detoxify” dehydrated children. Their institution of IV
therapy decreased the current mortality rate for childhood dehydration from 63% to 23%.2 Over the next 30
yr, work by Gamble, Darrow, Crawford, Wallace, and
others further defined thenature of the body’s extracellular fluid and the rationale for fluid therapy.3– 6
The 1957 publication by Holliday and Segar7 first
presented a practical method for clinicians to prescribe
IV fluids. The suggestions made in this classic article
evolved into what is now termed the “4-2-1 rule” for
maintenance fluid therapy in children. Based on earlier research done by their peers, the authorsdescribed
the intimate relationship between physiologic fluid
losses and caloric expenditure. The physiologic deficits from urine output and insensible losses of the skin
and respiratory tract are equal to approximately 100
mL per 100 kcal metabolized per day. Simply stated, 1
mL of “water” is required for every 1 kcal of energy
expended. Based on the computed caloric needs of the...