What are the recommended colloids and their indications in pediatric patients?

Colloids Selection and Indications in Pediatric Patients

Isotonic saline should be the first-choice fluid for initial resuscitation in pediatric patients with hypovolemia, with synthetic colloids reserved for specific clinical scenarios requiring large fluid volumes. 1

First-Line Fluid Therapy

• Isotonic crystalloid solutions, particularly normal saline, are recommended as the first-choice fluid for initial resuscitation in children with hypovolemia 1
• Initial fluid bolus should be 10-20 mL/kg with repeated doses based on individual clinical response 1
• Crystalloids are preferred due to their effectiveness, lower cost, and wider availability compared to colloids 1, 2

Indications for Colloid Use

Specific Clinical Scenarios

• Synthetic colloids may be considered when large amounts of fluids are required (e.g., in sepsis) due to their longer intravascular duration 1
• Severe shock states with persistent hemodynamic instability despite initial crystalloid resuscitation 3
• Severe burns with total body surface area >20-30% may benefit from albumin administration to maintain serum albumin levels >30 g/L 1
• Pediatric dengue shock syndrome with pulse pressure <10 mmHg may benefit from colloid solutions 3

Types of Colloids and Their Specific Indications

1. Albumin (5%):

   • May be considered in severe burns to reduce crystalloid administration volume 1
   • Early administration (8-12 hours post-burning) in children with burns >15% TBSA has shown decreased crystalloid requirements and reduced fluid creep 1, 4
   • Has minimal effects on hemostasis compared to synthetic colloids 5

2. Synthetic Colloids:

   • Hydroxyethyl Starch (HES):

     • Tetrastarch (6% HES 130/0.4) has fewer adverse effects on coagulation than older HES formulations 6
     • Should be avoided in patients with renal dysfunction or coagulopathy 7
     • FDA-approved for use in pediatric postoperative volume expansion 7
     • Contraindicated in severe burns according to European Medicines Agency 1

   • Gelatins:

     • Less impact on coagulation compared to HES but greater than albumin 5
     • Higher risk of anaphylactoid reactions compared to other colloids 6
     • Limited beneficial volume effect compared to other colloids 6

3. Dextrans:

   • Rarely used in pediatric patients due to negative effects on coagulation and potential for anaphylactic reactions 6

Clinical Considerations and Caveats

• Cost considerations: Colloid solutions are significantly more expensive than crystalloids (albumin ~140 Euro/L, HES ~25 Euro/L, isotonic saline ~1.5 Euro/L) 1

• Safety concerns:

  • Albumin carries a theoretical risk of viral transmission, though modern processing has minimized this risk 6
  • HES may impair coagulation and renal function, particularly at higher doses (>20 mL/kg) 7, 5
  • Colloids may leak into the interstitial space in conditions with increased capillary permeability, potentially worsening edema 1

• In pediatric cardiac surgery for infants <5 kg, artificial colloids have shown comparable outcomes to albumin-containing priming solutions, with potentially reduced platelet consumption 8

Monitoring Response to Fluid Therapy

• Fluid administration should be guided by clinical indicators of adequate tissue perfusion 3:

  • Normal capillary refill time
  • Absence of skin mottling
  • Warm extremities
  • Well-felt peripheral pulses
  • Return to baseline mental status
  • Adequate urine output

• Measuring hourly resuscitation ratio (fluid infusion to urine output) can help evaluate fluid demands during resuscitation 4

Common Pitfalls to Avoid

• Delaying fluid resuscitation in shock states can increase morbidity and mortality 3
• Administering excessive fluid boluses in patients without shock can lead to fluid overload and respiratory complications 3
• Using colloids as first-line therapy when crystalloids would be equally effective and less expensive 1
• Failing to recognize hypernatremia risk in neonates, though studies have not shown significant differences in sodium levels between colloid and crystalloid administration 1