Colloid Use in Pediatric Craniotomy
Isotonic crystalloids (normal saline) should be used as first-line fluid therapy for intravascular volume expansion during pediatric craniotomy, and colloids should generally be avoided in this setting. 1, 2
Primary Fluid Recommendation for Pediatric Neurosurgery
Normal saline 0.9% is the crystalloid of choice for managing pediatric patients with acute brain injury, including those undergoing craniotomy, because it is the only commonly available truly isotonic crystalloid solution (osmolarity ~308 mOsm/L) that prevents cerebral edema formation and maintains adequate cerebral perfusion. 2
The European Society of Pediatric and Neonatal Intensive Care recommends isotonic crystalloid solutions, particularly normal saline, 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
Why Colloids Are Not Recommended
Albumin is Contraindicated in Traumatic Brain Injury
Albumin solutions should not be used in any traumatic brain injury patient, as the SAFE study demonstrated increased mortality in TBI patients treated with 4% albumin (n=460; RR 1.63,95% CI 1.17-2.26, p=0.003). 2
While the question asks about craniotomy (which may include non-trauma cases), the evidence strongly suggests avoiding albumin in all acute brain injury contexts due to risk of pulmonary edema and intracranial hemorrhage. 3
Synthetic Colloids Worsen Neurological Outcomes
Synthetic colloids (gelatins, hydroxyethyl starch) are associated with worse neurological prognosis at 6 months in brain injury patients and should be avoided. 3, 2
A prospective study comparing synthetic colloids and crystalloids reported a deleterious effect on neurological prognosis at 6 months in subarachnoid hemorrhage patients in the colloid group. 3
The European Medicines Agency recommends that hydroxyethyl starch no longer be used for volume resuscitation, particularly in patients with renal dysfunction or coagulopathy. 1
When Colloids Might Be Considered (Non-Neurosurgical Context)
While not applicable to craniotomy specifically, colloids may have limited indications in other pediatric settings:
Severe burns with total body surface area >20-30% may benefit from albumin (5%) administration to maintain serum albumin levels >30 g/L and reduce crystalloid administration volume. 1
Severe shock states with persistent hemodynamic instability despite initial crystalloid resuscitation may benefit from colloid administration, though this remains controversial. 1
Synthetic colloids may be considered when large amounts of fluids are required (e.g., in sepsis) due to their longer intravascular duration, but this does not apply to neurosurgical patients. 1
Critical Pitfalls to Avoid
Do not use Ringer's Lactate despite its common availability—it is hypotonic (osmolarity ~273-277 mOsm/L) and associated with increased mortality in traumatic brain injury. 2
Avoid all hypotonic solutions (<280 mOsm/L) due to risk of cerebral edema formation. 3, 2
Do not administer albumin in any pediatric patient with acute brain injury undergoing craniotomy due to proven increased mortality. 2
Using colloids as first-line therapy when crystalloids would be equally effective and less expensive is not recommended by the American College of Critical Care Medicine. 1
Cost Considerations
Colloid solutions are significantly more expensive than crystalloids: albumin costs ~140 Euro/L, hydroxyethyl starch costs ~25 Euro/L, while isotonic saline costs ~1.5 Euro/L. 1, 4
Given the lack of benefit and potential harm in neurosurgical patients, the cost differential further supports avoiding colloids in this population. 1