Perioperative fluid management

N. Najafi Department of Pediatric Intensive Care Department of Anesthesiology UZBrussel

BAPA Annual Symposium

25 April 2014

Objectives The objectives of this talk are: To give you a brief overview of the

importance of administrating iv fluid in perioperative period in children

To guide you through a short flow chart the

rationales in choosing the desired fluid

To improve the care and safety of all children

Introduction

Holliday and Segar. Pediatrics 1957.

Introduction

From Holliday MA and Segar WE. Pediatrics 1975

Maintenance requirements

Electrolyte composition

Daily needs of 2 mEq/100 kcal K+ and Cl–

Daily needs of 3 mEq/100 kcal Na+ Needs of glucose 5%

Maintenance fluid requirements

¼th of daily fluid = 5% glucose in 0.9% NaCl + ¾th of daily fluid = 5% glucose in water

BUT

Association between maintenance fluid tonicity, postoperative deaths or significant neurological damage and hospital-acquired hyponatremia in previously healthy surgical children

Potentially hazardous iatrogenic complications in our current practice ???

Carandang F et al. Association between maintenance fluid tonicity and hospital-acquired hyponatremia. J Pediatr. 2013,

Surgical children

Original population

Described by Holliday and Segar

Breastfed small babies

Dilemma

Enteral based argumentation iv fluid ??

Differences in needs

Where are the differences ?

What are the needs?

What are we afraid of ?

How we can prevent the complications ?

Complications

Hypoglycemia Hyponatremia

Hypo- and hyperglycemia

Hypo- and hyperglycemia: detrimental to brain Hypoglycemia due to higher metabolic rate ? Hyperglycemia due to stress- induced insulin

resistance and high glucose intake ≥ 2.5 %

Hypoglycemia < < Hyperglycemia

Hirshberg E, et al. Alterations in glucose homeostasis in the pediatric intensive care unit; hyperglycemia and glucose variability are associated with increased mortality and morbidity. Pediatr Crit Care Med 2008

Glucose concentration

Perioperative use of infusion solutions containing No glucose 1% glucose 2.5% glucose 4% glucose 5% glucose

Sümpelmann R et al. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children, Paediatr Anaesth 2010

Glucose concentration Perioperative use of infusion solutions containing No glucose 1% glucose Normal blood gluc conc 2.5% glucose 4% glucose Hyperglycemia, 5% glucose Dilutional hypoNa

Sümpelmann R et al. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children, Paediatr Anaesth 2010 Au A et al. Incidence of postoperative hyponatremia and complications in critically ill children treated with hypotonic and normotonic solutions. J Pediatr 2008

Perioperative hyponatremia

Prevalence of up to 31% in surgical children

Perioperative hypoNa

ADH Osmotic and non- osmotic stimuli

Increased ADH

secretion

Extracellular compartment

Intracellular compartment

Na molecules

Belgian recommendations of perioperative iv fluid

Najafi et al. Belgian recommendations on perioperative maintenance fluid management of surgical pediatric population. Acta Anaesth Belg 2012,

Minor surgery Or

Day- case surgery

Intra- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume

Post- operative period Isotonic fluid + Glucose 5% First 24 h post op: - 70% of the maintenance volume - Isotonic replacement fluids as needed After 24h: full maintenance volume

Intra- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume Isotonic replacement fluids as needed

Post- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume Allow to drink and to eat ASAP

Major surgery Or

Nil- by- mouth ≥ 24 h post op

Take home messages

Considering iv. fluids as medications Prescribing fluid volume and composition appropriately Using isotonic solutions instead of hypotonic solutions

during the intraoperative and postoperative period Restricting the administration of hypotonic solutions to

very specialized clinical areas based on careful monitoring of plasma electrolytes

Take home messages

Administering isotonic fluids as a bolus in the event of hypovolemia

Monitoring plasma electrolytes and glucose concentration regularly

Considering these recommendations as a framework that

should be adapted to clinical situations of each child

http://www.google.be/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fwww.123rf.com%2Fphoto_8989138_stone-question-mark-at-water--3d-illustration.html&ei=wco3VZXxMIPsasrUgegJ&bvm=bv.91071109,d.d2s&psig=AFQjCNHXj0ZviUWdzQAsNKPFKTf0EpG3tA&ust=1429806027770502