Perioperative Fluid Management in

childrenPresenter-Dr. Bunty Sirkek

Moderator-Prof. Dr. Ajay Sood

TOTAL BODY WATER ECF compartment ICF compartment

Vary with ageOsmolarity remains constant, only fluid

fraction changes

Body fluid compartments

TOTAL BODY WATER ( 28 wk – 80 %

INFANTS – 70 – 75 %

OLDER CHILDREN & ADULTS – 60 -65 %)

ICF- 2/3 rd OF TBW

30 – 40 % OF wtECF -1/3 rd OF TBW

50 % OF wt AT BIRTH

20 – 25 % OF wt IN ADULTS

PLASMA- 4-5% OF wtINTERSTITIAL FLUID-16 % OF wt

TRANSCELLULAR FLUID

1 – 3% OF wt

CSF

AQ. & VITREOUS HUMOR

SYNOVIALFLUID

PERITONEAL FLUID

PLEURAL FLUID

To supply water and thereby create enough urine volume to excrete solutes

To replace insensible fluid losses To replace electrolytes lost from urine,

skin,or gut To satisfy caloric needs ,reducing tissue

catabolism and providing a more normal ratio of carb,fat,and protein for energy

To supply necessary vitamins and minerals

Aim of fluid therapy

RATE OF CALORIC EXPENDITURE & GROWTH

RATIO OF SURFACE AREA TO BODY WEIGHT

DEGREE OF RENAL FUNCTION MATURATION &REDUCED RENAL CONC. ABILITY

AMOUNT OF TOTAL BODY WATER

Fluid requirements of children are greater than adults

BASED ON BODY S.A. BODY WEIGHT CALORIC CONSUMPTION CALORIMETRY

Assessment of fluid requirement

BODY SURFACE AREA-CALORIC EXPENDITURE IS PROPORTIONAL

TO BSA

BODY WEIGHT- WEIGHT HRLY 24 HRLY <10 Kg 4ml/Kg 100ml/Kg 11 -20 40ml+2ml/Kg>10 1000ml +

50ml/kg>10 >20 Kg 60ml+1ml/Kg>20 1500+20ml/Kg>20

BASED ON CALORIC CONSUMPTION(HOLLIDAY &SEGAR)WEIGHT CALORIC EXPENDITURE0 -10 100kcal/kg/day10-20 1000+50kcal/kg

above10kg>20 1500+20kcal/kg above

20kg

FOR EVERY 100 CALORIES CONSUMED 67 ml of water for solute excretion 50 ml/100 kcal for insensible loss 17 ml produced by oxidation

THUS 67+50-17=100 100ml of water for 100 kcal OR 1ml fluid per 1kcal requirement

BODY WEIGHT FLUID REQUIREMENT(HOLLIDAY & SEGAR) 0 -10 Kg : 4 ml / Kg /hr 10 -20 Kg : 40ml +2ml/Kg/hr above 10 kg >20 Kg : 60 ml+1ml/Kg/hr above 20 kg

CALORIMETRY-LINDAHL FORMULA

CALORIE REQUIRED-1.5 * kg +5 (kcal/hr) FLUID REQUIRED – 2.5 * kg +10 (ml/hr) Na+ REQUIRED – 0.045*k+0.16(mEq/hr) K+ REQUIRED – 0.03 * kg +0.1 (mEq/hr)

NORMAL LOSSES AND MAINTENANCE REQUIREMENTS FOR FLUID,ELECTROLYTES, AND DEXTROSE IN INFANTS AND CHILDREN

H2O = 100 TO 125 mL/100kcal EXPENDED

COMPONENTS: INSENSIBLE LOSS (mL) 45

SWEAT (mL) 0 TO 25

URINE (mL) 50 TO 75

STOOL (mL) 5 TO 10

FOOD OXIDATION (mL) 12

Na+= 2.5 mmol/100 kcal EXPENDED

COMPONENTS: BODY GROWTH

SWEAT VARIABLE

URINE VARIABLE

STOOL VARIABLE

K+ = 2.5 mmol/100 kcal EXPENDED

COMPONENTS: AS FOR Na+

Cl- = 5 mmol/100 kcal EXPENDED

COMPONENTS: AS FOR Na+

DEXTROSE = 25g/100 kcal EXPENDED

COMPONENTS: BASAL METABOLIC RATE

GROWTH AND TISSUE REPAIR

PHYSICAL ACTIVITY

MAINTENANCE SOLUTION (PER LITRE OF WATER)

DEXTROSE (g) 50 K+ (mmol) 25

Na+ (mmol) 25 Cl- (mmol) 50

Fluid management is divided into 3 phases-o Deficit therapyo Maintenance therapyo Replacement therapy

Fluid management in children

Management of fluid & electrolyte losses before pts. presentation for surgery

Fluid deficits due to overnight fasting 3 components 1.severity of dehydration 2.type of fluid deficit 3.repair of deficit

Deficit therapy

Signs and symptoms

Mild Moderate Severe

Weight loss (%) 5 10 15

Deficit (ml /kg) 50 100 150

Appearance Thirsty,restless,alert

Thirsty,restless,lethargic,but arousable

Drowsy to comatose,cold,limp,cyanosed

Skin turgor normal decreased Markedly,decreased

Mucous membranes

Moist dry Very dry

Anterior fontanelle

normal sunken Very sunken

Pulse normal Rapid & weak Rapid& feeble

BP normal Normal/low low

Respiration normal deep Deep & rapid

Urine output(ml /kg/ h)

<2 <1 <.5

Assessment of dehydration

TYPE OF DEHYDRATION ISOTONIC HYPOTONIC HYPERTONIC

ISOTONIC DEHYDRATION-

• S.Na+ LEVELS-NORMAL

• RESULT IN ECF DEFECIT

• CAUSES-GI LOSSES,PLEURAL EFFUSION

• Rx – BSS

HYPOTONIC DEHYDRATION-

• INAPPROPRIATE SELECTION OF I/V FLUIDS /HYPOTONIC FLUID OVERLOADING

• Rx – MILD- ISOTONIC SALINE SOL.

SEVERE- 3% SALINE

ABNORMAL LOSSES-

DI

OSMOTIC DIURESIS

EXCESSIVE SWEATING

VOMITING

INADEQUATE INTAKE OF WATER

VOMITING

DISEASES OF PHARYNX ,ESOPHAGUS ,CNS

HYPERTONIC DEHYDRATIONS.Na+ LEVEL- ↑

EC &ICF EQUALLY AFFECTED CAUSES - ABNORMAL LOSSES

INADEQUATE INTAKE OF WATER Rx – 2.5 -5% D

ALL DEGREE OF DEGREE OF DEHYDRATION / HYPOVOLEMIA MUST BE CORRECTED BEFORE INDUCTION OF ANAESTHESIA UNLESS THE NATURE OF ILLNESS & OPERATION PRECLUDE THIS

REPLACEMENT VOLUME (L)

% DEHYDRATION * TBW +DAILY MAINTENANCE FLUID

% DEHYDRATION = IDEAL WT – PRESENT WT

IDEAL WT FOR AGE

HYPOVOLEMIA (LOSSES FROM IV SPACES) BOLUSES OF ISOTONIC SALINE/COLLOID BLOOD IF- Hb IS LOW & >40 ml/Kg OF FLUID IS

REQUIRED DEHYDRATION(TOTAL BODY WATER LOSS)

SHOULD BE CORRECTED SLOWLY PREFERABLY BY ORAL ROUTE IF TOLERATED & TIME

ALLOWS,OTHERWISE I/V

RAPID REHYDRATION TECHINQUE- (ASSADI & COPELOVITCH)

INITIAL RAPID INFUSION OF NS TO CORRECT HYPOVOLEMIA SLOWER CORRECTION OF DEHYDRATION OVER 24-72 hrs WITH 0.9%,0.45%,OR 0.25% SALINE

REPLACE FOR NPO DEFICITMAINTENANCE FLUIDONGOING LOSSES & THIRD SPACE LOSSES

INTRAOPERATIVE FLUID THERAPY

• NPO GUIDELINES FOR PAEDIATRIC PATIENT

SOLID FOOD 6HRS

MILK 4HRS

CLEAR FLUIDS 2HRS

ESTIMATED FLUID DEFICIT hrs of NPO * hourly fluid requirement

FLUID INFUSION RATE 1st hr =1/2 of EFD + maintenance fluid +

losses 2nd hr =1/4 of EFD + ” 3rd hr = ¼ of EFD + ”

EFD & Losses are replaced with balanced salt solution

Maintenance Fluid--5%D IN N/2 –N/5 2.5% IN N/2 – N/5

COMPOSITION OF REPLACEMENT FLUIDS CHO Prot. Cal/L Na+ K+ Cl- HCO3

- Ca2+ OSM

LIQUID (g/100mL) (mEq/L) (mg/dL)

D5W 5 -- 170 -- -- -- -- -- 255 D10W 10 -- 340 -- -- -- -- -- --

NORMAL SALINE -- -- -- 154 -- 154 -- -- 308

(0.9%NaCl)

½ NORMAL -- -- -- 77 -- 77 -- -- --

SALINE(0.45% NaCl)

D5(0.2%NaCl) 5 -- 170 34 -- 34 -- -- --

3%SALINE -- -- -- 513 -- 513 -- -- --

8.4% SODIUM -- -- -- 1000 -- -- 1000 -- --

BICARBONATE

(1 mEq/mL)

RINGER’S 0 to 10 -- 0 to 340 147 4 155.5 -- 4.5 273

RINGER’S LACTATE 0 to 10 -- 0 to 340 130 4 109 28 3 --

AMINO ACID -- 8.5 340 3 -- 34 52 -- --

8.5%(TRAVASOL)

PLASMANATE -- 5 200 110 2 50 29 -- --

ALBUMIN -- 25 1000 150 to 160 -- <120 -- -- --

25%(SALT POOR)

INTRALIPID 2.25 -- 1100 2.5 0.5 4.0 -- -- --

Acute sequestration of fluid to a nonfunctional compartment

Occurs in –surgical trauma blunt trauma burns infections

Vary with surgical proceeduresTYPE OF SURGERY 3rd SPACE LOSSIntra abdominal. 6-10ml/Kg/hrIntra thoracic 4-7ml/Kg/hrSuperficial/eye surg 1-2ml/Kg/hrneurosurgery

INTRAOP THIRD SPACE LOSSES

Allowable blood loss It is important to have a

plan for blood-loss replacement based on the child’s preoperative condition, haematocrit and nature of the surgery.

ABL = weight x EBV x (H0 – H1)/Ha

Where H0 = patient’s original haematocrit,

H1 = lowest acceptable haematocrit,

and Ha = the average

haematocrit =(H0 +H1)/2

IN CHILDREN ALL BLOOD LOSS SHOULD BE REPLACED

WITH PRBC,WB,COLLOID CRYSTALLOIDS IF CRYSTALLOID IS USED- EACH 1ml OF BLOOD

LOST TO BE REPLACED BY 3 ml OF FLUID DAVENPORT’S LAW-

FOR <10% BLOOD LOSS- NO BLOOD REQUIRED >20% LOSSES MUST BE REPLACED BY PACKED CELLLS

OR WB 10-20% CONSIDER CASE BY CASE

REPLACEMENT OF BLOOD LOSS

Skin color, mucus membrane, nail beds-anaemia, low cardiac output, hypothermia,hypoxia

Blood Pressure

Pulse Rate

CRITICALLY ILL/COMPLEX PROCEDURE INVASIVE BP MONITORING BLOOD GASES Hct, RBS S.ELECTROLYTES &PROTEINS

Urine output& Urine Na+ levels

CVP Monitoring

MONITORING INTAOP. FLUID THERAPY

Maintain iv drip till child is NPO Loss of ECF due to Ryle’s tube,fistula

drainage to be replaced by BSS Blood loss monitored and replaced if

necessary Maintain U.O >0.8 ml/kg /hr

POSTOPERATIVE FLUIDS

FEVER ↑ CALORIE REQURIMENT BY 12% FOR EACH 1ºC RISE IN TEMP

HYPOTHERMIA ↓ FLUID REQUIREMENT HYPERMETABOLIC STATES ↑ CALORIE

REQUIREMENT BY 25 -75% HYPOMETABOLIC STATES ↓ REQUIREMENT BY 10-

25% STOOL WATER LOSS DOUBLED BY

PHOTOTHERAPY RADIANT WARMERS ↑TRANS EPITHELIAL LOSS BY

50-140% PLASTIC COVERING↓LOSS BY 50-70% IF VENTILATION WITH NONHUMIDIFIED GASES

ADD 5ml/Kg/hr FOR RESPIRATOY FLUID LOSS

ADJUSTMENT REQUIRED IN FOLLOWING CASES

MAJORITY OF FIT PAEDIATRIC PATIENT UNDERGOING MINOR SURGERY RE-ESTABLISH ORAL INTAKE IN EARLY POSTOP.PHASE AND NOT NEED ROUTINE I/V FLUIDS

HYPOTONIC FLUIDS SHOULD BE USED WITH CARE & MUST NOT BE INFUSED IN LARGE VOLUMES OR AT GREATER THAN MAINTENANCE RATES

HYPOVOLEMIA SHOULD BE CORRECTED WITH RAPID INFUSION OF SALINE WHILE DEHYDRATION CORRECTED SLOWLY

ONGOING LOSSES SHOULD BE MEASURED & REPLACED

PLASMA ELECTROLYTES & GLUCOSE SHOULD BE MEASURED REGULARLY IN ANY CHILD REQUIRING LARGE VOLUMES OF FLUID OR WHO IS ON I/V FLUIDS FOR >24HRS

CONCLUSION

Thankyou