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& feebleBP normal Normal/low lowRespiration normal deep Deep & rapidUrine 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