Lecture Content

I. Fluid Resuscitation

Fluid resuscitation and perioperative fluid therapy

COTWAF, Chennai, 20 22 February 2008
Dr Thomas Engelhardt, MD, PhD, FRCA Royal Aberdeen Childrens Hospital, Scotland Children

II. Maintenance fluid requirements III. Perioperative fluid management IV. Controversies and recommendations

Fluid resuscitation
PALS APLS EPLS

Symptoms and signs of dehydration

CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT IN CHILDREN Sept 2007

Judge severity of dehydration

Fluid resuscitation
APLS Algorithm Type of fluids IV access

Fluid resuscitation

IV access large bore ? central

COOK Jamishidi needle Sherwood Illinois needle

Fluid resuscitation

Fluid resuscitation
Dehydration Assessment

APLS: oral rehydration

Fluid resuscitation
POCA registry 1994-2004

Fluid resuscitation

Bhananker, Anesth Analges, 2007

Bhananker, Anesth Analges, 2007

Maintenance fluid requirements

Aspects of perioperative fluids

Maintenance fluid requirements

Volume Electrolytes Glucose

Lack of large prospective randomised controlled clinical trials

Holliday & Segar, Pediatrics 1957; 19: 823-32

Maintenance fluid requirements

Maintenance fluid requirements

Holliday Segar: 4-2-1 Rule

Example 15 kg child: (4 x 10) + (2 x 5) = 50 ml per hour (100 x 10) + (50 x 5) = 1250 ml per day (52 ml/hr)

Energy expenditure 50% lower during anaesthesia

Lindahl SG, Anesthesiol 1988; 69: 377

Maintenance fluid requirements

APA consensus statement:
Maintenance

Maintenance fluid requirements

Electrolytes daily requirements:
Sodium: Potassium: Chloride: 3 mmol/kg 2 mmol/kg 2 mmol/kg

fluid requirements should be calculated

according to the recommendations of Holliday and Segar for children and infants older than 4 weeks of age, using body weight. It is important that all formulae should be used as a starting point only and the individual childs response to fluid therapy should always be monitored and appropriate adjustments made.

Hypotonic solution
Holliday, Pediatrics 1957; 19: 823-32

Glucose 4% - iso-osmolar painless injection

Hypotonic solution

Maintenance fluid requirements

Hyponatraemia
Mild: Severe: 125-130 mmol/l <125 mmol/l

Maintenance fluid requirements

Hyponatraemia
Mild: Severe: 125-130 mmol/l <125 mmol/l

Causes
Hypotonic fluid administration Impaired free water elimination (ADH secretion) ADH secretion: Haemorrhage, relative hypovolaemia, pain, stress, nausea, sleep, morphine NSAIDs

Causes
Hypotonic fluid administration Impaired free water elimination (ADH secretion) Brain injuries/ tumours

Maintenance fluid requirements

Hyponatraemia consequences

Maintenance fluid requirements

DEATH
Decreasing levels consciousness Disorientation Nausea & vomiting Seizure activity
J Pediatr Urol. 2008; 4: 231-3. Acta Otorrinolaringol Esp. 2006; 57: 247-50. Pediatr Nephrol. 2005; 20: 1687-700. Ann Fr Anesth Reanim. 2000; 19: 467-73. Int J Pediatr Otorhinolaryngol. 1994; 30: 227-32.

DEATH

Maintenance fluid requirements

Glucose too little or too much

Maintenance fluid requirements

Glucose Hypoglycaemia risk

Lacking glycogen storage of adults Risk of hypoglycaemia / brain damage neonates

Neonates first 48 hours of life Interrupted glucose infusion Long term TPN
Larsonn LE et al. Br J Anaesth 1990: 64: 419

Osmotic diuresis/ dehydration and electrolyte imbalance Neurological deficits in cardiac surgery Worse hypoxic ischaemic brain or spinal cord damage

Maintenance fluid requirements

Hypoglycaemia APA consensus guideline (2007)
Majority of children over 1 month of age will maintain a normal blood sugar if given non-dextrose containing fluids during surgery Children at risk of hypoglycaemia are those on parental nutrion or dextrose containing solution, low body weight (<3rd centile) or surgery longer than 3 hours

Maintenance fluid requirements

Ideal maintenance fluid

S ON C Give dextrose containing solutions or need to monitor blood

glucose level

S SU EN

Y NL O

Near isotonic (Saline 0.9%, Lactated Ringers or Hartmanns) Maintain blood glucose
? 1% dextrose containing solutions (Murat I. Pediatr Anesth 2007; 18: 363)

Plasma osmolarity 280-300 mosm/l Thrombophlebitis risk small <450 mosm/l

Maintenance fluid requirements

Ideal maintenance fluid
Solution Osmolarity mosm/l Tonicity mosm/l Na+ K+ Ca2+ ClHCO3-

Maintenance fluid requirements

Operative period Fluid choice Number of anaesthetists (%)

Intraoperative fluid maintenance

Hypotonic dextrose saline solutions Dextrose 4%/saline 0.18% Dextrose 2.5 or 5%/saline 0.45% 99 (50%) 31 (15.7%)

Hartmanns 980ml +Glucose 50% 20mls (1% glucose final concentration) Hartmanns 950ml +Glucose 50% 50mls (2.5% glucose final concentration) Hartmanns 900ml +Glucose 50% 100mls (5% glucose final concentration)

Isotonic solutions

352

272

127

4.9

1.96

109

28
Bolus for hypovolaemia

Hartmann's solution Saline 0.9% Hypotonic dextrose saline solutions Isotonic solutions (saline 0.9%, Hartmann's or colloid)

72 (36.4%) 48 (24.2%) 22 (11.1%)

646

264

124

4.75

1.90

105

28

intraoperatively Postoperative fluid maintenance

161 (81.3%)

Hypotonic dextrose saline solutions Dextrose 4%/saline 0.18% 130 (65.7%) 43 (21.7%)

650

250

117

4.5

1.80

100

26

Dextrose 2.5 or 5% Isotonic solutions Hartmann's solution

with saline 0.45%

25 (12.6%) 24 (12.1%)

Thornton KL. BJA 2006; e-letters

Way C Br J Anaesth 2006; 97:371

Saline 0.9%

Perioperative fluid managament

Aspects of perioperative fluid management

Perioperative fluid managament

Existing fluid deficits Fasting (APA consensus)

Existing fluid deficits Maintenance fluid requirements Losses (blood loss, 3rd space)

Clear fluids: Breast milk: Solids:

2 hours 4 hours 6 hours

Dehydration without hypovolaemia slow correction Hypovolaemia rapid correction

450

Perioperative fluid managament

Excessive Fasting

57.8 %
400 350 300 250

Are you hungry or thirsty?

33.9 % 29.9%

Hunger
Severity n= 698 Fasting times (h)
1 268 12:44 (3:36) 2 135 11:12 (4:27) 3 194 10:40 (4:44) 4 101 10:22 (4:47) 1 94 9:27 (4:50)

Thirst
2 115 9:04 (5:04) 3 281 9:51 (4:59) 4 208 10:08 (5:24)

200 150 100 50 0

23.8 %

6.1 %

Engelhardt T. ASA 2008; A1012

Very Hungry

Very Thirsty

Hungry & Hunger Thirsty Alone

Thirst Alone

Engelhardt T. ASA 2008; A1012

Perioperative fluid managament

Replacement fasting deficits
Halliday Segar formula (4-2-1) rule Replace at least half fasting deficits in first hour
15 kg child 10 hour fasted: Deficit Replace at least half in first hour Add hourly maintentance (50 ml) 1st hour fluids 10 hours x 50 ml = 500 ml = 250 ml + 50 ml = 300 ml
Yaster M, COTWAF 2007

Perioperative fluid managament

Replacement fasting deficits
Halliday Segar formula (4-2-1) rule Replace at least half fasting deficits in first hour
45 kg child 10 hour fasted: Deficit Replace at least half in first hour Add hourly maintentance (50 ml) 1st hour fluids 10 hours x 85 ml = 850 ml = 425 ml + 85 ml = 510 ml
Yaster M, COTWAF 2007

Perioperative fluid managament

Perioperative fluid losses

Perioperative fluid managament

Perioperative fluid losses
Blood losses

Blood losses Insensible/ 3rd space losses Crystalloids/ colloids debate

Low cost, no effect on coagulation, no anaphylactic reaction

Replacement: 1:1 blood/ colloid or 3:1 crystalloid (use colloids after 50ml/kg) Estimated blood volume = weight (kg) x
Premature Term neonate 100 ml/kg 90 ml/kg 80 ml/kg 75 ml/kg 65 ml/kg

Choice of colloids
Gelatins/ Albumin / Starches (limit quantities)

VPC = Hct x weight (kg) x (1.5)

6 months 1 year Teenager

Perioperative fluid managament

Perioperative fluid losses
Insensible/ third space losses
Body surface surgery Major laparotomy Necrotizing enterocolitis 1ml/kg/h 15-20ml/kg/h 50ml/kg/h

Perioperative fluid managament

15 kg child 10 hour fasted, major laparotomy: Deficit Replace at least half in first hour Add hourly maintentance (50 ml) Insensible losses 1st hour fluids 15 ml x 10 ml/kg/h 10 hours x 50 ml = 500 ml = 250 ml + 50 ml + 150 ml = 450 ml

Use isotonic solutions only (0.9% Saline, Hartmanns) Hyperchloraemic metabolic acidosis (? benign)
Yaster M, COTWAF 2007

Perioperative fluid managament

Perioperative fluid managament

Postoperative fluid management
= 850 ml = 425 ml + 85 ml

45 kg child 10 hour fasted, major laparotomy: Deficit Replace at least half in first hour Add hourly maintentance (50 ml) Insensible losses 1st hour fluids 85 ml x 10 ml/kg/h 10 hours x 85 ml

Early oral intake

Superhydration reduced PONV (Goodarzi M Pediatr Anesth 2006; 16: 49)

+ 850 ml = 1360 ml

Delayed oral intake

Provide basic metabolic requirements (4-2-1) Replace ongoing losses (isotonic fluids)

Yaster M, COTWAF 2007

Controversies and recommendations

Controversies
Volume of maintenance
80 % of 4 - 2 1

Controversies and recommendations

Recommendations
Avoid dehydration and correct hypovolaemia Consider fluid composition
Compromise between sodium, energy requirements and osmolarity

Composition of fluids
Provide basic metabolic requirements (4-2-1) Replace ongoing losses (isotonic fluids)

Monitor sodium and glucose daily in acute patients Risk of hypoglycaemia small (except neonates, TPN) Beware hidden fluid administration (drugs) Beware hyponatraemia

Controversies and recommendations

Further readings
APA consensus guidelines (2008) Murat I et al Pediatr Anesth 2008; 18: 363-370. Lonnqvist PA Pediatr Anesth 2007; 17: 203-205. Cunliffe M et al Br J Anesth 2006; 97: 274-277.

CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT IN CHILDREN Sept 2007

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