PERIOPERATIVE FLUID

MANAGEMENT IN CHILDREN

Presented By: Dr. Sourav Saha

(1st year PGT)
Moderated By: Dr. Ranjit Reang
(Asst. Proff)
Physiology:
 Water is the most abundent single constituent of the
body.

 Water accounts for about 60% of the weight in an

adult man and about 50% of the body weight in an
adult woman.

 The difference is due to increased body fat reflecting

decreased water content in adipose tissue.
 Body fluid are divided into intracellular and extracellular
compartments.
 Approximately two-third of TBW constitute intracellular
fluid.

 Rest one-third is extracellular fluid.

 Extracellular fluid id divided into interstitial fluid and

intravascular fluid.

 Most of the intestitial fluid is held in gel structure in

between the cells. Others are CSF, gastroistestinal fluid
and fluid in potential space(pleural fluid, pericardial fluid,
peritoneal fluid, synovial fluid)
Fluid physiology difference between adult
and children:
 TBW is different in children from adult.
 Total body water content changes drastically from
before birth until one year of age.

 At 24 weeks gestational age, a baby’s total body

water content is close to 80% of total body weight.

 This slowly decreases due to gradual increase in fat

and muscle mass until the child is around one year of
age, when total body water content is about 60% of
total body weight.
 In addition to total body water differences, the
percent of body weight accounted for intracellular
and extracellular water also changes.

 Newborn babies have more extracellular water—

45% of total body weight—compared with only 35%
of total body weight that is intracellular water.

 These changes in total body fluid have important

implications for drug therapy, particularly for water
soluble drugs.
 Drugs generally distribute into the
extracellular space, thus the larger
extracellular component of fluid in neonates
also contributes to the need for larger doses.
Different intravenous fluids:
 Crystalloids:
1. They are aqueous solution of ion with or without
glucose considered as the initial resusitating fluid in
patients.

2. Mostly intraoperative fluids are isotonic crystaloid

solution like NS orbalanced electrolyte solution like
lactated ringer solution or plasmalyte.

3. NS in large volume can cause hyperchloramic metabolic

acidosis due to high Cl- content & lack of bicarbonate &
may lead to perioperative acute kidney injury.
4. An addition of 1–2.5% glucose in order to avoid
hypoglycaemia.

5. Many a time, neonates and infants present to

operating room with various paediatric solution
infusions (Isolyte P, D5%+ NS0.45%., etc.)

6. Their advantages include low cost, lack of effect on

coagulation, no risk of anaphylactic reaction and no
risk of transmission of any known or unknown
infectious agent.
 Colloids:
1. They are osmotically active high molecular weight
substance.

2. Their intravascular half life is 3-6 hrs.

3. They are used in severe intravascular fluid deficit or

severe hypoproteinaemia.

4. They are derived from either plasma protein or

synthatic glucose polymer supplied in isotonic
electrolyte solution.
5. Synthetic colloids are gelatin or dextrose starch.

6. Gelatin are associated with histamine mediated

allergic reactions.

7. Albumin occurs naturally and is regarded as the

colloid “gold standard.” An albumin 5% solution is
osmotically equivalent to an equal volume of plasma,
whereas a 25% solution causes intravascular volume
expansion 3–5 times because of fluid translocation
from the interstitial compartment.
Intraoperative fluid therapy in children:
 Pediatric patients have higher fluid requirement than
adults.
 There are multiple reasons behind this-
1)First, the higher metabolic rate of children
requires a greater caloric expenditure, which
translates into higher fluid requirements.

2) Secondly, children, especially infants, have a much

higher body surface area to weight ratio, and this
translates into relatively more water loss from skin
compared with adults.
3) In addition, children, especially infants, have higher
respiratory rates, and this equates to higher
insensible losses from the respiratory tract.

4) Congenital abdominal wall defects such as

omphalocele and gastroschisis can lead to higher
evaporative losses before surgical correction, and
thus careful attention should be paid to fluid and
electrolyte balance.
 So, meticulous attention to fluid intake and loss is
required in pediatric patient because they have
limited margin of error.

 Fluid therapy can be divided into:-

a) maintainance
b) deficit correction
c) loss replacement
a) Maintainance:-
 The basis for calculating maintainance fluid derived
from by Holliday and Segar.

 They found that daily fluid requirements directly

depend on metabolic demand- specifically, that 100
ml of water is required for 100 cal of expanded
energy.

 Relating this to weight produces hourly fluid

requirement of-
 1) 4 ml/kg/hr upto 10 kg
2) 2ml/kg/hr for next 10 kg.
3) 1 ml/kg/hr above 20 kg.

 A solution such as D5 + ½ NS with 20 mEq/L of

potassium chloride is preferable.

 D5 + ¼ NS may be a better choice in neonates because

of their limited ability to handle sodium loads.

 Children below 8 years require 6 mg/kg/min to maintain

euglycaemia and premature neonates require 6-8
mg/kg/min.
 The original Holliday and Segar formula would be
problematic for children with acute illness or
signicant renal or cardiac dysfunction.

 So, it is recommended to administer 20-40 ml/kg of

balanced salt solution during the course of the
anaesthesia. Postoperative fluid management should
be reduced to 2, 1, 0.5 rule with isotonic fluid. If after
12 hrs the child is unable to convert to oral intake,
than a standerd hypotonic solution is initiated at the
4-2-1 rule rate to avoid hypernatremia.
b) Deficit correction:
 In addition to maintainance, any preoperative fluid
deficits must be replaced.

 As a result of the fasting state, children are presumed

to develop preoperative fluid deficits secondary to
continuing insensible losses and urine output.
 Preoperative fluid deficit administered with hourly
maintainance in a ratio of 50% in first hour and 25%
in second and third hour.

 It is done with balanced salt slution. Glucose in

omitted to avoid hypoglycaemia.
Fasting guidelines for children:
 Following fasting and sensible fluid loss child may
develop dehydration.
 Estimation of degree of preoperative dehydration is
based on classical clinical signs.
 The most important sign of normal hydration status
is kidney function. Thus, monitoring of urinary output
is essential for evaluating and treating any fluid
deficit.
 Correction of 1% of dehydration requires about 10
ml/kg of fluids.
 Rate of fluid administration depends on seriousness
and on rapidity of dehydration.
Clinical assessment for degree of
dehydration:
c) Loss replacement:
 Blood loss:
a)It can be easily measured by amount of blood
collected in suction jar, guazes used and amount of
irrigation fluid used. A fully soaked (45×45cm) guaze
contains about 120-150 ml of blood.

b) For calculation of loss replacement, we need to

know Maximal Allowable Blood Loss(MABL) for a
child.
MABL= EBV ×{(starting hematocrit-target
hematocrit)÷starting hematocrit}
-EBV:- Estimated blood volume
-MABL would be replaced by 3 ml RL per ml of
blood loss or 1 ml colloid per ml of blood loss.

c) If blood loss is equal to or less than MABL, then no

need of blood transfusion.

d) If the child has reached the MABL and significant

more blood loss is expected during surgery, then
PRBC has to be transfused to make hematocrit in
20% to 25%.
Volume of PRBC to be transfused=
{(desired HCT-present HCT)×EBV}÷HCT of
PRBC(60%)

 Third space loss:- they could not be measured

accurately. So they are replanished according to
surgical procedure like
a) minor procedure like herniotomy- 1 ml/kg/hr
b)major procedures like surgical repair of
gastroschisis- 15 ml/kg/hr
Monitoring of Fluid therapy:-
 In pediatric patients monitering of fluid therapy is
very important as they have limited margin of error.

 Clinical examination is the most imp measure, for

example-
a) Weight of the child
b) Urine output
c) periorbital edema
d) Bl Basal crepts in both lungs
 For example:
 A child of 25kg will be undergoing herniotomy. He
is on 6 hr fasting without any signs of dehydration.
Surgery expected to last for 1 hr with minimal
blood loss.

 So maintainace fluid is 65 ml/hr

 Deficit is (65×6)= 390 ml, out of which 195 ml to
be transfused in 1 hr rest in next 2 hr.
 Loss replacement is 25ml/hr
 So, during 1 hr of operation about 285 ml fluid to
be transfused.
 Other invasive measures like:-
a) Central Venous pressure
b) Pulmonary artery pressure monitering

 Non invasive fluid therapy guidence by arterial pulse

contour analysis and estimation of stroke volume by
using:-
a) Esophageal doppler
b) Transesophageal echocardiography
c) Transthoracic echocardiography.
Thank You
Next Topic:- Death in operation table-
How to resolve?
Date:22/11/19
presenter- Dr. Tapan Debbarma.