The Endocrine &

Metabolic response
to Stress in
Neonate / pediatrics

Poerwadi , Pediatric Surgeon

TRAUMA

ilness
a pt
Ad tur
Ma e/
z
Si ap
sh
e

ia
s
e
h
st
Ane ery
g
Sur

GROWTH DEVELOPMENT

Critical
WOUND HEALING

(ACTH), TSH,
NE/E
Vasopressin,ADH,
GH, and prolactin
release

Afferent

Stres

Nociceptors
chemoreceptors,
baroreceptors

efferent fibers via the parasympathetic

and sympathetic NS the periphery,
neuromuscular junctions in the
circulatory system & receptors at
end-organs, which stimulate the
release of peripheral hormones.

Stres

nocic
ep
emore torsch
c
baror eptors,
ecept
ors

MECHANISMS
OF HORMONE
RELEASE

(a) Humoral: in response to changing

levels of ions or nutrients in the blood
(b) Neural: stimulation by nerves
(c) Hormonal: stimulation received from
other hormones

Hypothalamus__
Anterior pituitary__
_____________Posterior pituitary
(adenohypophysis)
(neurohypophysis)

toperative or posttraumatic :

morbidity & mortality correlated with the

magnitude and duration of the endocrine and
metabolic response
to the
stressful
event.
Severe
weight
loss,
Complicatio
ns :

Cardiopulmonary insufficiency,
Thromboembolic disorders,
Gastric stress ulcers,
impaired Immunologic function,
prolonged convalescence, or
death

. have been related to aspects of the hormonal

7
and metabolic

The hormonal and metabolic response to

stress
( neuro endocrie reflexs) in the neonate &
These hormonal and metabolic responses to stress in
Child
adults have been the subject of laboratory and clinical
investigation for the past century, however similar

in newborn infants are not as

adaptation
well documented.
responses

Neonates have welldeveloped neural

pathways for pain !!!

immature organs
size
growth &
development
thin subcutan fat

RESPONSE

Morbidity & Mortality

Endorphins
Stress
hypothalamic receptors

sympathetic nervou
system response

Catecholamine ,
Endorphines secretion

Neonates have well-developed neural pathways for

pain !!!
These substances have been shown to be elevated
in neonatal blood following periods of stress and
in amniotic fluid during periods of fetal distress .
Altered beta-endorphin levels have also been
demonstrated in neonatal with septic shock

Stress

Pituitary hormones
Anterior and posterior pituitary
hormones including ACTH,
growth hormone, and arginine
ADH are liberated in the adult
stress response
No perioperative data for
neonates have been reported.
Boix-Ocha et al.(recently )
published a study examining
the cortisol response to
operative stress in neonates
and the response to
exogenously administered
ACTH .
He demonstrated significant
increases in cortisol levels
following ACTH administration

Catecholamines (CA)
STRESS E / NE >> (in adult patients), are
responsible for the initiation of the stress-related
catabolic response.
Studies investigating in neonates are :
Nakai and Yamada : CA level in asphyxia neonates
2X >>>
Anand et al : CA response to surgery (A highly
significant
increase in plasma E/NE concentrations
Pancreatic
was
documented at the end of surgery.
hormones
.

1.Insulin

Ross : plasma insulin levels

intraoperatively <<
( adult) & elevated at
postoperative period
Anand and Aynsley-Green : no
significant changes in the plasma
insulin levels
of pre-term
neonates,
Preterm
neonates
:
( same adult
in aterm )

immature pancreas
Hyperglycemia

2. Glucagon
Post OP :
Significant
elevations in
plasma glucagon
concentrations
(adult)
to increase in glucose production :
( glucagon acts on skeletal muscle to cause amino acid
mobilization , stimulate gluconeogenesis, increase urea
production, replenish hepatic cell mass, and lead to the
production of acute-phase reactant glycoproteins)

Anand et al : in term neonates

NO significant alteration in plasma glucagon levels during
or soon after surgery) 24 h postoperatively a significant
decrease from preoperative values had occurred

Adrenocortical hormones:
1.Cortisol

major mediators of the posttraumatic metabolic respo

ution of glucocorticoids to changes the substrate pro
Adult : cortisol acts directly on adipose tissue
lipolysis and the release of free fatty acids .
mobilization of amino acids from skeletal muscle,
stimulation of glucagon production, and augmentation
of
catecholamine-induced hepatic glycolysis, cortisol
alsoinfluences
It is well established that glucocorticoid hormones,
the hyperglycemic
primarily
cortisol, arestate.
crucial in the metabolic
response to surgical stress in the adult, modulating
the breakdown of proteins and leading to the
release of gluconeogenic amino acids from skeletal

NEONATUS ?
Solomon et al. : the adrenocortical response to
operative stress neonates has DELAYED progress
Anand et al.
: demonstrated that the adrenocortical
responses of premature babies were diminished secretion
( immaturity of the steroid biosynthetic process )
Boix-Ocha :
(1) neonates did not have the normal adult circadian cycle
of plasma cortisol levels (this difference was postulated
to be secondary to neuroendocrinological immaturity);
(2) the cortisol response to surgical or biochemical (ACTH)
stress was agedependent, with neonates mounting a
quantitatively lesser response than infants; and
(3) neonates less than 9 days of age had a more rapid
response yet released significantly lower amounts of
cortisol following surgical stress.

. Aldosterone
Adult : Plasma aldosterone to increase within minutes
following surgery
and to remain elevated for up to 24 h postsurgery
Enquist et al : the aldosterone response to surgery
could be inhibited by intravenous saline given during the
surgical procedure.
These authors proposed that infusion of saline inhibits the
renin release seen during surgery and thus decreases the
aldosterone response.

Growth
(GH)
No data hormone
regarding the
aldosterone response

(adult) release was

proportional
to the
degree
inGH
postoperative
neonates
were
found
in of
our
stress.
review of the literature.
GH
neonatal
operative
stress metabolism
has received
GH response
improve to
the
efficiency
of protein
littleattention
after
surgery
: protein synthesis rate 209% higher .
Postoperative
The protein breakdown rate was 170% higher

Antidiuretic hormone
Coran and Drongowsld : postoperative neonates
suggest that water retention occurs in the early
postoperative period in newborns and ADH has been
postulated to be involved in this process

Renin-angiotensin system
Adult patients : increase in plasma renin activity following
surgery correlated with blood pressure changes during
surgery . This appears to be a transient phenomenon,
with a return to normal renin levels shortly after surgery.
Operative stress in newborns : observed to follow the
stress of venipuncture in a group of full-term neonates .
A significant increase in plasma renin activity was noted
within 5 min after venipuncture with a return to basal
levels 60 min thereafter.

6. Thyroid hormones

Adult : operative trauma results in a fall in adult serum

active tri iodothyronine and a rise in inactive triiodothyronine (reverse T3) levels
No data specifically concerning changes in thyroid
hormones in postoperative neonates are available.

Conclusions
The endocrine response of patients to
operative and nonoperative trauma is
characterized mainly by a substantial
increase in circulating
concentrations of the catabolic
hormones and a decrease in
plasma concentrations of the
global anabolic hormone, insulin.

.. Conclusions
The magnitude and duration of this
response, particularly with respect to
changes in the plasma concentrations of
cortisol, catecholamines, glucagon,
growth hormone, and ADH appears to
be proportional to the extent o the
surgical injury. the changes in the
blood concentrations of some of these
These hormonal
changes may
have
hormones
may be prolonged
in patients
profound
effects complications.
on metabolic
with
postoperative
homeostasis, circulatory hemodynamics,
immunocompetence, renal homeostasis,
and gastrointestinal physiology as well
as having behavioral and psychological
effects on patients undergoing surgery.

.. Conclusions
The neonatal hormonal response to stress is
much less well characterized, it is
predominantly catabolic, with documented
elevations of catecholamines and endorphins.
The alterations in glucagon and insulin levels
in neonates do not parallel the adult data.
Cortisol responsiveness is also diminished in
comparison with data from the adult
literature, and this difference may be
maturation-dependent.
In many literaturs of the hormonal response
to operative and nonoperative stress that
have not been thoroughly investigated in the

THE METABOLIC RESPONSE TO

SURGERY
The evidence suggests that neonates frequently
respond to trauma and stress in a manner different
from that of adults or older children.
Adult patients show an increase in oxygen consumption
(VO2) after trauma or operation & increases catabolic rate
Ito et al : the VO2 of a full-term, normally-fed, non
operated neonate increases with advancing age until
approximately the 2nd or 3rd week of life some
postoperative newborns, manifest a lower postoperative
VO2 than would be expected for their age and size
Postoperative VO2 in neonates is better correlated
with caloric intake than with the intensity of the
operative stress, in contrast to the increased
metabolic-rate findings in adults.

Carbohydrate metabolism
Decrease
insulin
concentrati
ons

an increase in glucose
production
a diminution in peripheral
glucose utilization

a significant hyperglycemic response both

during and after surgery.

t and Talbot :
ormal newborn babies , 80% of the energy requirement is fulfilled from fat,
er birth and even before feeding is started, a rapid fall in glycogen reserves has b
Blood glucose concentrations are also known to fall in the early postnatal
period
An increase in plasma FFA and ketone bodies has been shown to occur
concurrent with these changes in glucose and glycogen, adding support to
the importance of fat-derived calories in the newborn as he/she changes
his/her major metabolic foodstuff.
Unfortunately, operations on neonates are frequently accompanied by
periods of starvation that may be prolonged, especially if the gastrointestinal
tract is involved.

Glucose
(1)babies may be less able than adults to form glycogen
from glucose;
(2)there may be temporary increased insulin dependence
in newborn
(3)the uptake of glucose by the tissues may be reduced
by high
circulating concentrations of substances such
The
prolonged use of parenteral glucose severe hyperglycemia
as epinephrine
and growth hormone.
..infants
: their
capacity to handle infused glucose << ).
A postoperative increase in blood glucose concentrations to twice
than preoperative levels in newborns, but noted that they returned to
normal within 12 h .
This is in contrast with adult surgical patients, where blood,
glucose levels may

 The human fetus is dependent upon the

mother for its
glucose needs, and no glucose
production has been
During
demonstrated
during
intrauterine
life (a
the perinatal
suggest
that the
fetal gluconeo
source
of the available
genesis
gluconeogenic
enzymes
glucose
isby
chiefly
from the process
ofin
fetal
<< ) rather
glycogenolysis
Theliver
available
evidence in adult patients
than gluconeogenesis
suggests
that
increased glucose production from the
splanchnic tissues
may contribute
substantially
to the
Unfortunately,
similar
stable isotope
hyperglycemic
studies to elucidate
response
to surgical
stress
stress-induced
changes
in postoperative
glucose

 The available evidence in adult patients suggests

that increased
glucose production from the splanchnic tissues
may contribute
substantially to the hyperglycemic response to
surgical stress.
The
response
in newborn
:
Thehyperglycemic
studies showing
alteredis,
glucose
tolerance
,
complex
however,and multifac
torial
(both the
ability
to utilize glucose
also
suggest
a role
for decreased
glucosein
peripheral
tissues
in an
utilization in
this state.
impaired state and the mechanism of utilization
may be altered with
shifts
in the balance
of energy
derived from
THUS,
ALTHOUGH
THE PRECISE
MECHANISM
OF THE
aerobic and anaerobic
HYPERGLYCEMIC
metabolism).
RESPONSE IS NOT CLEAR, THE CLINICAL
IMPLICATIONS OF SIGNIFICANT HYPERGLYCEMIA IN
A NEONATE ARE IMPORTANT.

Pyruvate, lactate, alanine

increases in blood lactate and pyruva

concentrations in postoperative adult
patients
epinephrine release
during surgery increases lactate
and pyruvate production as a result of glycogen
breakdown in peripheral tissues,

Protein metabolism

Metabolic demands of protein in illness or trauma/

surgery >>>
Muscle
( catabolic process) negative nitrogen
balance
atrophy
utilization of energy substrate
Infection
Wound
combat infection
dehisc
ability to heal wounds
Death
sufficient muscular strength to
breathe adequately,

low caloric
reserves
Thin subcut fat
Glycogen
stroage <
Gluconeogenesi
s<

The concluded that the metabolic response of

pediatric patients to multiple trauma differs from
that of adults and noted that pediatric trauma
patients need not only increased caloric intake,
but, more importantly, a significant increase in
protein intake
in order to
optimize intake
the balance
recommended
a
nitrogen
of 450
Duffy
and
between mg/kg
proteinper
synthesis
and breakdown.
day
Pencharz

with a non-protein energy intake of 85-90

Fat metabolism

In adult patients the postoperative state produces a

catabolic
response that, in addition to the already mentioned
changes in
carbohydrate and protein metabolism, also results
in
of Non-Essterified
Fatty Acids
(NEFA)
Inmobilization
the human baby,
depot fat accounts
for 10%from
adipose
15%
of
body
Anand
et alwgt
( in neonates) : demonstrated an
tissues in
( lipolysis
) and increased
formation
of
increase
blood levels
of total ketone
bodies
ketone
bodies during
.
and glycerol
surgery in neonates ..
A prime importance in providing
an endogenous
catecholamine-stimulated
lipolysis
and
energy
source a strong correlation between
ketogenesis
serum levels of glycerol, E/NE at the end of an
operation . postulated that the primary
sources of energy in the surgical neonate are

CONCLUSIONS
Catecholamines :
The agents of primary importance in
stress conditions
The metabolic changes : inhibition of
insulin release
hyperglycemia, and breakdown of
the neonate's
stores of nutrients, carbohydrate,
protein, and fat.
These result in the release of glucose,
NEFA, ketone
bodies, and amino acids.
The ill neonate with limited reserves of
nutrients and

Perioperative
Fluid Management
In Pediatric
Patient

The commonly used systems for

calculating fluid needs of the pediatric
patient:
Body weight,
Surface area,
Caloric
Multiple physiologic factors

These systems are unfortunately

inadequate because their basic
physiologic assumptions have inherent
problems, and they are too rigid to
account for the variability among
pediatric surgical patients

WEIGHT ALONE CANNOT ACCURATELY !!!

THE DIFFERENCE IN BODY COMPOSITION AND
PHYSIOLOGIC CHARACTERISTICS OF THE WIDE
SPECTRUM OF PEDIATRIC SURGICAL PATIENTS.

To base fluid management on a more

scientific basis :
PHYSIOLOGIC ALTERATIONS / METABOLIC
ACTIVITY
It was concluded that maintenance fluid
requirements were directly related to the
metabolic activity necessary for the body to

Physiology
- Percentage of body water exceeds that of adult.
- Expanded extracellular space which contracts
during first week of life :
1. Increasing glomerular filtration rate
2. Physiologic diuresis occurs with loss of
about 10% of total body weight
3. Some SGA / dysmature infants may not
have expanded extracelllar space by 6
months of age, healthy infants have kidney
function that is almost normal.

Composition of Body Fluid

y weight, body surface and body fluid in childr
and adults
Premature
Neonate Newborn
Weight (kg)

1 year 3 year9 years Adult

1.5

10

15

30

70

Surface area(m2)
S/W

0.15
0.1

0.2
0.07

0.5
0.05

0.6
0.04

1
0.03

1.7
0.02

Total water (%)

80

78

65

60

60

60

ECF (%)
ICF (%)

50

45
35

25
40

20
40

20
40

20

30

40

Hochman et.al. Reproduced

ECF ISF : non protein

IVF : with
protein

Fluid distribution
Premature / Newborn
80 70 % TBW

Child
ICF
30-35%

ISF
40-37.5%

IVF
10 - 7,5%

ICF
40%

65 60 % TBW

ISF
18-15%

IVF
7-5%

Composition of Body Fluid

Comparison of body composition of
infants & adults

Water

Blood
Solids
Fat
1500g

2500g

3500g

Adult

omposition of Body Fluid........

Cations (mEq/L)
Na+

ntracellular fluid

K-

10 150

Ca++ Mg++

CL

HCO3

HPO4-

40

10

0.3

103

27

109

28

142

130
Lactated ringer solution

Extracellular fluid

NH4+

Amions
(mEq/L)
-

0.45 NaCL

77

77

0.9% NaCL

154

154

3% NaCL

590

590

rce: Herrin J, Fluid & electrolytes, 1997

Composition
of Body
Fluid
Composition of Body
Fluid
Source

Gastric
Pancreas
Bile
Illeostomy
Diarrhea
Sweat
Blood
Urine

Na+

50
140
130
130
50
50
140
0-100

K+(mEq/L) CI-(mEq/L)

10-15
5
5
15-20
35
5
4-5
20-100

Source: Herrin J, Fluid & electrolytes, 1997

150
50-100
100
120
40
55
100
70-100

HCO3-

pH

1
9
0
8
100
8
40
25-30 Alkaline
50
7.4
0
4.5-8.5
25
0

Osmolality
(mOsm/L)

300
300
300
300
285-295
50-1400

rmal water losses in infants & childr

Cause of Loss

Volume of Loss
(mL/100 kcal)

Output
Urine
Insensible loss
Skin
Respiratory tract

70
30
15
15

Hidden intake (from

burning 100 calories)

100

Total

erioperative fluid management

I. Maintenance
II.Deficit
III.Replacement

How should be
given ?
What kind of fluid ?

I. MAINTENANCE

1.Maintenance fluid and caloric requirements

of neonate /
newborn
Age Vol (mL/kg/day)Energy (KCal/kg/day)
Day
Day
Day
Day
Day

1
2
3
4
5

50 80
80 100
100 120
120 150
150

40 50
50 70
70 -90
90 110
110 120

Weight
(kg)

First 48
hours

End of first
week

< 1ooo

80-140

150-200

10001500

60-100

140-160

60-80

110-150

105140-60
Amounts
are
given
as
ml/kg/d
2000

100-150

Hourly and Daily Maintenance Fluid Requireme

of Children to based on weight
Maintenance fluid requirements
Weight (kg)
0-10
10-20
>20

Day
100mL/kg
1000mL + 50 mL/kg
1500 ml + 20 mL/kg

Hour
4mL/kg
40mL + 2 mL/kg
60 mL + 1 mL/kg

For example : a 25 kg child would required

1000 ml + 500 ml + 100 ml = 1600 ml
Holliday & Segar
Method

3. Fluid requirements to be based on

BSA Average BSA values
Neonate

0.25 m

Child 2 years

0.5

Child 9 years

1.07 m

Child 10 years

1.14 m

"Normal"

BSA is generally
taken to be 1.73 m (adult).

Child 12-13 years 1.33 m

For men

1.9

For women

1.6

Fluid req in Children : 1500ml / m2 BSA / day

For example :
3 kg infant : 1500 ml x 0.25 / day = 375 ml/day

ource: Holiday MA, Segar WE; The maintenance need

for water in parenteral fluid therapy padiatrics

hoice of the maintenance fluid

Crystalloid :
Depent on the glucose and electrolyte
needs
Hypotonic : D 10% 0.18 NS
D 5% 0.225 NS
D 5% 0.45 NS
Neonate & premature or small for
gestation age are
at risk for perioperative of
hypoglycaemia.

Is
intraoperative
glucose necessary ?

Perioperative Fluid Management :

Intraoperative Glucose Administration
Effects :
intraop hyperglycemia
hyperosmolality
osmotic diuresis
worsen neurologic outcome during cerebral
ischemia

Perioperative Fluid Management

Intraoperative Glucose Administration
Exceptions : patients at risk for hypoglycemia

neonates and young infants

debilitated patients with chronic illness
patients on parenteral nutrition
neonates of diabetic mothers
Beckwith-Wiedeman syndrome
nesidioblastosis

Perioperative Fluid Management

Intraoperative Glucose Administration

Existing infusions of dextrose-containing fluid

may be continued at a reduced rate (50% of
maintenance) to compensate the effect of
surgical stress on glucose control

II. DEFICIT
Preoperative fluid deficits :
Maintenance + fluid deficit
1. Fasting period
2. Hydration
3. Electrolyte imbalance
1. Fasting period
Fasting (NPO) guidelines for children and adults
Fasting time (Hours)
Age
< 6 months
6-36 months
> 36 months

Solids

Clear liquids

4
6
8

2
3
3

2. Hydration :
Assessment of the degree of dehydration

Clinical findings

Mild

Moderate

Severe

% body weight loss

Estimation fluid defisit

4-5%
40-50ml/kg

6-9%
60-90 ml/kg

>10%
100-110 ml/kg

Pulse
Blood pressure
Respiration
Skin turgor
Mucous membranes
Peripheral perfusion
Urine

Normal
Normal
Normal
Normal
Moist
Normal
Reduced

, Weak
Normal of low
Deep

Dry
Poor
Oliguria

, feeble
Reduced
Deep & rapid

Very dry
Poor, cool, extremitas
Marked oliguria

Source: Nelson W

REPLACEMENT OF FASTING
Hourly fluid requirement x length of
fasting
(hours)
For example :
a 5 kg child
5 kg x 4ml/kg/h x 4 h = 80 ml
Given : 50% in the first hour
25% in the second and third hour
Choice of fasting fluid :
- Crystalloid fluid
- Hypotonic solution
- Isotonic solution

Management of dehidration
a. Estimated fluid deficit
b. Rehydration
For example : a 10 kg child is assessed to severe
dehydration with an estimated 10%
Dehydration 10%, 10 kg
EFD : 100 ml x 10 = 1000 ml
Initial fluid resusitation : 20ml/kg (20-30)
Reassess the clinical state
Improved

- Respiration
- Circulation
- Mental status

Non improvement

First 8h

: 50% rest fluid deficit +

Repeat : 20 ml/kg/20-30
fluid maintenance
Second 16h : 50% rest fluid deficit +
Resassess
fluid maintenance

Choice of the fluid :

Rehydration : Isotonic crystalloid
Maintenance : Hypotonic crystalloid

3. Electrolyte im balance

trolyte composition of stomach, small bowel and diar

Stomach

Small bowel

Diarrhea

160
140
HCO3

120
100

H+

80

Cl+

Na+

60

Cl+

Na+

HCO3

K+

Cl+

40
20
K+

K+

Maintenance electrolyte requirement

in children
Electrolytes
Sodium : 3-4 mEq/kg/day
Potassium : 2-3 mEq/kg/day
Chloride : 2-3 mEq/kg/day
Calcium: 150-500 mg/kg/day
Phosphorus : 0.5-2 mmol/kg/day
Magnesium : 0.25-0.5 mEq/kg/day

Source : J Allan Paschall

DEFICIT.......

Daily Electrolyte Requirements

Na

2-3 mEq /kg/day

day 2-3

1-2 mEq /kg/day

day 3-4

Cl

2-3 mEq /kg/day

Ca

20-100 mg/kg/day day 1

* 1 mEq = 1 mmol

Hypo Natremia

Estimated fluid deficit

Resucitation from shock : NS / RL
Calculated deficit hourly IV rate
Maintenance + deficit Na- / 24 hours
mEq Na+ = (Desired Na+ - Observed Na+) x weight (kg) x 0.6
Infuse D5 0.45 NS or D5 NS or D5 LR
Add 10 20 mq kcl/l based on renal function and K+ level

okalemia
0.5 1 meq/kg (max.20 meq) / 2 hour
peat : 4- 8 hours as need
onitoring : ECG

rkalemia
Cl
: 0.1 0.3ml/kg a. 10% solution
Gluconas : 0.3-1ml/kg a.10% solution
bic : 1-2 mEq/kg + mild to moderate hyperventilation
ucosa + insulin : 0,5g /kg Glucose + 0.1U/kg insulin / 30-60

III. REPLACEMENT
Intraoperative fluid management
- Maintenance
- Replacement

Replacement
- Third space lossess
- On going lossess

Guidelines for intraoperative fluids in pediatric patiens

1. First hour, hydrating solution:
Age 3 year : 25ml/kg, plus item 3
Age 4 year : 15 ml/kg, plus item 3
2. All other hours basic hourly fluid plus item 3 below
Maintenance fluid = 4 mL/kg
Maintenance + trauma = basic hourly fluid
4 mL/kg + mild trauma (2 mL/kg) = 6 mL/kg
4 mL/kg + moderate trauma (4 mL/kg) = 8 mL/kg
4 mL/kg + maximal trauma (6 mL/kg) = 10 mL/kg
3. Blood replacement with 3:1 volume replacement
with crystalloid or colloid, or blood
From: Berry Reproduced

BLOOD REPLACEMENT

stimated blood volume (EBV) in pediatric patie

Age
Premature infant
Newborn
Infant < 1 y
Child > 1 y

EBV (mL/kg)
90-100
80-90
75-80
70-75

Mean & lower normal hemoglobin levels in

pediatric patients
Normal hemoglobin (g/100mL)
Age

Mean

Lower limit

1 day
1 week
1 mo
3 mo
0.5 5 y
5 9y
12 14 y
girls
boys

18
17
14
12.5
13
13.5

13.5
13
13
9
11.5
12

13.5
14

12
12.5

Dallman & Siimes, Oski & Neiman, and Saarinen & Siimes

Normal & acceptable hematocrit

(Hct) values in pediatric patients
Normal hct (%)
Age
Premature
Newborn
3 mo
1y
6y

Mean

Range

Acceptable hct (%)

45
54
36
38
38

40-45
45-65
30-42
34-42
35-43

35
30-35
25
20-25
20-25

LOOD REPLACEMENT TO USE HAEMOTOCRIT LE

EBV (starting Hct - target Hct)
MABL =
Starting Hct
Packed Red Blood Cells:
WARNING !!!! ..The use has diminished
because of disease transmission (HIV, Hep C,B.
etc)

Blood required :
PRC = (Start Hct target Hct) x body weight (kg)
WB = (Start Hct target Hct) x body weight (kg)

Packed Red Blood Cells .........

Child usually tolerates Hct ~ 20 in mature

children
If :
Premature,
Cyanotic congenital disease
O2 carrying capacity

Hct ~
30

No one formula permits a definitive decision

Replace 1ml blood with 3 ml of LR
Lactic acidosis is a late sing of decreased O2
carrying capacity

Fresh Frozen Plasma:

Use to replenish clotting factors during massive
transfusion, DIC,
congenital clotting factor deficits

Usually replenished if EBL = 1-1.5 TBV

A patient should be never given FFP to replace
bleeding that is
surgical in nature
If transfused faster than 1.0 ml/kg/min severe
ionized
hypocalcemia may occur
If occurs - Rx. with 7.5-15 mg/kg Ca++ gluconate

Platelets:
Find etiology - TTP, ITP, HIT, DIC, hemodilution
after
massive blood transfusion
Consider transfusion if Platelets < 50.000
In certain hospitals platelet function test is
available
If Platelets < 100.000 and EBL = 1-2 TBV
transfusion
more likely

Guidelines for red cell transfusion

to neonate and premature
Shock associated with acute blood loss
Hb< 13g/100mL, Hct<40%, and presence of pulmonary
failure, cyanotic heart disease, or congestive heart failure
Comulative loss of 10% or more of the blood volume
within 72 h or less if additional sampling is required
Hb<80g/100mL, or Hct<25% in a stable neonate with
clinical manifestations of anemia, e.g. tachycardia,
tachypnea, poor feeding

Source: Kevy SV, Gorline JB, in Hemetology of infancy & childhood, 1998

Postoperative Fluid Management

Maintenance fluid
Replacement of fluid deficit
Replacement of other losses
- Chest tube
- Nasogastric tube
- Weeping incision
- Continous slow bleeding
Correction of electrolyte inbalance
Maintenance fluid requirement on the first
most
operation day are decreased to 2/3 of the
usual

Fluid restriction:
Situation which require fluid restriction include patiens with
- cerebral edema
- congestive heart failure
- renal failure
- SIADH
- PDA
- Pulmonary disorders
Calculated :
as a percent of maintenance fluids ( e.g 2/3 or 3/4
maintenance )
as insensible loss ( 300-400 ml/m) plus urine

Conclusion
Fluid therapy for pediatric patients must be based on
the
knowledge of the fluid and electrolyte needs in
healthy infants
and children on physiologic responses to the surgical
procedure
Formula for fluid therapy are guidelines that need to
be
revaluated according the patients response
Even more than in the adult, improper fluid
management in
infants and children can cause life threatening
consequences
The inadverten administration of a seemingly

HYSIOLOGY OF INFECTIONS

HOST DEFENSES OF THE NEONATE

The newborn infant :

= Host-defense system is functional in the perinatal

period and undergoes progressive maturationpostnatally.
= The host-defense: immune system ( nonspecific and specific
immune syst ),can recognize and eliminate foreign
antigen.

Nonspecific immunity mechanisms that operate without

requiring prior exposure to antigen.that is, "experience" is
not necessary. Included are the mucocutaneous barriers,
phagocytic cells, and the complement system.

Specific immunity is keyed to antigen presentation and

exposure-. that is, experience is necessary.
It comprises cellmediated (T-Iymphocyte) and humoral (BIymphocyte and immunoglobulin) systems.

Although each system is referred to as a separate entity,

they complement and supplement each other, often
communicating via various cellular factors.

 Newborns,

especially premature infants,

are vulnerable to infection during the first
6 weeks of extrauterine life because of an
inexperienced and immature immune
system

This

inexperience results from the neonatal

immune system's development and
maintenance within a sterile intrauterine
environment, which in most cases precludes
antigen presentation.

Immunologic immaturity is manifested by

qualitative and quantitative deficits in
both components of the defense system,
even though many of the essential
elements are present at birth.
The degree of immunologic immaturity
varies directly with gestational age
and accounts for the high incidence of
infections and infection-related
mortality in the premature and very
low-birth weight infant.

NONSPECIFIC IMMUNITY

Poly Morphonuclear Neutrophil System

The most primitive host-defense mechanism involves

the ingestion and killing of microorganisms by
PHAGOCYTIC cells.
The polymorphonuclear neutrophil (PMN) is the
first line of defense that microorganisms
penetrate the mucocutaneous barrier. It migrates
from the bone marrow and bloodstream to the
site of the invading organism.termed
CHEMOTAXIS .

ANTIGEN

increasing concentration
gradient of chemotactic
factors (complement
proteins, cytokines,
leukotrienes)

Chemotactic

factors interact with specific cellsurface receptors on the PMN, promoting its
adherence to endothelial cells.

PMNs

must then change their shape to slip

between the endothelial cells and pass from
the intravascular to the extravascular space-a
process termed DIAPEDESIS.
Once within the extravascular tissue, the cell
moves along a chemotactic gradient until the
microorganisms are encountered.

opsonized or
coated

NGULFMENT PROCESS

Opsonins are a group of plasma proteins

consisting chiefly of immu- noglobulins and
complement proteins that promote
phagocytosis by preparing the microorganism
for engulfment.

MMARY OF THE FOUR STEPS LEADING TO NONSPECIFIC BACTERIAL KILL

A, Chemotaxis, the migration of neutrophils toward the
site of the invading organism, occurs in response to an
increasing concentration gradient of any of a variety of
chemotactic factors (e.g., complement proteins)

B, Bacteria are "prepared" or

opsonized before engulfment
occurs. Opsonins are plasma
proteins consisting chiefly of
immunoglobulins and complement
proteins.

A, Chemotaxis,
D, The neutrophil
destroys the ingested
bacterium by either of
two mechanisms: oxygendependent or oxygenindependent killing.

C, The bacterium, now opsonized, is

engulfed by the neutrophil, a process

D
Killing

Oxygen-independent

killing utilizes cellular

lysozyme,lactoferin and acid,

Oxygen-dependent

killing : microbicidal-reactive
oxygen intermediates such as super oxide radicals,
hydrogen peroxide, and reactive hydroxyl radical

The

neonatal PMN system, in contrast to the

adult PMN system, suffers from both
quantitative and qualitative deficiencies. The
greatest deficiencies are present in premature
infants.

Quantitatively,

the neonate's total peripheral

granulocyte count is comparable with that of a
normal adult, but the neutrophil storage pool,
which consists of band and metamyelocyte forms,
is markedly reduced.

Neonates,

when faced with a bacterial

challenge, often develop neutropenia and a
left shift, signifying rapid depletion of an
already reduced neutrophil storage pool.

Similarly,

qualitative defects in PMN

function are obvious in either term or
preterm infants. For example, neonatal
neutrophils have decreased bactericidal
capacity for Escherichia coli and
Staphylococcus aureus at
neutrophil/bacteria ratios

thank you

Str
es
nociceptors
chemorece
ptors,
barorecept
ors