Fluid management in the paediatric patient anaesthetist consideration...

FLUID MANAGEMENT IN THE
PAEDIATRIC PATIENT
Dr Riyas A

Water physiology
 Water is the most plentiful constituent of the
human body
 approximately 75% of birthweight for a term
infant
 decreases to approximately 60% of body
weight during the 1st yr of life and basically
remains at this level until puberty

Fluid Compartments
 TBW is divided between 2 main compartments
 intracellular fluid (ICF)
 extracellular fluid (ECF)
 ECF
 Plasma
 Interstitial fluid
 Transcellular fluid

Fluid compartments & volumes
changes with age
Compo
nents
Premat
ure
Neonat
e
Infant Adult
ECF 50 35 30 20
ICF 30 40 40 40
Plasma 5 5 5 5
Total 85 80 75 65

Transcellular fluid
 CSF
 Synovial fluid
 Digestive juices
 Intraocular
 Pleural
 Pericardial
 peritonial

Continu….
 Plasma water is 5% of body weight
 Blood volume is usually 8% of body weight
 The volume of plasma water can be altered by
pathologic conditions
 dehydration, anemia, polycythemia, heart failure,
abnormal plasma osmolality and hypoalbuminemia

Continu…
 Interstitial fluid - normally 15% of body
weight
 can increase dramatically in diseases
associated with edema
 heart failure, protein-losing enteropathy, liver
failure, nephrotic syndrome, and sepsis

Electrolytes
 Exist as ions
 Cations – positively charged
 Anions – negatively cahrged
 Concentrations expressed as meq/L

Electrolyte Content of Body
Fluids

Electrolyte Composition in
Body Fluids (Normal)
Electroly
te
Plasma Exracellu
lar
Intra
cellular
Na+ 142 145 10
K+ 4 4 159
Mg2+ 2 2 40
Ca2+ 5 3 1
Cl- 103 117 10
HCO3
- 25 27 7

Daily Loss of Water
Source of Loss
Normal
Activity and
Temperature
(mL)
Normal
Activity High
Temperature
(mL)
Prolonged
Exercise (mL)
Urine 1400 1200 500
Sweat 100 1400 5000
Feces 100 100 100
Insensible
losses
700 600 1000
Total 2300 3300 6600

Determining fluid
requirement
 Howland ----1911----energy consumption in
children
 In 1957 holliday and segar correlated
calorie requirement with basal metabolism
and active energy needs

Calorie requirement is
 0-10kg=100kcal/kg/day
 10-20kg=50kcal/kg/day+1000kcal
 >20kg=1500kcal+20cal/kg
 Mb of 1cal produces 0.2ml of water and
consumes 1.2ml
 On transporting this in to hourly basis

Continu…
 0-10kg4ml/kg/hr
 10-20kg40ml+2ml/kg/hr
 >20kg60ml+1ml/kg/hr
 Fever increses the calorie requirement by 10-
20%for every centigrade rise

Clinical assessment of
dehydartion
Symptoms&sign
s
Mild Mode Severe
Wt loss <5 5-10 >10
General condition Alert/restless Thirsty/lethrgic Cold/thirsty
Pulse Normal rate
/voume
Rapid/weak Rapid/feeble
Respiration Normal Rapid Rapid/deep
Systolic pressure N N/Low Unrecordable
Anterior fonta N/sunken Sunken Very sunken
Eyes n/sunken Sunken/dry Grossly sunken
Skin N Decreased Markedly
decresed
Mucous
membrane
Moist Dry Very dry
Urine output Adequate Less ,dark
coloured
Oliguria/anuria
Capillary filling Normal <2sec >3sec
Estimated deficit 30-50ml/kg 60-90ml/kg 100ml

Investigation for confirming
dehydration
 Serum osmolarity /serum sodium
 Acid base status,serum ph and base deficit
 Serum potassium compared with ph
 Urine output

Correction of flui deficit
 Done in three phases
 Emergency phase20-30ml/kg over 10-
20min (intital resucitation with isotonic saline
 Repletion phase 125-50ml/kg over 6-8hr(or
half the deficit)
 Repletion phase 2remainder of the deficit

Mild dehydration
 Correction is with ORS
 Package containing
 Glucose 20gm/Lwater
 Nacl 3.5gm/Lwater
 Kcl4.5gm/Lwater
 Trisodium citrate 2.9gm/Lwater
 Sodium bocarbonate2.5gm/L water

Compensatory mechanism
 Definite
 temporary

Nil per oral guidlines
Age Milk and fat free
solids
Fluids
<6mnths 3-4hr (breast milk) 2hrs
6-36mnths 6hrs(formula
breast feeds)
3hrs
>36mnths 8hrs fatty feeds or
solids
3hrs

Body requires
 Maintenance fluid
 Replacement fluid
 Maintenance fluid hypotonic fluid
 4 basic reason
 1)evaporation
 2)excretion through kidney and stools
 3)through respiratory tract
 4)growth

Fluid required to compensate
for fasting
 The younger child with higher basl
metabolism
 Prolonged fsting which occurred inadverently
or out of necesssity
 In the hot summer m0nth
 A febrile child
 In polycythemia when there is a risk of
dehydration predisposing to thrombosis

Monitoring fluid loss an
replacement
 Routine monitoring pulse
oxy,nibp,ecg,precordial stethescope 15-20%
 Urine out put

Selection of fluid
 Depend on condition of patient
 Surgery hct

Intra operative fluid
replacement
Surgical
trauma
Type of
surgery
Fluid
replacement
Minimal Inguinal repair 1-2ml/kg/hr
Moderate Ureter
reimplantatio
n
4ml/kg/hr
Severe Scoliosis,intra
abdominal
surgery
>6-8ml/kg/hr

heamatocrit
 A normal hct means ,a hct within two
standard deviation for the age
 An acceptable hct is with which an infant or
child can tolerate with out blood transfusion

Blood
 The use of blood products in pediatric surgical
patients has diminished greatly because of the
fear of transmission of disease—particularly
human immunodeficiency virus (HIV). Because
HIV, hepatitis B virus (HBV), hepatitis C virus
(HCV), and a number of other disease-causing
viruses can be transmitted with as little as
10 mL of packed red blood cells (PRBCs),
administration of any blood product requires
clear, medically defensible clinical indications
that are preferably recorded on the anesthetic
record

Blood loss and replacement
 In general, blood volume is approximately
100 to 120 mL/kg for a preterm infant,
90 mL/kg for a full-term infant, 80 mL/kg
for a child 3 to 12 months old, and 70 mL/kg
for a child older than 1 year.These are
merely estimates of blood volume.The
individual child's blood volume is calculated
by simple proportion by multiplying the
child's weight by the estimated blood
volume (EBV) per kilogram

Maximum allowable blood loss
 MABL=EBV*(Starting hct-target hct)/strting
hct
 Volume to be transfused=(desired hct-
presenthct)8ebv/hct of prbc

Normal and acceptable hct
value
Premature 40-45 35
Newborn 45-65 30-35
3months 30-42 25

Composition of IV fluids (per 1000 ml)
Fluid Na K Cl Glucose Others
5%
dextrose
- - - 50 g -
10%
dextrose
- - - 100 g -
Normal
saline
154 mEq - 154 mEq - -
N/2 saline 77 mEq - 77 mEq - -
N/5 saline
in 5%
dextrose
30 mEq - 30 mEq 40 g -
3% saline 513 mEq - 513 mEq - -
Ringer’s
lactate
130 mEq 4 mEq 109 mEq - Lactate 29
Isolyte P 26 mEq 19 mEq 22 mEq 50 g acetate 24,
PO4 3, Mg
3

Some other fluids meq/L
Fluid Na K Cl Glucose Others
Plasmalyte
A
140 5 98 Mg3
acetate 27
Albumin
5%
145+15 <2.5 100
Hexa
starch 6%
154 154

Conclusion
 Fluid therapy should be tailored to the needs
of individual patient
 Basal fluid and energy requirements as well
as correction of derangements may be met
by crystalloids
 Infusion of large volume of crystalloid to
correct intravascular deficit may produce
tissue oedema,coagulation abnormality and
organ dysfunction

conclusion
 Intravascular correction should be made with
crystalloids

 thank you

Fluid management in the paediatric patient anaesthetist consideration...

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