Pediatric Fluid Management

1
Pediatric Fluid Management and Blood Product
Therapy Joy Loy, M.D. MetroHealth Medical
Center April, 2004
2
ASA Fasting Guidelines
Clear liquids 2 hours Breast Milk 4
hours Infant Formula Neonates 4
hours Infants 6 hours Nonhuman Milk
6 hours Solids 8 hours
3
Clear Liquids

• water, juice without pulp, carbonated
• beverages, clear tea, black coffee
• should not contain alcohol
• type of liquid ingested important than
• volume
• infants lt 5 mos 10 ml/kg
• children and adults 15 ml/kg

4
Breast Milk

• is NOT a clear liquid
• does contain milk solids

• cleared from the stomach more
• quickly than nonhuman milk

5
ASA Fasting Guidelines

• pre-op fast does not guarantee an empty stomach
• timing of last fluid ingestion has little
  relation to volume of gastric contents at
  induction

6
ASA Fasting Guidelines

• gastric fluid volume and pH are independent
  of duration fluid fast beyond 2 hours
• main determinant endogenous gastric
  secretion

7
ASA Fasting Guidelines

• reduces the risk of pulmonary aspiration
• offering clear liquids up to 2 hours before
• induction
• gt reduces hunger and irritability
• gt preserves hydration
• gt ? risk of hypoglycemia

8
BODY FLUID COMPOSITION
Compartments
Total Body Water (TBW) Intracellular Fluid
( ICF ) Extracellular Fluid ( ECF )
a) interstitial fluid ( ISF ) no
protein b) plasma volume ( PV )
with protein ISF and PV
basically same electrolyte content
9
Body Fluid Composition

INFANT CHILD ADULT Total Body Water 75
70 55-60
ECF
40 30 20 ICF
35 40 40
Fat 16
23 30

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PHYSIOLOGIC CONSIDERATIONS Developmental Factors
CVS incomplete myocardial
development immature sympathetic
innervation
IMPLICATION neonates and young infants are
more


sensitive to
hypovolemia
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PHYSIOLOGIC CONSIDERATIONS Developmental Factors
RENAL immature renal function at birth
? GFR 25 of
adult level at term adult
level at age of 2 years ?concentrating
capacity of newborn kidney
term infant max. 600-700 mOsm/kg
adult max. 1200 mOsm/kg
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PHYSIOLOGIC CONSIDERATIONS Developmental Factors

• free H2O clearance
• excrete markedly dilute urine up to 50
• mOsm / kg vs. 70-100 Osm/kg in adults
• ? Na reabsorption
• ? HCO3 /H exchange
• ? urinary losses of K and Cl-

13
PHYSIOLOGIC CONSIDERATIONS Developmental Factors
IMPLICATION Newborn kidney has limited
capacity to compensate for volume excess or
volume depletion
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PHYSIOLOGIC CONSIDERATIONS Developmental Factors
HEPATIC limited hepatic glycogen stores
gt risk of hypoglycemia gt
provide 5-10 dextrose in fluid
maintenance gt supplemental insulin
for sustained hyperglycemia
from dextrose
15
PHYSIOLOGIC CONSIDERATIONS Metabolic and Fluid
Requirements
? metabolic rate O2 consumption
neonates 6-9 ml/kg/min
adults 3 ml/kg/min growth 120
kcal/kg/day
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PHYSIOLOGIC CONSIDERATIONS Metabolic and Fluid
Requirements
? fluid requirement gt greater BSA to
mass ratio in infants gt other factors
radiant warmers
fever illness
injury thinner skin
and lack of keratinization of
stratum corneum in premature neonates
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Compensatory Mechanisms
1) Temporary mechanism 2) Definitive mechanism
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Compensatory Mechanisms
Temporary Mechanism gt activated to
maintain normal BP and normal
fluid volume a) endogenous vasopressors
ADH, angiotensin II,
catecholamines b) transcapillary refill
ISF ? PV (?skin turgor) c) ADH ? free
H2O absorption
caution hyponatremia using hypotonic
fluids
19
Compensatory Mechanisms
Definitive Mechanism gt through
the kidneys gt activation of renin -
angiotensin - aldosterone (RAA)
system gt ? urine output and ? urine
specific gravity
20
Maintenance Fluids

• replaces water and electrolytes lost under
  ordinary conditions
• Evaporative / insensible water loss (ISWL)
• Urinary and stool losses
• Growth

21
Maintenance Fluids
1) Evaporative or Insensible Water Loss (ISWL)
solute-free H2O losses from skin and
lungs ? 30-35 of total maintenance
volume 1/3 of total maintenance
requirement affected by ambient
humidity and temperature minimum
replacement 60-100 ml/kg/day

22
Maintenance Fluids
2) Urinary Losses 280-300 mOsm /kg
of H2O specific gravity
1.008-1.015 2/3 of total
maintenance fluids 3) Growth

23
Maintenance Fluids Hourly Maintenance Fluid
Requirement
1) 4 - 2 -1 rule WEIGHT
FLUID 0 - 10 kg
4 ml/kg/hr 10 - 20 kg
2 ml/kg/hr gt 20 kg
1 ml/kg/hr reliable up to body weight
of ?80 kg

24
Hourly Maintenance Fluid Requirement
2) Holliday and Segar WEIGHT
FLUID/day 0 - 10 kg
100 ml / kg /day 10 - 20 kg
1000 50 ml/kg/day gt 20 kg
1500 20 ml/kg/day
based on caloric requirement of hospitalized
patients

25
Maintenance Fluids Hourly Maintenance Fluid
Requirement
3) OH Method WEIGHT
FLUID/hr 0 - 10 kg 4 ml /
kg / hr 10 - 20 kg 20 2
ml/kg/hr gt 20 kg 40
1ml /kg/hr

26
Choice of Maintenance Fluids

• Remains controversial
• Hypotonic solution
• D5 1/2 NS 20 mEq KCl
• D5 1/4 NS may be a better choice in
• neonates due to their limited
  ability
• to handle Na loads
• Balanced salt solution

27
Guide for Maintenance Fluid Therapy
Newborn Term Day 1 50-60 ml/kg/day
D10 W Day 2 100 ml/kg/day
D10 1/2 NS gtDay 7 100-150 ml/kg/day
D5-D10 1/4 NS Older Child 4-2-1 rule
Holliday Segar method

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Daily Electrolyte Requirements
Na 2-3 mEq /kg/day day 2-3 K
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

29
Glucose Requirements
term and preterm infants 5 - 6
mg/kg/min goal maintain normoglycemia
40 - 120 mg/dl D10W 60-80 ml/kg/day gt1kg
infants D5W 100 ml/kg/day lt1kg infants

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Perioperative Fluid Management

• 3 Phases
• Maintenance Fluid Replacement
• Replacement of Preop Deficit
• Replacement of Ongoing Losses

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Perioperative Fluid Management Maintenance Fluid
Replacement
4 - 2 -1 rule WEIGHT
FLUID 0 - 10 kg
4 ml/kg/hr
10 - 20 kg
2 ml/kg/hr
gt 20 kg
1 ml/kg/hr
32
Perioperative Fluid Management Preoperative
Deficit
DEHYDRATION MILD (1-5 )
history of vomiting or diarrhrea ?
urine output (1st) MODERATE (6-10)
skin turgor sunken eyes and
fontanelles weight loss dry
mucous membranes lethargic
33
Perioperative Fluid Management Preoperative
Deficit
SEVERE (11-15) cardiovascular instability
? BP mottled
skin tachycardia
anuria sensory changes 20
coma shock
34
Perioperative Fluid Management Preoperative
Deficit Therapy
Components 1) dehydration severity
Hx and PE electrolyte
values serum tonicity 2)
type of dehydration isotonic
hypotonic hypertonic

35
Perioperative Fluid Management Preoperative
Deficit Therapy
3) replacement of deficit
goal restore CV, CNS and renal
function monitor adequacy
based on response clinical
condition urine output
and urine specific gravity
vital signs
36
Perioperative Fluid Management Estimated Preop
Fluid Deficit

number of fasting hrs x maintenance fluids
infuse 1/2 on the first hr infuse 1/4 on the 2nd
hr infuse 1/4 on the 3rd hr

37
Perioperative Fluid Management Choice of Fluids
Isotonic Crystalloids generally the
most appropriate for preop and
intraop deficits Hypotonic Fluids
can cause significant hyponatremia
38
Perioperative Fluid Management
Lactated Ringers (LR) reasonable for
maintenance fluids less expensive than
other BSS provide Na and K avoid
infusion with blood due to calcium content
39
Perioperative Fluid Management
Normal Saline (NS) higher Na content
(154) preferred in patients high risk
for cerebral edema prolonged infusion
can lead to hypernatremia
hyperchloremia metabolic
acidosis
40
Perioperative Fluid Management Composition of IV
Crystalloid Solution
SOLUTION pH Osm Gluc Na
K CL Lact Ca
mg/dl
mmol/L D5 5.0
253 500 -- -- --
-- -- LR
6.7 273 -- 130 4
109 28 3 D5 LR
5.3 527 500 130 4 109
28 3 D5 0.22 NSS 4.4
330 500 38.5 -- --
-- -- D5 0.45 NSS 4.2 407
500 77 -- 77 --
-- 0.9 NSS 5.7 308
-- 154 -- 154 --
-- Normosol R 7.4 295 --
140 5 98 acetate 27
--


gluconate 23

Stoelting RK Pharmacology and Physiology in
Anesthetic Practice, ed 2, Philadelphia 1991, JB
Lippincott
41
Perioperative Fluid Management Composition of
Colloid Solutions
Na Cl
Osm 5 Albumin 145 100
330 mOsm/L Hespan 154 154 308
mOsm/L Hextend 143 124
307 mOsm/L

42
Is intraoperative glucose necessary?



43
Perioperative Fluid Management Intraoperative
Glucose Administration
Effects intraop hyperglycemia
hyperosmolality osmotic diuresis
worsen neurologic outcome during cerebral
ischemia


44
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


45
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


46
Perioperative Fluid Management
Replacement of Ongoing Losses
1) Real Losses blood loss
insensible losses urine output
drainage from various sites 2) 3rd Space
Loss trauma
peritonitis burns
upper GI drainage



47
Perioperative Fluid Management Replacement of
Ongoing Losses
Degree of
Additional Fluid Tissue Trauma
Required Minimal Incision
3-5 cc/kg/hr Moderate
Incision 5-10 cc/kg/hr
with viscus exposure Large Incision
8-20 cc/kg/hr
with bowel exposure



48
Perioperative Fluid Management Replacement of
Ongoing Losses
EBL Replacement crystalloid (31 ratio)
3 cc / 1 cc blood lost
colloid solution (11 ratio) 1 cc / 1 cc
blood lost blood products (11 ratio)
1 cc / 1cc blood lost




49
Perioperative Fluid Management Replacement of
Ongoing Losses

Albumin 25 and 5 solutions
pooled from human donors no ABO testing or
blood filter required remains expensive
in short supply




50




Is albumin risk-free?
51
Perioperative Fluid Management Composition of
Colloid Solution
New Zealand albumin may be related to
Creutz-Jacob disease (CJD) or prion disease with
long incubation period (gt5-10 yrs) processing of
human albumin does not destroy the prions no
blood screening for prion diseases


52
Perioperative Fluid Management Replacement of
Ongoing Losses
Determinants of Blood Transfusion 1)
Estimated Blood Volume 2) Preoperative
Hematocrit 3) Co-existing Illness




53
Perioperative Fluid Management Replacement of
Ongoing Losses
Estimated Blood Volume Premature Neonates
95 -100 ml /kg Full Term
Neonates 85-90 ml / kg Infants
80 ml / kg
Adults 75 ml / kg
(male)
65 ml / kg (female)




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Perioperative Fluid Management Replacement of
Ongoing Losses
Guidelines for Pediatric Normal Acceptable
Hematocrit
NORMAL (x) ACCEPTABLE premature
40-45 (45) 35
newborn 45-65 (54)
30-35 3 months 30-42 (36)
25 1 year
34-42 (38) 20-25 6 years
35-43 (38) 20-25





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Perioperative Fluid Management Blood Product
Replacement
Normal Hematocrit Hct within 2 standard
deviations for age Acceptable Hematocrit
Hct that is tolerated by infants and children
without the need for blood
transfusion




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Perioperative Fluid Management Blood Product
Replacement
Allowable Blood Loss (ABL) Hct patient - Hct
target X EBV Hct patient




57
Perioperative Fluid Management Blood Product
Replacement
PRBC 10 cc/kg will ? the hgb by 3 gm/dl
and hct by 10 (adult1 unit will ? the
hgb by 1 gm/dl and hct by 2-3) Platelets and
FFP 10-15 ml/kg given when EBL
gt 1-2 x the patients blood volume 1 unit /
10 kg raises the platelet count by
50,000/uL Cryoprecipitate 1
unit/10 kg




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SUMMARY
Total Intraoperative Fluid Replacement MF
EFD ISL EBL
MF Maintenance Fluid EFD
Estimated Preop Fluid Deficit ISL
Insensible Losses EBL
Estimated Blood Loss




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Summary
Brief Procedures ( myringotomy, PET)
replacement may be unnecessary 1-2 hr Procedures
IV placement after inhalation induction
replace 10-20 cc/kg EBL in 1st
hour Longer and Complex Procedures
4-2-1 rule acute intravascular loss
10-20 cc/kg LR / NS
60
Summary
Meticulous fluid management is required in
pediatric patients due to limited margin of
error
Liberalization of fasting guidelines compatible
with safety limits preop deficit
Crystalloid solution is the first choice to
restore intravascular volume
61
Summary
Limit glucose-containing solutions for patients
at risk for hypoglycemia
Tranfusion trigger points preop
hematocrit and hemodynamics
co-existing medical problems potential
for further blood loss 25 decrease in
EBV