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Perioperative Fluid Management in children

Perioperative Fluid Management in children. Presenter-Dr. B unty S irkek Moderator-Prof. Dr. Ajay S ood. Body fluid compartments. TOTAL BODY WATER ECF compartment ICF compartment Vary with age Osmolarity remains constant, only fluid fraction changes. TOTAL BODY WATER ( 28 wk – 80 %

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Perioperative Fluid Management in children

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  1. Perioperative Fluid Management in children Presenter-Dr. BuntySirkek Moderator-Prof. Dr. Ajay Sood

  2. Body fluid compartments TOTAL BODY WATER • ECF compartment • ICF compartment Vary with age Osmolarity remains constant, only fluid fraction changes

  3. TOTAL BODY WATER ( 28 wk – 80 % INFANTS – 70 – 75 % OLDER CHILDREN & ADULTS – 60 -65 %) ICF- 2/3 rd OF TBW 30 – 40 % OF wt ECF -1/3 rd OF TBW 50 % OF wt AT BIRTH 20 – 25 % OF wt IN ADULTS TRANSCELLULAR FLUID 1 – 3% OF wt INTERSTITIAL FLUID-16 % OF wt PLASMA- 4-5% OF wt CSF AQ. & VITREOUS HUMOR SYNOVIALFLUID PERITONEAL FLUID PLEURAL FLUID

  4. Aim of fluid therapy • To supply water and thereby create enough urine volume to excrete solutes • To replace insensible fluid losses • To replace electrolytes lost from urine, skin,or gut • To satisfy caloric needs ,reducing tissue catabolism and providing a more normal ratio of carb,fat,and protein for energy • To supply necessary vitamins and minerals

  5. Fluid requirements of children are greater than adults • RATE OF CALORIC EXPENDITURE & GROWTH • RATIO OF SURFACE AREA TO BODY WEIGHT • DEGREE OF RENAL FUNCTION MATURATION &REDUCED RENAL CONC. ABILITY • AMOUNT OF TOTAL BODY WATER

  6. Assessment of fluid requirement BASED ON • BODY S.A. • BODY WEIGHT • CALORIC CONSUMPTION • CALORIMETRY

  7. BODY SURFACE AREA- • CALORIC EXPENDITURE IS PROPORTIONAL TO BSA • BODY WEIGHT- WEIGHT HRLY 24 HRLY <10 Kg 4ml/Kg 100ml/Kg 11 -20 40ml+2ml/Kg>10 1000ml + 50ml/kg>10 >20 Kg 60ml+1ml/Kg>20 1500+20ml/Kg>20

  8. BASED ON CALORIC CONSUMPTION (HOLLIDAY &SEGAR) WEIGHT CALORIC EXPENDITURE 0 -10 100kcal/kg/day 10-20 1000+50kcal/kg above10kg >20 1500+20kcal/kg above 20kg FOR EVERY 100 CALORIES CONSUMED 67 ml of water for solute excretion 50 ml/100 kcal for insensible loss 17 ml produced by oxidation

  9. THUS 67+50-17=100 100ml of water for 100 kcal OR 1ml fluid per 1kcal requirement BODY WEIGHT FLUID REQUIREMENT (HOLLIDAY & SEGAR) 0 -10 Kg : 4 ml / Kg /hr 10 -20 Kg : 40ml +2ml/Kg/hr above 10 kg >20 Kg : 60 ml+1ml/Kg/hr above 20 kg

  10. CALORIMETRY-LINDAHL FORMULA • CALORIE REQUIRED-1.5 * kg +5 (kcal/hr) • FLUID REQUIRED – 2.5 * kg +10 (ml/hr) • Na+ REQUIRED – 0.045*k+0.16(mEq/hr) • K+ REQUIRED – 0.03 * kg +0.1 (mEq/hr)

  11. NORMAL LOSSES AND MAINTENANCE REQUIREMENTS FOR FLUID,ELECTROLYTES, AND DEXTROSE IN INFANTS AND CHILDREN H2O = 100 TO 125 mL/100kcal EXPENDED COMPONENTS: INSENSIBLE LOSS (mL) 45 SWEAT (mL) 0 TO 25 URINE (mL) 50 TO 75 STOOL (mL) 5 TO 10 FOOD OXIDATION (mL) 12 Na+= 2.5 mmol/100 kcal EXPENDED COMPONENTS: BODY GROWTH SWEAT VARIABLE URINE VARIABLE STOOL VARIABLE K+ = 2.5 mmol/100 kcal EXPENDED COMPONENTS: AS FOR Na+ Cl- = 5 mmol/100 kcal EXPENDED COMPONENTS: AS FOR Na+ DEXTROSE = 25g/100 kcal EXPENDED COMPONENTS: BASAL METABOLIC RATE GROWTH AND TISSUE REPAIR PHYSICAL ACTIVITY MAINTENANCE SOLUTION (PER LITRE OF WATER) DEXTROSE (g) 50 K+ (mmol) 25 Na+ (mmol) 25 Cl- (mmol) 50

  12. Fluid management in children • Fluid management is divided into 3 phases- • Deficit therapy • Maintenance therapy • Replacement therapy

  13. Deficit therapy • Management of fluid & electrolyte losses before pts. presentation for surgery • Fluid deficits due to overnight fasting • 3 components 1.severity of dehydration 2.type of fluid deficit 3.repair of deficit

  14. Assessment of dehydration

  15. TYPE OF DEHYDRATION • ISOTONIC • HYPOTONIC • HYPERTONIC • ISOTONIC DEHYDRATION- • S.Na+ LEVELS-NORMAL • RESULT IN ECF DEFECIT • CAUSES-GI LOSSES,PLEURAL EFFUSION • Rx – BSS • HYPOTONIC DEHYDRATION- • INAPPROPRIATE SELECTION OF I/V FLUIDS /HYPOTONIC FLUID OVERLOADING • Rx – MILD- ISOTONIC SALINE SOL. • SEVERE- 3% SALINE

  16. HYPERTONIC DEHYDRATIONS.Na+ LEVEL- ↑ EC &ICF EQUALLY AFFECTED CAUSES - ABNORMAL LOSSES INADEQUATE INTAKE OF WATER Rx – 2.5 -5% D • INADEQUATE INTAKE OF WATER • VOMITING • DISEASES OF PHARYNX ,ESOPHAGUS ,CNS • ABNORMAL LOSSES- • DI • OSMOTIC DIURESIS • EXCESSIVE SWEATING • VOMITING

  17. ALL DEGREE OF DEGREE OF DEHYDRATION / HYPOVOLEMIA MUST BE CORRECTED BEFORE INDUCTION OF ANAESTHESIA UNLESS THE NATURE OF ILLNESS & OPERATION PRECLUDE THIS REPLACEMENT VOLUME (L) % DEHYDRATION * TBW +DAILY MAINTENANCE FLUID % DEHYDRATION = IDEAL WT – PRESENT WT IDEAL WT FOR AGE

  18. HYPOVOLEMIA (LOSSES FROM IV SPACES) • BOLUSES OF ISOTONIC SALINE/COLLOID • BLOOD IF- Hb IS LOW & >40 ml/Kg OF FLUID IS REQUIRED • DEHYDRATION(TOTAL BODY WATER LOSS) • SHOULD BE CORRECTED SLOWLY • PREFERABLY BY ORAL ROUTE IF TOLERATED & TIME ALLOWS,OTHERWISE I/V RAPID REHYDRATION TECHINQUE- (ASSADI & COPELOVITCH) INITIAL RAPID INFUSION OF NS TO CORRECT HYPOVOLEMIA SLOWER CORRECTION OF DEHYDRATION OVER 24-72 hrs WITH 0.9%,0.45%,OR 0.25% SALINE

  19. INTRAOPERATIVE FLUID THERAPY • REPLACE FOR • NPO DEFICIT • MAINTENANCE FLUID • ONGOING LOSSES & THIRD SPACE LOSSES • NPO GUIDELINES FOR PAEDIATRIC PATIENT • SOLID FOOD 6HRS • MILK 4HRS • CLEAR FLUIDS 2HRS

  20. ESTIMATED FLUID DEFICIT hrs of NPO * hourly fluid requirement • FLUID INFUSION RATE 1st hr =1/2 of EFD + maintenance fluid + losses 2nd hr =1/4 of EFD + ” 3rd hr = ¼ of EFD + ” • EFD & Losses are replaced with balanced salt solution • Maintenance Fluid--5%D IN N/2 –N/5 2.5% IN N/2 – N/5

  21. COMPOSITION OF REPLACEMENT FLUIDS CHO Prot. Cal/L Na+ K+ Cl- HCO3- Ca2+ OSM LIQUID (g/100mL) (mEq/L) (mg/dL) D5W 5 -- 170 -- -- -- -- -- 255 D10W 10 -- 340 -- -- -- -- -- -- NORMAL SALINE -- -- -- 154 -- 154 -- -- 308 (0.9%NaCl) ½ NORMAL -- -- -- 77 -- 77 -- -- -- SALINE(0.45% NaCl) D5(0.2%NaCl) 5 -- 170 34 -- 34 -- -- -- 3%SALINE -- -- -- 513 -- 513 -- -- -- 8.4% SODIUM -- -- -- 1000 -- -- 1000 -- -- BICARBONATE (1 mEq/mL) RINGER’S 0 to 10 -- 0 to 340 147 4 155.5 -- 4.5 273 RINGER’S LACTATE 0 to 10 -- 0 to 340 130 4 109 28 3 -- AMINO ACID -- 8.5 340 3 -- 34 52 -- -- 8.5%(TRAVASOL) PLASMANATE -- 5 200 110 2 50 29 -- -- ALBUMIN -- 25 1000 150 to 160 -- <120 -- -- -- 25%(SALT POOR) INTRALIPID 2.25 -- 1100 2.5 0.5 4.0 -- -- --

  22. INTRAOP THIRD SPACE LOSSES • Acute sequestration of fluid to a nonfunctional compartment • Occurs in –surgical trauma blunt trauma burns infections • Vary with surgical proceedures TYPE OF SURGERY3rd SPACE LOSS Intra abdominal. 6-10ml/Kg/hr Intra thoracic 4-7ml/Kg/hr Superficial/eye surg 1-2ml/Kg/hr neurosurgery

  23. Allowable blood loss • It is important to have a plan for blood-loss replacement based on the child’s preoperative condition, haematocrit and nature of the surgery. • ABL = weight x EBV x (H0 – H1)/Ha Where H0 = patient’s original haematocrit, H1 = lowest acceptable haematocrit, and • Ha = the average haematocrit =(H0 +H1)/2

  24. REPLACEMENT OF BLOOD LOSS • IN CHILDREN ALL BLOOD LOSS SHOULD BE REPLACED • WITH PRBC,WB,COLLOID CRYSTALLOIDS • IF CRYSTALLOID IS USED- EACH 1ml OF BLOOD LOST TO BE REPLACED BY 3 ml OF FLUID • DAVENPORT’S LAW- • FOR <10% BLOOD LOSS- NO BLOOD REQUIRED • >20% LOSSES MUST BE REPLACED BY PACKED CELLLS OR WB • 10-20% CONSIDER CASE BY CASE

  25. MONITORING INTAOP. FLUID THERAPY • Skin color, mucus membrane, nail beds-anaemia, low cardiac output, hypothermia,hypoxia • Blood Pressure • Pulse Rate • CRITICALLY ILL/COMPLEX PROCEDURE INVASIVE BP MONITORING BLOOD GASES Hct, RBS S.ELECTROLYTES &PROTEINS • Urine output& Urine Na+ levels • CVP Monitoring

  26. POSTOPERATIVE FLUIDS • Maintain iv drip till child is NPO • Loss of ECF due to Ryle’s tube,fistula drainage to be replaced by BSS • Blood loss monitored and replaced if necessary • Maintain U.O >0.8 ml/kg /hr

  27. ADJUSTMENT REQUIRED IN FOLLOWING CASES • FEVER ↑ CALORIE REQURIMENT BY 12% FOR EACH 1ºC RISE IN TEMP • HYPOTHERMIA ↓ FLUID REQUIREMENT • HYPERMETABOLIC STATES ↑ CALORIE REQUIREMENT BY 25 -75% • HYPOMETABOLIC STATES ↓ REQUIREMENT BY 10-25% • STOOL WATER LOSS DOUBLED BY PHOTOTHERAPY • RADIANT WARMERS ↑TRANS EPITHELIAL LOSS BY 50-140% • PLASTIC COVERING↓LOSS BY 50-70% • IF VENTILATION WITH NONHUMIDIFIED GASES ADD 5ml/Kg/hr FOR RESPIRATOY FLUID LOSS

  28. CONCLUSION • MAJORITY OF FIT PAEDIATRIC PATIENT UNDERGOING MINOR SURGERY RE-ESTABLISH ORAL INTAKE IN EARLY POSTOP.PHASE AND NOT NEED ROUTINE I/V FLUIDS • HYPOTONIC FLUIDS SHOULD BE USED WITH CARE & MUST NOT BE INFUSED IN LARGE VOLUMES OR AT GREATER THAN MAINTENANCE RATES • HYPOVOLEMIA SHOULD BE CORRECTED WITH RAPID INFUSION OF SALINE WHILE DEHYDRATION CORRECTED SLOWLY • ONGOING LOSSES SHOULD BE MEASURED & REPLACED • PLASMA ELECTROLYTES & GLUCOSE SHOULD BE MEASURED REGULARLY IN ANY CHILD REQUIRING LARGE VOLUMES OF FLUID OR WHO IS ON I/V FLUIDS FOR >24HRS

  29. Thankyou

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