Lecture Content

I. Fluid Resuscitation

Fluid resuscitation and perioperative II. Maintenance fluid requirements

III. Perioperative fluid management
fluid therapy IV. Controversies and recommendations

COTWAF, Chennai, 20 – 22 February 2008

Dr Thomas Engelhardt, MD, PhD, FRCA

Royal Aberdeen Children‘
Children‘s Hospital, Scotland

Fluid resuscitation

PALS

APLS

EPLS

Symptoms and signs of dehydration

Judge severity of dehydration
CONSENSUS GUIDELINE ON
PERIOPERATIVE FLUID
MANAGEMENT IN CHILDREN
Sept 2007

Fluid resuscitation Fluid resuscitation

APLS Algorithm
IV access

Type of fluids

IV access
• large bore
• ? central COOK Jamishidi needle Sherwood Illinois needle

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 Fluid resuscitation Fluid resuscitation

Dehydration Assessment

APLS: oral rehydration

Fluid resuscitation Fluid resuscitation

POCA registry 1994-2004

Bhananker, Anesth Analges, 2007 Bhananker, Anesth Analges, 2007

Maintenance fluid requirements Maintenance fluid requirements

Aspects of perioperative fluids

Volume

Electrolytes

Glucose

Lack of large prospective randomised Holliday & Segar, Pediatrics 1957; 19: 823-32
controlled clinical trials

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 Maintenance fluid requirements Maintenance fluid requirements

Holliday Segar: 4-2-1 Rule

Example 15 kg child:

(4 x 10) + (2 x 5) = 50 ml per hour

(100 x 10) + (50 x 5) = 1250 ml per day (52 ml/hr)

Energy expenditure 50% lower during anaesthesia

Lindahl SG, Anesthesiol 1988; 69: 377

Maintenance fluid requirements Maintenance fluid requirements

APA consensus statement: Electrolytes daily requirements:

‘Maintenance fluid requirements should be calculated
Sodium: 3 mmol/kg
according to the recommendations of Holliday and
Potassium: 2 mmol/kg
Segar for children and infants older than 4 weeks of age,
Chloride: 2 mmol/kg
using body weight. It is important that all formulae
Hypotonic solution
should be used as a starting point only and the
Holliday, Pediatrics 1957; 19: 823-32
individual child‘s response to fluid therapy should always
be monitored and appropriate adjustments made.‘

Glucose 4% - iso-osmolar – painless injection

Hypotonic solution

Maintenance fluid requirements Maintenance fluid requirements

Hyponatraemia Hyponatraemia
Mild: 125-130 mmol/l Mild: 125-130 mmol/l
Severe: <125 mmol/l Severe: <125 mmol/l

Causes Causes

Hypotonic fluid administration
Hypotonic fluid administration

Impaired free water elimination (ADH secretion)
Impaired free water elimination (ADH secretion)
ADH secretion:
Brain injuries/ tumours
Haemorrhage, relative hypovolaemia, pain, stress, nausea,
sleep, morphine NSAIDs

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 Maintenance fluid requirements Maintenance fluid requirements

Hyponatraemia consequences
DEATH

Decreasing levels consciousness
J Pediatr Urol. 2008; 4: 231-3.

Disorientation Acta Otorrinolaringol Esp. 2006; 57: 247-50.

Nausea & vomiting Pediatr Nephrol. 2005; 20: 1687-700.

Ann Fr Anesth Reanim. 2000; 19: 467-73.

Seizure activity
Int J Pediatr Otorhinolaryngol. 1994; 30: 227-32.

DEATH

Maintenance fluid requirements Maintenance fluid requirements

Glucose –too little or too much Glucose – Hypoglycaemia risk

Lacking glycogen storage of adults
Neonates first 48 hours of life

Risk of hypoglycaemia / brain damage neonates
Interrupted glucose infusion

Long term TPN

Larsonn LE et al. Br J Anaesth 1990: 64: 419

Osmotic diuresis/ dehydration and electrolyte imbalance

Neurological deficits in cardiac surgery

Worse hypoxic ischaemic brain or spinal cord damage

Maintenance fluid requirements Maintenance fluid requirements

Hypoglycaemia – APA consensus guideline (2007) Ideal maintenance fluid

NLY

Majority of children over 1 month of age will maintain a
normal blood sugar if given non-dextrose containing fluids

Near isotonic (Saline 0.9%, Lactated Ringers or Hartmanns)
O
Maintain blood glucose
US
during surgery
S ? 1% dextrose containing solutions

EN

Children at risk of hypoglycaemia are those on parental
(Murat I. Pediatr Anesth 2007; 18: 363)

NS
nutrion or dextrose containing solution, low body weight (<3rd
centile) or surgery longer than 3 hours
C O
Plasma osmolarity 280-300 mosm/l
Give dextrose containing solutions or need to monitor blood
glucose level
Thrombophlebitis risk small <450 mosm/l

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 Maintenance fluid requirements Maintenance fluid requirements
Operative period Fluid choice Number of
Ideal maintenance fluid anaesthetists (%)

Solution Osmolarity Tonicity Na+ K+ Ca2+ Cl- HCO3- Intraoperative fluid Hypotonic dextrose saline solutions
mosm/l mosm/l maintenance Dextrose 4%/saline 0.18% 99 (50%)

Dextrose 2.5 or 5%/saline 0.45% 31 (15.7%)

Hartmann’s 980ml Isotonic solutions

+Glucose 50% 20mls 352 272 127 4.9 1.96 109 28 Hartmann's solution 72 (36.4%)
(1% glucose final
concentration) Saline 0.9% 48 (24.2%)

Bolus for hypovolaemia Hypotonic dextrose saline solutions 22 (11.1%)

Hartmann’s 950ml
intraoperatively Isotonic solutions
+Glucose 50% 50mls 646 264 124 4.75 1.90 105 28
(2.5% glucose final (saline 0.9%, Hartmann's or colloid) 161 (81.3%)
concentration) Hypotonic dextrose saline solutions
Postoperative fluid maintenance
Hartmann’s 900ml Dextrose 4%/saline 0.18% 130 (65.7%)
+Glucose 50% 100mls 650 250 117 4.5 1.80 100 26 Dextrose 2.5 or 5% with saline 0.45% 43 (21.7%)
(5% glucose final
Isotonic solutions
concentration)
Hartmann's solution 25 (12.6%)
Way C Br J Anaesth 2006; 97:371 Saline 0.9% 24 (12.1%)
Thornton KL. BJA 2006; e-letters

Perioperative fluid managament Perioperative fluid managament

Aspects of perioperative fluid management Existing fluid deficits – Fasting (APA consensus)

Existing fluid deficits
Clear fluids: 2 hours

Maintenance fluid requirements
Breast milk: 4 hours

Losses (blood loss, 3rd space)
Solids: 6 hours

Dehydration without hypovolaemia – slow correction

Hypovolaemia – rapid correction

450

Perioperative fluid managament 400

57.8 % Are you hungry or thirsty?
350

Excessive Fasting 300

250 33.9 %
29.9%
Hunger Thirst 200
1 2 3 4 1 2 3 4
23.8 %
Severity
150
n= 698 268 135 194 101 94 115 281 208

Fasting times 12:44 11:12 10:40 10:22 9:27 9:04 9:51 10:08 100
(3:36) (4:27) (4:44) (4:47) (4:50) (5:04) (4:59) (5:24)
(h)
6.1 %
50

0
Engelhardt T. ASA 2008; A1012 Very Very Hungry & Hunger Thirst
Hungry Thirsty Thirsty Alone Alone
Engelhardt T. ASA 2008; A1012

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 Perioperative fluid managament Perioperative fluid managament

Replacement fasting deficits Replacement fasting deficits

Halliday Segar formula (4-2-1) rule
Halliday Segar formula (4-2-1) rule

Replace at least half fasting deficits in first hour
Replace at least half fasting deficits in first hour

15 kg child 10 hour fasted: 45 kg child 10 hour fasted:

Deficit 10 hours x 50 ml = 500 ml Deficit 10 hours x 85 ml = 850 ml
Replace at least half in first hour = 250 ml Replace at least half in first hour = 425 ml
Add hourly maintentance (50 ml) + 50 ml Add hourly maintentance (50 ml) + 85 ml
1st hour fluids = 300 ml 1st hour fluids = 510 ml

Yaster M, COTWAF 2007 Yaster M, COTWAF 2007

Perioperative fluid managament Perioperative fluid managament

Perioperative fluid losses Perioperative fluid losses

Blood losses

Blood losses
Replacement:

Insensible/ 3rd space losses
1:1 blood/ colloid or 3:1 crystalloid (use colloids after 50ml/kg)

Crystalloids/ colloids debate Estimated blood volume = weight (kg) x Premature 100 ml/kg
Low cost, no effect on coagulation, no anaphylactic reaction
Term neonate 90 ml/kg

Choice of colloids 6 months 80 ml/kg
VPC = ∆Hct x weight (kg) x (1.5)
Gelatins/ Albumin / Starches (limit quantities) 1 year 75 ml/kg

Teenager 65 ml/kg

Perioperative fluid managament Perioperative fluid managament

Perioperative fluid losses

15 kg child 10 hour fasted, major laparotomy:

Insensible/ third space losses Deficit 10 hours x 50 ml = 500 ml
Replace at least half in first hour = 250 ml
Body surface surgery 1ml/kg/h
Add hourly maintentance (50 ml) + 50 ml
Major laparotomy 15-20ml/kg/h
Insensible losses 15 ml x 10 ml/kg/h + 150 ml
Necrotizing enterocolitis 50ml/kg/h
1st hour fluids = 450 ml

Use isotonic solutions only (0.9% Saline, Hartmanns)

Hyperchloraemic metabolic acidosis (? benign)

Yaster M, COTWAF 2007

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 Perioperative fluid managament Perioperative fluid managament

Postoperative fluid management

45 kg child 10 hour fasted, major laparotomy:
Deficit 10 hours x 85 ml = 850 ml
Early oral intake
Replace at least half in first hour = 425 ml ‘Superhydration‘ reduced PONV (Goodarzi M Pediatr Anesth 2006; 16: 49)
Add hourly maintentance (50 ml) + 85 ml
Insensible losses 85 ml x 10 ml/kg/h + 850 ml
Delayed oral intake
1st hour fluids = 1360 ml Provide basic metabolic requirements (4-2-1)
Replace ongoing losses (isotonic fluids)

Yaster M, COTWAF 2007

Controversies and recommendations Controversies and recommendations

Controversies Recommendations

Volume of maintenance
Avoid dehydration and correct hypovolaemia
80 % of 4 - 2 – 1
Consider fluid composition
Compromise between sodium, energy requirements and osmolarity

Composition of fluids
Monitor sodium and glucose daily in acute patients

Provide basic metabolic requirements (4-2-1)
Risk of hypoglycaemia small (except neonates, TPN)
Replace ongoing losses (isotonic fluids)

Beware hidden fluid administration (drugs)

Beware hyponatraemia

Controversies and recommendations

Further readings

APA consensus guidelines (2008)

Murat I et al Pediatr Anesth 2008; 18: 363-370.
Lonnqvist PA Pediatr Anesth 2007; 17: 203-205.
Cunliffe M et al Br J Anesth 2006; 97: 274-277.

CONSENSUS GUIDELINE ON
PERIOPERATIVE FLUID
MANAGEMENT IN CHILDREN
Sept 2007

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Thank You