Professional Documents
Culture Documents
20
One would think that the management of fluid and electrolytes would be
a subject that has long since been defined and quantified, but this is not the
case. Mismanagement of fluid and electrolytes still contributes to morbidity
and death for infants and young children undergoing even the simplest
procedures such as herniorrhaphies. Failure to resuscitate young patients from
hypovolemic deficiency states leads to multisystem failure and, often, to their
demise. Inappropriate overhydration of the young infant during the stresses of
anesthesia and surgery can produce interstitial fluid shifts and pulmonary
edema leading to respiratory difficulties in situations in which one would not
expect to find them. If this occurs in a hospital or ambulatory care setting that
is ill-equipped to deal with critical care management of infants and children,
unexpected morbidity and death can result.
Therefore, it is essential that the surgeon assess the fluid needs of the
patient throughout the entire period of surgical management: in the preopera-
tive resuscitation phase, if there is one; during intraoperative management,
tailoring the fluid and electrolyte administration to the degree of deficiencies
created by the surgical procedure and the underlying disease state; and
throughout the postoperative recovery phase until the patient has regained the
normovolemic state and is back to baseline maintenance fluid requirements.
This assessment must take account, not only of the volume requirement and
the rate of administration and resuscitation, but also of the composition of the
fluid with regard to electrolyte, osmotic, and colloid requirements. Considera-
tions such as the need for additional oxygen-carrying capacity and clotting
factors will influence the choice of some of the fluids in the program. A
thorough understanding of the role of such regulatory factors as the renin-
angiotensin mechanism and, most particularly, antidiuretic hormone is essential
From the Division of Pediatric Surgery and Pediatric Trauma, Department of Surgery,
University of Tennessee Medical Center, Knoxville, Tennessee
blood loss, in which the peritoneal cavity is not significantly invaded, and in
which the disease produces neither inflammation, edema, nor ascites, fluid
administration should consist primarily of replacing insensible losses. Insensible
losses are maintenance losses and reflect the constant evaporation of water and
a very small amount of electrolyte from the surface of the body as well as the
considerable volumes of water lost during breathing as the respiratory passages
hydrate the inspired air to a partial pressure of water vapor of approximately
47 mm Hg. Because only a small amount of oxygen is extracted from the
inspired air and the rest of the oxygen and all of the nitrogen and pollutants
that have been hydrated during inspiration are then expired, most of this water
of hydration is lost to the atmosphere.
The average adult (defined as one who has a body surface area of
approximately 1. 73 m2 and weighs approximately 70 kg) requires 1000 mL of
water per square meter or approximately 25 mLlkg. This volume will replace
.the free water losses of evaporation from the skin and the losses from hydration
of inspired gases that are subsequently exhaled. In addition, it will supply an
adequate volume of free water as a solvent for the day's metabolic wastes,
which are excreted as urine. I have generally rounded off the typical adult's
maintenance fluid requirement to 1500 mL of free water, to which must be
added 5% dextrose to provide a minimal caloric load to operate the Krebs cycle
and provide an osmotic content to avoid lysis of red cells at the site of fluid
administration. The insensible loss of electrolytes for an adult is primarily in
the form of urinary and fecal excretion, with a small amount of loss by
evaporation from the skin surface. For a typical adult, this requirement amounts
to 45 to 60 mEq of sodium chloride per 24 hours and approximately 40 to 45
mEq of potassium per 24 hours.
To define the insensible or maintemmce requirements for infants and
children ranging from the extremely premature low-birth-weight neonate to
the child who is approaching adult weight and body habitus requires one or
more formulas that relate these requirements to the patient's size and the
increased volume requirement per weight for the tiny infant. The most com-
monly applied formula is that which states that the free water requirement per
day is equal to:
100 mLlkg up to 10 kg
50 mLlkg from 11 to 20 kg and
20 mLlkg beyond 20 kg
with a maximum cut-off at adult maintenance, which we have defined for our
purposes as 1500 to 2000 mLiday. A second formula '2 that approximates the
first over a wide range of sizes and ages defines the maintenance requirement
as being equal to:
(100 mL - 3 x age [years]) x weight (kg)
When this formula yields 1500 mL, the maximum has been reached. Notice
that these are essentially reduction formulas that account for the fact that the
newborn infant requires 100 mL of fluid per kilogram per day whereas the
adult requires only 25 mLlkg daily.
Similarly, electrolytes can be defined for the infant by a formula which
states that the need for sodium, chloride, and potassium is equal to 3 mEq/kg
per 24 hours. However, we have already stated that the adult requires 45 to 60
mEq of sodium chloride and 40 to 45 mEq of potassium per day. Were we to
utilize a formula of 3 mEqlkg throughout the entire age spectrum leading to
adulthood, the adult would require 3 mEqlkg, so the average adult at 70 kg
1192 FILSTON
would require 210 mEq/day, which is far in excess of the requirement previously
stated. On the other hand, by adding 3 mEqlkg to the 100 mLlkg free-water
requirement for the infant, we would produce a solution equivalent to one-
fifth (20%) normal saline. Normal saline has 154 mEq/L or 15.4 mEq/dL, and
one-fifth normal saline would have 3 mEq/dL. If we use one-fifth normal saline
as a standard maintenance solution and apply appropriately the formulas that
we know reduce the volume of fluid administration throughout the childhood
age groups, we would find that when we reach the 1500-mL maximum that
we defined for the typical adult, we would be giving 45 mEq of sodium chloride
per day in our 1500 mL of fluid (3 mEq/dL = 30 mEq/L = 45 mEqll.5 L).
We have now ascertained the insensible losses for children as an amount
calculated by a formula that defines the volume and electrolyte needs in relation
to size throughout a wide range up to a maximum for the typical adult. If we
take an example, then, of a 6-kg 4-month-old infant undergoing an inguinal
herniorrhaphy scheduled for 10 AM, we should first of all let him have his
regular feeding schedule up until 7 AM the morning of surgery, at which time,
he should get a clear liquid feeding. After he is anesthetized for the surgical
procedure, an intravenous line is started, and, considering that a herniorrhaphy
usually lasts approximately 1 hour (not actually operating time), we would
plan to give him half of his insensible loss requirement for a 4-hour period
during the operating time. His 24-hour requirement, 100 mL - 3 x his age in
years, means that he would require 98 to 100 mLlkg or 600 mL in 24 hours. In
4 hours, he would, therefore, require one sixth of this amount, or 100 mL of a
solution containing 3 mEq of sodium chloride per 100 mL, or 100 mL of one-
fifth normal saline containing 5% dextrose. We could add to this fluid 3 mEq
of potassium chloride (or potassium phosphate) to provide him with his
potassium maintenance requirement. An acceptable rate of fluid administration
for this child would be 50 mL during his hour in the operating room and 50
mL in the hour following surgery, at which point, he would be returned to his
maintenance rate of 25 mLlhour until he is taking clear liquid adequately by
mouth. Unless the child for some reason was dehydrated prior to being fluid
restricted to assure an empty stomach, there is little to substantiate a need for
any additional significant volumes of fluid; therefore, hypotension in the
operating room must be addressed in terms other than the administration of
additional volumes of dilute fluid. Obviously, if the patient has been fluid
restricted for a longer period of time, additional volume considerations are
appropriate.
MEASURED LOSSES
plasma or serum and are best replaced by balanced salt solutions such as
lactated Ringer's solution (D5%/LR).
Most patients undergoing elective surgery will not have a measured loss
consideration, at least until the postoperative period. However, when a meas-
urable loss is recognized, particularly those of significant volume from the
gastrointestinal tract, a timely replacement (at least an every-4-hour schedule)
should be ensured.
Whenever the patient has experienced losses beyond the standard insen-
sible losses, or when measurable losses of body fluids have not been replaced
in a timely fashion, the hypovolemic state exists; and fluid considerations
become not only more significant, but more sophisticated. Other than loss of
airway integrity, there is no more urgent state than that of the patient who is
in hypovolemic shock or near-shock from volume deficits, as in this state, at
least some of the body's tissues are being underperfused and therefore made
ischemic. The longer such a condition persists, the more damage there will be
to vital tissues. Eventually, not only is there irreversible hypoxic injury to the
tissues, but there is release of destructive subcellular elements that may
deleteriously alter the function of enzyme systems in other organs and bring
on a state of respiratory failure. 7 It also leaves the patient with depressed
immune function and open to the further destructive effects of this septic state.
Therefore, assessment of the patient's history and physical findings, together
with a judgment about the effects of the patient's illness on the state of volume
integrity, must be achieved rapidly.
If there is any doubt about the patient's state of volume integrity, a rapid
infusion or "push" of an osmotically active solution such as balanced salt
solution (D5%/LR) should be administered. It has been shown experimentally,
and extensively confirmed clinically, that a fully volume-repleted patient can
tolerate a rapid expansion of the blood volume of 25% without any deleterious
circulatory effects. Using 8% as the blood volume for infants and children, the
blood volume would be 80 mLlkg, and the 25% "push" would equal 20 mLi
kg. If hypovolemia is suspected, therefore, a rapid infusion of D5%ILR, 20 mLi
kg, should improve circulatory dynamics to the point of allowing a small
urinary response, which would confirm the hypovolemic state, while at the
same time such a push will not harm the fully repleted patient who has a
normal circulatory system. Obviously, there may be an occasional patient in
incipient heart failure who is volume repleted and who will be tipped into
heart failure by such a volume expansion. Nevertheless, this risk is a better
one to take than to leave a patient volume depleted.
Although one would hope that a thorough understanding of the principles
1194 FILSTON
restitution. Blood products such as plasma and whole blood have even greater
holding power as far as their ability to restore vascular volume deficits without
significant shifts to the extravascular space. However, the relative risks of the
use of these products limit them to situations in which either red cell carrying
capacity is severely depleted, in which case, the use of packed red blood-cell
transfusions combined with balanced salt solution would be appropriate, or in
which clotting factor deficiencies exist, in which case, the use of plasma will
not only give excellent restoration of volume but will also provide the needed
clotting factors. Plasma can also be used where the need for excellent volume
restoration with minimal edema formation makes the risk of transfusion
reactions and the introduction of infectious agents worth taking.
Whenever volume depletion is recognized or anticipated, some type of
osmotically active fluid (e.g., DS%/LR) should be administered to the patient
until the volume depletion is overcome. Only then should the more hypotonic
solutions that are generally used to replace measured losses (such as gastric
aspirates) or the even more dilute quarter-normal or one-fifth normal saline
solutions used for replacement of insensible losses be introduced into the fluid
program. Preoperative volume restoration should continue at a rapid pace until
volume normalcy is confirmed by the resumption of an appropriate urine
output.
Blood pressure alone is not an adequate measure of volume restoration,
because the ability of the vascular system to constrict and shunt blood from
less vital tissues means that normal central blood pressure will be maintained
until quite late in the hypovolemic shock state. In a young, healthy individual
with highly responsive cardiac function and the ability to constrict the peripheral
arterioles, more than 30% of the blood volume may be lost before a significant
fall in central blood pressure is appreciated. 2 By the time that state exists,
severe restriction of flow to many vital tissues has already occurred.
During the operative procedure, the fluid choice should be that of the
most dominant fluid loss. For simple elective procedures such as treatment of
hernias and "lumps and bumps," insensible loss is the dominant fluid deficit,
and appropriate hypotonic fluids should be given to replace free water and
minimal electrolytes. For procedures in which significant blood loss occurs or
in which major prolonged invasion of the abdominal or thoracic cavity is
involved, volume-restoration fluids of the balanced salt or blood products
variety should be chosen. It would be best to base this volume restoration on
a combination of the assessment of the preoperative volume restoration state
and the intraoperative and postoperative fluid requirements. If the patient
arrives in the operating room fully volume restored, this estimate can be based
on the intraoperative and postoperative requirements alone.
Until the early 1960s, the guiding principles for fluid and electrolyte
management of the postoperative patient in general, and the child patient
specifically, were fluid restriction and absolute electrolyte restriction. High
levels of aldosterone and antidiuretic hormone were noted to be present in the
1196 FILSTON
For infants and young children, a urine output of 40 mLlkg per 24 hours
reflects adequate volume restitution. For an adult, on the other hand, 1200 mLi
day, which represents about twice the amount of urine needed for adequate
clearing of the day's metabolic solutes, should be sufficient. The older child
does not need a greater urine output than an adult, so the formula 40 mLlkg
per day should be used only until the child weighs 30 kg, at which time, the
calculation equals 1200 mL. For the young infant, 40 mLlkg per day is
approximately 1.5 to 2.0 mLlkg per hour. This hourly formula can be utilized
until the child weighs 25 to 30 kg, at which point, the calculation becomes 50
to 60 mLihour (1200 mLlday).
We have shown elsewhere that the guess can be refined by relating the
degree of intra-abdominal trauma or obstructive or inflammatory disease to the
size of the patient. 4 The abdominal cavity is divided into quadrants. An
additional volume of osmotically active solutions will be required that is equal
to one fourth of the maintenance volume for each quadrant that is affected by
either an obstructive or inflammatory disease or a surgical intervention. With
this system, the patient could require a maximum of two times the maintenance
volume in the form of balanced salt solution or more active osmotic solution
(red cells, plasma) if the disease affects the entire peritoneal cavity (four
quadrants) and the surgeon explores the entire abdominal cavity (four quad-
rants).
FLUID AND ELECTROLYTE MANAGEMENT IN THE PEDIATRIC SURGICAL PATIENT 1199
EXAMPLE
A 4-year-old, 20-kg child has had several days of crampy abdominal pain
that has become more severe and less intermittent. For the last 2 days, he has
been vomiting repeatedly, and the vomitus, which was originally made up of
ingested food and liquids, has become first bile stained and then greenish
brown. His fever has gradually inched up to the 38° to 39°C range, and his
urine output has dropped significantly, with his urine darkening over the past
24 hours. He has become increasingly lethargic and is dizzy when he arises
from bed.
On physical examination, he is found to have a temperature of 38.3°C, his
abdomen is quite tender with guarding throughout, and bowel activity is
depressed. He was thought to have a ruptured appendix and was hydrated
with lactated Ringer's solution until his urine output came up to 38 mLihour
for 2 hours, at which point, he was taken to the operating room and his
abdomen explored. A ruptured Meckel's diverticulum with inflammatory adhe-
sions of bowel loops and a high-grade distal partial small-bowel obstruction
was encountered. The diverticulum was wedged out with a transverse closure
of the bowel, inflammatory adhesions were taken down, and the peritoneal
cavity was lavaged with warm saline and closed without drainage. An incidental
appendectomy was performed.
Question: Do we have evidence that his volume status was reasonably reconstituted
prior to the operative procedure?
Assuming that his 38 mLihour urine output represented adequate initial
1200 FlLSTON
volume restoration, but also assuming that he has both uncorrected long-term
losses and an ongoing inflammatory state that will result in additional fluid
losses, we would calculate his 24-hour volume requirements first by the formula
for maintenance-IOO mLlkg to 10 kg and SO mLlkg to 20 kg, which reaches
our maximum volume of lS00 mL, which we will eventually give as DS%I
quarter NS with 20 to 30 mEq of potassium chloride added per liter. Assuming
he had 100 mL of loss through his nasogastric tube before and during the
operation, he will need an additional 100 mL of fluid in the form of DS%/half
NS plus 30 mEq of potassium chloride per liter. His nasogastric losses must be
monitored continually on at least a 4-hour basis and his measured-loss resto-
ration increased as indicated. Applying the quadrant scheme, his generalized
peritonitis would mandate four quadrants or one additional maintenance
volume. The extent of surgical trauma is open to some debate, but with a
general exploration of the abdominal cavity, running of the bowel, and resection
of the Meckel's diverticulum, at least three or four quadrants would probably
be an appropriate guess. Using four quadrants, we would then have eight
quadrants or two additional maintenance volumes, which we will give in the
form of DS%/LR to this patient who is otherwise in good health and should be
able to tolerate the fluid shifts that will occur when his volume deficit is
restored with a fluid that is deficient in colloid osmotic pressure. He has no
requirement for additional red cell carrying capacity, and we have no infor-
mation that he has any clotting deficit. We could certainly use an albumin-
containing solution, but the question of expense versus benefit must be factored
in.
This child's total fluid administration for the 24 hours following surgery
would then look like this: volume restitution-3000 mL of DS%/LR, mainte-
nance fluid-1S00 mL of DS%/quarter NS plus 30 mEq of KCl, and measured
10ss-100 mL of DS%/half NS plus 3 mEq of potassium chloride with additional
volumes added every 4 hours depending on nasogastric losses. This totals 4600
mL, or approximately 190 mLihour. We should, therefore, begin by adminis-
tering 190 mL of DS%/LR per hour and monitor his urine output. If it is
significantly less than 30 mLihour (1.S mLlkg per hour), we should increase
the rate of volume administration; if it is significantly greater than 40 mLihour
(2 mLlkg per hour), we should decrease the rate of volume administration.
Careful monitoring of urine output and adjustments of rate should allow us to
bring this child into normovolemia and maintain him there in the postoperative
period.
Once a rate is achieved that results in the appropriate hourly urine output,
we can assume that his volume is restored and that he will tolerate the less
osmotically efficient fluids that are reqUired for replacement of insensible losses.
We can then administer fluid in a variety of ways, anyone of which will ensure
that the patient continues to receive the volumes of balanced salt solution for
the remainder of the 24 hours that will maintain his urine output in the
appropriate range. One way is to continue to give only DS%/LR until the rate
of fluid required is down to the maintenance rate, at which point, the fluid is
changed to maintenance fluid (DS%/quarter NS). Another plan is to give a
combination of the calculated insensible losses (the maintenance fluids), the
measured losses, and whatever additional balanced salt solution is required to
maintain the appropriate hourly urine output for the balance of the 24-hour
postoperative period.
In this example of a 4-year-old, 20-kg patient, we started running balanced
salt solution at 190 mLihour and found that after 3 hours, his urine output was
averaging SO mLihour. When the fluid administration rate was slowed to ISO
FLUID AND ELECTROLYTE MANAGEMENT IN THE PEDIATRIC SURGICAL PATIENT 1201
mLihour, his urine output gradually carne down to 38 mLihour and stayed
there. Because this is within the appropriate range, the rate of fluid adminis-
tration for the remainder of the postoperative period should be 150 mLlhour
as long as the urine output remains within the appropriate range. If 190 mL of
D5%/LR were run each hour for 3 hours for a total of 570 mL, and if 150 mL
were run in per hour for the next 3 hours, this would be an additional 450 mL,
or a total of 1020 mL of D5%/LR that had been administered out of our original
"guess" of 3000 mL based on the quadrant system.
However, we have demonstrated that his volume deficit has been corrected,
inasmuch as he is maintaining appropriate urine output at this fluid adminis-
tration rate. We now have 18 hours (24 - 6) during which we will need to
administer his maintenance fluid of D5%/quarter NS plus potassium, which we
calculated at 1500 mL, the 100 mL of nasogastric losses in the form of D5'[o/half
NS, and whatever additional D5%/LR is required to maintain a rate of 150 mLi
hour for the 18 hours. A volume of 150 mLihour for 18 hours is 2700 mL, of
which 1500 mL will be D5%/quarter NS and 100 mL will be D5%/half NS plus
potassium chloride 30 mEq/L. This leaves 1100 mL (2700 - 1600) to be
administered in the form of D5%1LR. The original guess of 3000 mL was off
880 mL (3000 - 2120).
Maintenance fluid of 1500 mL for this child would require a rate of
approximately 65 mLihour. If his urine output is not being maintained with a
rate of 65 mLlhour by the end of the first 24 hours, the child will need additional
third-space fluid in the second 24 hours until the fluid administration rate can
be reduced to 65 mLihour while still maintaining a urine output in the
appropriate range of 30 to 40 mLihour. In all probability, this will be possible,
and over the next 18 hours, we will probably be able to reduce the rate of
administration and thus eliminate more of the D5%/LR.
Should we choose to use balanced salt solution exclusively during the first
24 hours after the operation, this would be perfectly appropriate, and we could
then adjust the rate until it is down to 65 mLihour, the rate required to
administer maintenance fluid. At that point, the patient should be switched to
D5%/quarter NS with added potassium for his maintenance fluid. Failure to do
so, with a continued administration of balanced salt solution over the next 24
hours or more when the deficit has been made up, will result in a relative
deficit of free water as the child's primary loss becomes insensible loss.
Continued administration of isotonic electrolyte solutions will eventually
result in raising his serum osmolality in the form of hypertonic sodium and
chloride balances so that eventually antidiuretic hormone will be secreted, not
because the patient is hypovolemic, but because he is hypertonic or hyperosmotic.
Failure to recognize this would lead to the inaccurate conclusion that the patient
is again hypovolemic, and if this supposed hypovolemia is corrected by
administration of additional volumes of osmotically active solution (D5%/LR),
the situation will be worsened as the patient becomes more hyperosmotic and
continues to secrete antidiuretic hormone and retain fluid. Under these circum-
stances, the patient can become fluid overloaded, resulting in pulmonary
edema. He can be extracted from such a state only by volume restriction and
the administration, at maintenance rates, of D5%/water. This will allow the
slow excretion of his excess electrolytes and the appropriate replacement thereof
with water, bringing him back into balance. Consult the case report in the
article in this issue on "Surgical Management of Children with Hemoglobin-
opathies" for a graphic example of the dire consequences of failure to recognize
these factors in the postoperative patient.
1202 FlLSTON
SUMMARY
The following is a quick guide to the perioperative fluid program discussed
in this article.
FLUID AND ELECTROLYTE MANAGEMENT IN THE PEDIATRIC SURGICAL PATIENT 1203
1. Always assess the state of fluid repletion in any patient presenting for surgical
management (Note: This does not necessarily mean operative management).
2. If the patient is hypovolemic or if there is the possibility of hypovolemia and you
are uncertain, restore volumes equal to 25% of the patient's blood volume with a fluid
push made up of an osmotically active electrolyte solution modified for the additional
requirements of red cell carrying capacity or clotting factors. If this results in a urine
output and correction of hypoperfusion or hypotension, maintain an increased fluid
administration program until a stable urine output and good perfusion are achieved. If
the patient is normovolemic at the time of presentation, particularly if the patient is
having an elective operative procedure and does not have an intravenous line in place,
calculate the insensible losses that will occur during the time of fluid restriction before
surgery and correct at least 50% of these during the operative procedure.
3. Develop the postoperative fluid program as a combination of 24-hour insensible
loss replacement (maintenance fluid), restoration of measured losses, and an estimate
(guess) as to the volume'requirements for third-space fluid shifts. Restore blood loss~s if
appropriate or administer additional volumes of balanced electrolyte solution at a 3-to-1
ratio to replace measured blood loss.
4. Total the insensible loss measurement, the measured losses, and the estimate of
third-space requirement and divide this volume by 24 to get an initial hourly fluid
administration rate.
5. Select the most osmotically active fluid that you intend to use and administer it
first at the calculated rate. Carefully monitor the patient's urine output.
6. Increase or decrease the fluid administration rate to bring the hourly urine output
within the guidelines for the appropriate hourly urine output (milliliters) for the particular
patient based on size (kilograms).
7. When the urine output falls within the appropriate range, maintain that rate of
fluid administration, and recalculate the volumes required because of insensible loss,
measured loss, and third-space shifts by subtracting the amount of fluid already
administered from the volume that will be required in the remainder of the 24 hours;
this will yield the volumes of additional maintenance, measured loss, and third-space
fluids that will make up the remainder of the fluids needed for the 24 hours.
8. Alternatively, administer balanced salt solution for the remainder of the 24 hours
or until the rate of administration can be decreased to the rate of insensible-loss
administration for maintenance fluid and then shift to the more dilute maintenance-type
fluids.
9. Do not administer osmotically active fluids (balanced salt solution or blood
products) beyond the point at which the volume requirement falls to the rate of
maintenance fluid requirement except when these products are being given for their
primary use, namely, restoration of oxygen-carrying capacity or clotting factors. In the
latter cases, osmotically active fluids would be administered as additional fluids, beyond
those needed for the restoration of insensible losses, which would still be given as
hypotonic fluids.
10. Recognize that if, inadvertently, osmotically active fluids are given beyond the
appropriate period and the patient's osmolality increases above normal to a hyperelectro-
lyte state, antidiuretic hormone will be secreted. This problem can be corrected only by
the administration of extremely hypotonic fluids, particularly D5%/water.
and adult. The needs of the older infant and child can be extrapolated from
the program for the newborn.
The newborn infant requires about 120 kcallkg/day for normal growth. By
about 3 months of age, the formula (100 kcal - 3 x age [years]) x weight [kg]
= maintenance kcallday becomes useful. '2 Infant formulas are generally based
on breast milk, which has approximately 20 kca1l30 mL; most standard infant
formulas contain 20 kcallounce. Therefore, it requires 50% more volume to
provide a given number of kilocalories. That is, to provide 100 kcal/kg requires
150 mLlkg of a 20-kcallounce formula. Normal infants can easily tolerate enteral
feedings of 100 to 180 mLlkg; larger volumes may cause the ductus arteriosus
to remain patent in some premature infants. Nutritional formulas are available
that are more concentrated, and most products designed for enteral tube
feeding contain 1 kcallmL.
Infants require 2.5 gm of proteinlkg and an optimal amount of 3 gm of fat!
kg to provide essential fatty acids. An additional guideline' is that the fat
calories should not exceed one third of the total calories. Most commercial
formulas are constructed according to these guidelines.
To provide total parenteral support, start with the 120 kcallkg goal to be
provided in 120 mLlkg:
Protein = 2.5 gmlkg = 10 kcallkg (4 kcal/gm)
Fat = 3.0 gmlkg = 27 kcallkg (9 kcal/gm)
Maximum fat = one third of total calories = 40 kcal.
Begin on the low side at 3 gmlkg = 27 kcal. Subtracting the fat and protein
from the total leaves 120 - 37 = 83 kcal/kg to be provided by carbohydrate.
Glucose provides 3.4 kcallgm; therefore, 24.4 gm of glucoselkg (83 divided
by 3.4) in 120 mLlkg = 20% dextrose. Therefore, the nutrient solution would
contain 20% dextrose and 2.1 gm of protein/IOO mL; the fat is provided by
giving 20% fat emulsion. To provide 3 gmlkg requires 15 mL/kg. This fluid can
be administered over 24 hours or more rapidly to allow a fat-free time for
clearing of lipemia.
The other ingredients of the nutrient solution are electrolytes (sodium,
potassium, chloride, calcium, phosphorus, magnesium), trace elements (zinc,
iron, copper, manganese, chromium, and selenium), and multivitamins. The
recommended amounts of these substances vary with the age of the infant or
child and can usually be provided by the hospital pharmacist or nutritionist.
The Committee on Nutrition of the American Academy of Pediatrics regularly
updates recommendations for nutritional support of preterm and term infants
and children and publishes them in a handbook. Standard infant formulas are
made from complex proteins, carbohydrates, and fats. For infants with short-
bowel syndrome, malabsorptive states, specific enzyme deficiencies, biliary
obstruction, or pancreatic insufficiency, specially designed formulas are avail-
able that utilize partially hydrolyzed proteins, simple sugars, and medium-
chain triglycerides as the protein, carbohydrate, and fat sources, respectively.
References
4. Filston He, Edwards CH III, Chitwood WR Jr, et al: Estimation of postoperative fluid
requirements in infants and children. Ann Surg 196:76, 1982
5. Moss GS, Siegel De, Cockin MS, et al: Effects of saline and colloid solutions on
pulmonary function in hemorrhagic shock. Surg Gynecol Obstet 133:53, 1971
6. Poole GV, Meredith JW, Pennell T, et al: Comparison of colloids and crystalloids in
resuscitation from hemorrhagic shock. Surg Gynecol Obstet 154:577, 1982
7. Schuster DP, Lefrak SS: Shock. In Civetta JM, Taylor RW, Kirby RR (eds): Critical
Care. Philadelphia, JB Lippincott, 1988, p 903
8. Shires GT III, Peitzman AB, Albert SA, et al: Response of extravascular lung water
to intraoperative fluids. Ann Surg 197:515, 1983
9. Shires T: Fluid therapy in hemorrhagic shock. Arch Surg 88:688, 1964
10. Shires T: The role of sodium-containing solutions in the treatment of oligemic shock.
Surg Clin North Am 45:365, 1965
11. Shires T, Willims J, Brown F: Acute change in ECF associated with major surgical
procedures. Ann Surg 154:803, 1961
12. Wallace WM: Quantitative requirements of the infant and child for water and
electrolyte under varying conditions. Am J Clin Pathol 23:1133, 1953
13. Wiggers CJ: Physiology of Shock. New York, The Commonwealth Fund, Harvard
University Press, 1950, p 137
14. Wiggers CF: Reminiscences and Adventures in Circulation Research. New York,
Grune & Strutton, 1958, p 368