Fluid balance and vascular access in Children

By Khaled Ashour Paediatric Surgery Department

What should we know?

Distribution of body fluids in infants & children. Why are children more vulnerable for fluid imbalance. Fluid requirements for all age groups. Assessment of state of hydration. Vascular access.

•Fluid balance is fundamental to life.
•Monitoring and maintaining fluid balance in sick children requires an understanding of normal requirements and losses and of the effect of different clinical problems on fluid balance.

Why children are more prone for fluid imbalance and dehydration?

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Large body surface area High extracellular fluid ratio. Difficult calculation of the accurate requirement. Prematurity of kidneys. Frequent feeding problems Difficult venous access. Relatively small total body fluids.

Normal body water in children (Metheny and Snively 1983)
Age group Approx water content in body

Premature infant Newborn infant 12-24 months Adult

90% 70-80% 64% 60%

Body Fluids

Intracellular

Extracellular

Intravascular

Interstitial

Transcellular

“Plasma”

“Tissue fluid”

“Peritoneal fluid”

Intravascular fluid

Intracellular fluid

Interstitial fluid

Fluid distribution according to age (Hiu Lam 1998, Metheny and Snively 1983) Intracellular fluid Extracellular fluid
Newborn 12 months 24 months Adult male 47% 53% 60% 67% 53% 47% 40% 33%

Infants versus older children regarding extracellular fluid

Infants have a greater proportion of extracellular fluid than older children and adults. Because extracellular fluid is more easily lost from the body than intracellular fluid, infants are more at risk of developing dehydration than older children and adults (infants also have a larger surface area to body mass ratio).

Estimation of Blood volume
Neonate
Infants Older children adults

90 ml/kg
80 ml/kg 80 ml/kg 65 ml/kg

Importance of balanced & adequate body fluid

Balanced adequate body fluid is very important in maintaining adequate and effective circulation. Adequate circulation in turns will maintain normal tissue perfusion, and hence, all body cells will get adequate nutrition, and get rid of waste products.

Factors affecting tissue perfusion

Dynamic movement of body fluid between the vascular spaces and the tissues.
1.
2. 3.

Osmotic pressure. Oncotic pressure. Hydrostatic pressure.

Tissue perfusion regulation

Fluid intake & loss
IN
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OUT
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Oral fluids. Food. Retention enema Parentral: IV IO Peritoneal


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Urine. Stool. Perspiration. Bleeding. Surgical drains. Stoma. Burns.

How can we maintain the fluid balance in sick babies and children?

Fluid requirement for neonates, infants & Children
How much?? Amount of fluid How?? Route of administration What?? Type of fluid

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How much to give? Amount of fluid
Parameters of requirements: 1) Resuscitation: Replacement of previous loss 2) Maintenance fluid: Daily requirements. 3) Ongoing loss: NG suction, stoma out put, etc..

1) Resuscitation

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Given in case of initiating treatment for a dehydrated child, or with acute fluid loss. Rate of 10-20 ml/kg N saline. Child is to be reviewed / 15 min. Can be repeated.

2) Maintenance A – Neonates <44 weeks
Day ml/kg/day

require more than infants and children

0
1

40
60

2
3

80
100

4
5

120
150

2) Maintenance B - Children
Parenteral: 5-10 kg  4ml/kg/hr. >10 kg first 10 kg : 4 ml/kg/hr. Second 10 kg : 2 ml/kg/hr. third 10 kg and more: 1 ml/kg/hr.

3) Ongoing loss

The amount depends upon the calculated loss (NG, Drain, Stoma, etc..) Type of fluid: 0.9% N saline + KcL.

NB: For stoma loss, we may replace only the amount of stoma output that exceeds 15 ml/kg/day. UOP: Excess of 5 ml/kg/hr

What (Type of fluid) 1. Crystalloids

Neonates: - Maintenance: 10% Dextrose 0.18 N Saline - Replacement: 0.9% N Saline Infants and children: - Maintenance: 5% Dextrose 0.45% N saline - Replacement: 0.9% N Saline

What (Type of fluid) 2. Colloids

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Bloods, and blood products Factors PN Gelfusion (Synthetic colloids)

How to assess the adequacy of the fluid you are giving?
Assessment of dehydration and overhydration.

Assessment of the state of hydration.

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General status of the child. Activity. UOP. Skin & Mucus membrane. Capillary refilling time (CRT). Pulse, blood pressure. Respiration. Temperature. Body weight.

Venous access in Paediatrics

Venous access

Peripheral

PICC

Central

1. Peripheral lines

Types of catheters

Location

Rules for peripheral lines

Start from distal veins first, then proximal Upper limb then lower limb Preserve ACF for PICC lines Scalp and neck veins last resort.

Peripheral lines Durability??

Variable, can stay up to one week. Infection, superficial phlebitis, nondurability.

2. Central lines

Types of central lines
Tunneled
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Non-tunneled
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Hickman line Portacath

CVP lines Vascath lines PICC lines Femoral lines

Hickman line

Hickman lines

Hickman line

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Tunneled central line Inserted in the SVC / R Atrium Can be used for IVC in difficult cases. Durable (up to years) Main complications: Sepsis, blockage, and migration. Needs GA for removal.

Port a cath

Port a cath

Port a cath

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SVC / R atrium More durable More expensive No external tubes. Bigger scar Needs GA for removal.

Peripherally inserted central catheter PICC

PICC lines

PICC lines

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Can be as durable as Hickman line May not need GA. Removal doesn’t need GA Should be treated as a central line (Aseptic techniques).

Non- tunneled Vascath (CVP catheter)!!

Vas Cath

Femoral line

Intraosseous injection

IO route


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Only in critical emergency, with absolutely no apparent venous access, and urgent need for transfusion. Needs expertise, proper needles Very painful, not durable. Limited to <7 years old children