Perioperative Care of pediatric

surgical patients

Presenter- Dr.Goytoom(SRII)
Moderator-Dr.Siye(pediatric surgeon)
Date-26/09/2012 E.c
 Outline
• Introduction

 DISTRIBUTION OF FLUID AND ELECTROLYTES

 DEVELOPMENTAL & BIOLOGICAL VARIANCES IN CHILDREN

• Pre-operative care of newborn

• Pre-operative care in older Child

• Intra operative care

• Post operative care

• References 2
 Case scenario
 8 yrs old child, weighing 25 kg is having
elective lap and bowel resection for IBD after
he was kept NPO for 8 hrs. Initial Hct 36% .
• How much fluid should be given at first hr of
surgery considering minimal blood loss?
• What is the ALB for this child??
• What is the maintenance fluid for this kid and
fluid choice?
 Introduction

• Infants and children have distinct surgical diseases and special

perioperative needs

• The physiology of the neonate, infant, child, and adolescent

differ significantly from each other and from the adult.

• These physiologic parameters are often the primary

components that dictate the preoperative and postoperative
management.
DISTRIBUTION OF FLUID AND ELECTROLYTES
 Fluid distribution in infants
 At 28 wks of GA-Wt-1Kg
-TBW-80%,,,ECF
-body fat-1%

 Term new born-TBW-70-75%

-body fat-17%
-still ECF majority

 3rd month-TBW-60-65%
-body fat-30%
-progressive fluid shift to ICF

 Adult type ICF:ECF ratio will be

achieved by age of one yr
 High TBW-can be enough for 3days
even NPO
 Renal physiology
 Immature kidney

Poor concentrating capacity • At birth Estimated GFR 25% of the

50% of that of adult
adult(20m/min/1.73 M2) due to

This is due to – Low systemic arterial pressure
-Low ADH concentration – High renal vascular resistance
-Low renal ADH response
-Low tonicity of medullary – Low renal glomeruli capillaries
interstitium
permeablity
They are obligate Na+
lossers – Small size and number of
glomeruli
High diluting capacity • Has also poor concentrating ability
Low GFR is compensated by and high diluting capacity
this two and thus any infant
can withstand 2X
maintenance fluid load
 Cardiovascular system

 Has lower cardiac contractile mass/gram of cardiac tissue

 Limited ability to increase cardiac contractility and lower

ventricular compliance

 Extremely limited ability to increase stroke volume plus

immature SNS

 Thus need to increase heart rate to increase cardiac output

 Respiratory
 The head of a pediatric
patient is larger relative to
body size, with a prominent
occiput and short neck.
 This predisposes to airway
obstruction in asleep children,
because the neck is in flexed when
they lie on a flat surface. A folded
towel is often required as a shoulder
roll to achieve a neutral position of
the neck and open up the airway
 The internal diameter of
the airways in a child is smaller
 Narrower upper airway space
 Larger tongue
 Short mandible
 Prominent adenoids and tonsil
 Short and narrow hypopharynx
 Chest wall
 The ribs in infants and young children
are oriented more horizontally than in
adults and older children lessening the
movement of the chest.
 Rib cartilage is more springy in children
making the chest wall less rigid
 Less developed IC muscles-makes
difficult to raise rib cage especially in
supine position
 Continued…
 The larynx is relatively higher in
the neck in children.
 The cricoid ring is located
 The pediatric airway is
approximately at the level of the C4 funnel-shaped with the
vertebrae at birth, C5 at age 6, and
C6 as adult
narrowest portion of the
 Vocal cords are not typically found airway being found at the
at a right angle (90°) to the trachea. level of the cricoid.
They are angled in an anterior-
inferior to posterior-superior • This was contrasted to the
fashion. adult airway, where the
 While this typically does not affect narrowest portion is the
laryngoscopic view, it can make
insertion of the endotracheal tube
glottis and the airway is
more challenging or more traumatic described as cylindrical.
Hematologic….
 Has higher hemogloblin-14-20
Estimated blood volume
gm/dl
• Fetal Hgb ???(up to 6 months)

 At birth the V-K dependent factors

are 20-60% of the adult level
• Vitamin-K need
peri-operative care of newborn

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 General Principles

• History & physical examination

• Maintenance of body temperature
• Respiratory function
• Cardiovascular status
• Metabolic status
• Coagulation abnormalities
• Laboratory investigations
• Fluid & electrolytes
 FLUID THERAPY

This is divided into 3 phases.

1)Deficit therapy--Losses that occur prior to presentation.

2)Maintenance therapy-- replace loss under ordinary condition.

3)Replacement therapy--Replace ongoing abnormal loss.

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MAINTAINACE FLUID
 MAINTAINACE FLUID THERAPHY

• Newborn’s daily fluid requirement ml/kg/day

 Fluid choice-D10 W during the first 24-48 hrs of life

 D5 ¼ NS + 10mEq/L of KCl for patients <10kg
 D5 ½ NS + 20 mEq/L of KCl for patients >10kg
MF…..
  Methods of calculating fluid and
Maintenance Electrolyte
calorie requirement
Requirements
Body surface area(BSA)
Na: 2-3 mEq/kg/day – Energy expenditure is equivalent to
body surface area
K: 1-2mEq/kg/day – Prone to errors , not recommended
currently
Cl : 2-3 mEq/kg/day
Calorie consumption and body wt
Ca : 20-100 mg/kg/day – Standard method
– Based the concept that calorie
requirement is equal to fluid
requirement in infants
– Rule of 4:2:1 or Holliday-Segar
method

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Fluid choices
 DEFICIT THERAPHY

 Losses that occur prior to presentation for surgery or medical

care.
 Three essential components in deficit therapy :
 Estimation of severity of deficit

Determination of type of fluid deficit

Deficit replacement

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09/26/2023 21
 Assess deficit by:

% Dehydration = PIW (kg) – IW (kg) x 100%

PIW (kg)
*Pre-illness wt (PIW) * illness wt (IW)

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 TYPE OF DEFICIT

 ISOTONIC
– serum osmolarity 270-300 mOsmL, serum Na 135-145 meqL-1) or
– the losses of water and electrolytes have been proportional

 HYPOTONIC/HPONATREMIC
 Sodium <130 mEq/L & osmolarity less than 270 mOsm/kg
 The loss of salt over a period of time exceeds the loss of water
 HYPERTONIC/HYPERNATREMIC
 (serum osmolarity>310 mOsmL-1, serum Na >150 meqL-1).
 more commonly in infants under 6 months of age,
 The lost fluid consisted of more H2O than electrolytes
09/26/2023 23
Deficit replacement phases for iso/hypotonic def.
 Conti…………
 ORT may suffices for mild  Monitoring Therapy
to moderate DHN  V/S, Fluid balance ,weight ,
 Hypertonic/hypernatremic signs of depletion or
deficit rehydration should overload,input/output chart
slowly over 48 hrs

 Lab. Tests =>Electrolytes ,

 Fluid choice-usually 0.9%
↑ Urine specific gravity , RFT
NS(depends on the pt
, ↑Hct , ↑ serum proteins
findings)
 Fluid deficit due to NPO

• Fluid deficit due to NPO = Hourly MF requirements x hrs of

NPO

50% 1st hour

25% each in next 2 hours

Age (days) / Requirements: Hourly: mlkg-1hr-1 Type of fluid
Weight (kgs) mlkg-1day
1 20-40 2-3 10% dextrose
2 40-60 3-4 10% dextrose in 0.22%
NS

3 60-80 4-6 10% dextrose in 0.22%

NS

4 80-100 6-8 5-10% dextrose in

0.22% NS

0-10 kg 100 4 5% dextrose in 0.45%

NS

10-20 kg 1000+50ml/kg 40ml+2mk/kg/hr 5% dextrose in 0.45%

NS

>20 kg 1500+20ml/kg 60ml+1ml/kg/hr 5% dextrose in 0.45%

NS
 Replacement therapy

Real Losses 3rd Space Loss

Blood loss
 Trauma
Vomiting
 Peritonitis
Diarrhea  Burns
 Drainage from various  Bowel obstruction
sites
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 Thermoregulation
• Heat loss because of their
LBSA
low body fat to body weight ratio
limited heat sink capacity due to their small size.

• High thermo neutral temperature zone.

Adults : 26–28°C,
term infant: 32–34°C.
LBW infant: 34–35°C.

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 Thermogenesis in  Hypothermia increases mortality.
the neonate
By increasing
metabolic activity,  Fever increases basal metabolic rate
non shivering  For every 1 c0 temperature raise
using brown fat. above normal(37 co) 12%
Affected by: increase in calorie and fluid
requirement
Anesthesia
Depletion of
brown fat

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 Mgt

 Best controlled in an incubator :

 Term infants : 32–34°C,
 LBW infants ~ 35°C.

 Clothing : increase insulation, reducing radiant and convective

heat loss.
 Covering the head with an insulated hat.
 use of insulating pad.

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 In the OR

 Radiant warmers.  Any exposed intestine

should be wrapped.
 wrapping in :
 Clothing,cotton
 Overhead infrared
 plastic sheets or heating lamp.
 aluminum foil.
 A plastic sheet placed  Warm Solutions used
beneath the infant for skin cleansing,
irrigation.

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 Hematologic considerations-

 Vitamin-K • New born should be given

• At birth Vitamin-K vitamin-K 1mg IM soon
dependent factors are 20- after birth to prevent VKDB
60% of adult level
• Research shows Classical
• Reaches adult level by 6th VKDB mortality in Ethiopia
month of age is 25%(though very low in
developed countries)
• Vitamin-K is involved in
activation of coagulation • VKDB in breast fed VS
factors-2,7,9 and 10 formula fed babies ???
 Other hematologic….

 Correct thrombocytopenia and other

coagulopathies

 Correct anemia
Nutrition…
Age (yrs) Caloric needs
Energy Requirements
(kcal/kg/day) – High heat loss
– High BMR
– Growth &development
– Limited energy reserves
0-1 90-120
2-7 75-90
8-12 60-75
13-18 30-60
>18 25-35

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Pre-operative care in Older Child

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 History and P/E
Hx
 Full medical history
 Previous history of illnesses &
operations
 Current medications
 Respiratory disease
 Congenital heart disease
 Neuromuscular disease
 Recent URTI
 Any family hx of anaesthesia
related problems
 Allergies
Physical examination
 Overall condition
 Loose decidual teeth
 Signs for difficult airway
 Limited mouth opening
 Micrognathia
 Noisy breathing
 Respiratory exam
 temp 38°C,wheeze or
crepitation
 CVS exam
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 Investigations

 Full blood count

 Blood urea & serum electrolytes, blood glucose & calcium
 Coagulation profile
 Radiological studies
 Cross- matched blood
 Additional may be required in specific circumstances

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 Preoperative fasting

•The most common cause for surgical delay or cancellation.

•Preoperative fasting for different food.

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 PRINCIPLE OF FLUID MANAGEMENT

 Fluid management has 3 components

1. Deficit therapy
2. Maintenance therapy
3. Replacement therapy

N.B-More or less discussed before

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Intra-operative care

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 The Difficult Pediatric Airway

 is implicated as an important cause of respiratory complications

resulting in cardiac arrest.

 Anticipate most difficult airway.

 Many congenital syndromes are associated with difficult airway

management

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 Monitoring

continually evaluate the patient’s:

 oxygenation,
ventilation,
circulation, and
Temperature.

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INTRAOPERATIVE FLUID ADMINISTRATION

 In response to surgical procedure , fluid move from intravascular

space to interstitial space.
 The amount of fluid lost depends on the amount of tissue exposed
and the degree of surgical manipulation.
 Fluids used intraoperative should be isotonic(NS/RL),shouldn’t be
dextrose containing(or <1% dextrose) except for those <48hr hrs old

 MF + preoperative Fluid Deficits + 3rd space losses +

EBL
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Third space loss replacement
 Replacing Blood Loss

ESTIMATED BLOOD VOLUME EBL replacement

•Premature Neonates =95 -100 ml /kg
Soaked 4 x 4cm 5-10 cc
•Full Term Neonates = 85-90 ml / kg gauze
•Infants = 80 ml / kg
Soaked pack 80-100cc
Hand full clotted 450-500 cc
blood
•Replace Blood Loss with
 Crystalloid in 3:1 ratio Objective measurement in the
suction bottle
 Colloid solution in 1:1 ratio
 Blood products in 1:1 ratio
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 Estimating Allowable Blood Loss

ABL= Weight(kg)*EBV*(Ho - Hl)/H

 ABL-allowable blood loss, EBV- is estimated blood volume,

 Ho- is the original hematocrit, Hl- is the lowest acceptable
hematocrit, and
 H- is the average hematocrit ([Ho + Hl] / 2).
 Blood Replacement

 Criteria for transfusion

 Loss ≥15-20% of total blood volume or > ABL
 Baseline Hg < 7 g/dl
 Baseline Hg < 10g/dl + severe co-morbidities

 Volume of PRBCs to be transfused:

(Target HCT - Current HCT) X wt(Kg)X blood volume
per kg/HCT blood to be transfused
 given at 10 mL/kg /dose
 Hct of PRBC-55-75%(average-70) and Hct of whole blood-
50%
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 Massive transfusion protocol

 FFP & Platelets are needed if >30 mL/kg of PRBC has been
transfused.
 Plasma: at dose of 10 to 20 mL/kg.

 Platelets: at dose of 0.1 unit/kg this ↑platelet count by

app. 25,000/µL .

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 Intraop Glucose homeostasis

 Limited liver glycogen stores, rapidly depleted within 2–3

hrs.
 Severely Limited ability gluconeogenesis.

 Intraop hypoglycemia is very rare event,rather hypeglycemia is

more common

 Intraop Iv fluid should be isotonic or contain dextrose <1% except

for first 2 days of life
 Frequent blood glucose monitoring

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POST OPERATIVE CARE

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 Goal
Promote healing

Prevent complications

Intervene early if complications arise

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Assessment of fluid & electrolyte balance

V/S

Intake & output

Daily weights
Serum electrolytes
Capillary refill

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Postoperative Fluid Management

• MF + preoperative or intraoperative FD + OL

• Isotonic fluids are preferred during immediate post op

period

• After 24 to 48 hrs, fluids can be changed D5 ½ NS

• Daily fluid orders are revised based on volume status &

assessment of electrolyte abnormalities
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 Post-op Analgesia

 Pain assessment tools

 Multimodal analgesia

PIPP
 Dedicated pediatric pain
service is desirable standard FLACC
of care PASS

 Nonpharmacological
 Pharmacological(opioids ,
non-opioids , local
anesthetics)

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 Non opioid analgesics

• Non opioid analgesics are first line for mild-moderate

pains
• Also used with opioids and have opioid sparing effect
 Opioids

• Morphine remains the most widely used

• Patient-controlled analgesia (PCA) is now widely used
 Feeding
Limited hepatic glycogen stores

High Metabolic demand

Provide 5%-10% dextrose in maintenance fluid

Feeding is begun after the resolution of postoperative

ileus
passage of meconium or stool
absence of bilious fluid on gastric aspirate
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 Tips of pediatric perioperative electrolyte MX
 Hyponatremia is commonest perioperative electrolyte abnormality
 Don’t correct hyponatremia rapidly ,should be <1meq/l/hr or
<8meq/l/day
 Don’t correct hypernatremia rapidly, <10meq/l/day

 Treat the underlying cause of disturbance

 Hypokalemia- Rate of intravenous correction should not exceed 0.2
to 0.5 meqkg-1hour-1.
 Deficits can be calculated from the formula:
 Potassium deficit (meqL-1)=Body weight x (Expected serum K+ -
observed serum K+) x 0.3
 Conti……

 Na deficit=TBW*(target Na-current Na) in

Hyponatremia
 Target Na 125-130 meql

 Water deficit=(current Na-145)*TBW/145 in

hypernatremia

 K+ deficit=wt(kg)*(expected K+ level-current K+
level)*0.3
 REFERENCES
 Indian Journal of anesthesiologists
 A comprehensive text for Africa
CHAPTER 5 Fluids and Electrolyte
Therapy in the Pediatrics Surgical
Patient

09/26/2023 63