Perioperative Fluid Management
In Pediatric Patient
Arie Utariani
Department of Anesthesiology & Reanimation
Faculty of Medicine, Airlangga University
Surabaya
Physiology
- Percentage of body water exceeds that of adult.
- Expanded extracellular space which contracts during
first week of life :
1. Increasing glomerular filtration rate
2. Physiologic diuresis occurs with loss of about 10%
of total body weight
3. Some SGA / dysmature infants may not have
expanded extracelllar space
- By 6 months of age, healthy infants have kidney function
that is almost normal.
Composition of Body Fluid
Body weight, body surface and body fluid in children and adults
Premature
Neonate Newborn 1 year 3 year 9 years Adult
Weight (kg) 1.5 3 10 15 30 70
Surface area(m2) 0.15 0.2 0.5 0.6 1 1.7
S/W 0.1 0.07 0.05 0.04 0.03 0.02
Total water (%) 80 78 65 60 60 60
ECF (%) 50 45 25 20 20 20
ICF (%) 30 35 40 40 40 40
Hochman et.al. Reproduced
Fluid distribution
Premature/Newborn Child
80 – 70 % TBW 65 – 60 % TBW
ICF ISF IVF ICF ISF IVF
30-35% 40-37.5% 10-7.5% 40% 18-15% 7-5%
Composition of Body Fluid
Comparison of body composition of infants & adults
Water
Blood
Solids
Fat
1500g 2500g 3500g Adult
Composition of Body Fluid
Cations (mEq/L) Amions (mEq/L)
Na+ K- Ca++ Mg++ NH4+ CL- HCO3- HPO4-
Intracellular fluid 10 150 - 40 - - - 10
Extracellular fluid 142 4 5 3 0.3 103 27 3
Lactated ringer solution 130 4 3 109 28 -
0.45 NaCL 77 77
0.9% NaCL 154 154
3% NaCL 590 590
Source: Herrin J, Fluid & electrolytes, 1997
Composition of Body Fluid
Source Na+ K+(mEq/L) CI-(mEq/L) HCO3- pH Osmolality
(mOsm/L)
Gastric 50 10-15 150 0 1 300
Pancreas 140 5 50-100 100 9 300
Bile 130 5 100 40 8 300
Illeostomy 130 15-20 120 25-30 8 300
Diarrhea 50 35 40 50 Alkaline
Sweat 50 5 55 0
Blood 140 4-5 100 25 7.4 285-295
Urine 0-100 20-100 70-100 0 4.5-8.5 50-1400
Source: Herrin J, Fluid & electrolytes, 1997
Normal water losses in infants & children
Cause of Loss Volume of Loss
(mL/100 kcal)
Output
Urine 70
Insensible loss
Skin 30
Respiratory tract 15
“Hidden intake” (from 15
burning 100 calories)
Total 100
Perioperative fluid management
I. Maintenance
II. Deficit
III. Replacement
How should be given ?
What kind of fluid ?
How much ?
I. MAINTENANCE
1. Maintenance fluid and caloric requirements of neonate /
newborn
Age Vol (mL/kg/day) Energy (KCal/kg/day)
Day 1 50 – 80 40 – 50
Day 2 80 – 100 50 – 70
Day 3 100 – 120 70 -90
Day 4 120 – 150 90 – 110
Day 5 150 110 – 120
2. Hourly and Daily Maintenance Fluid Requirements
of Children
Maintenance fluid requirements
Weight (kg) Day Hour
<10 100mL/kg 4mL/kg
10-20 1000mL + 50 mL/kg 40mL + 2 mL/kg
>20 1500 ml + 20 mL/kg 60 mL + 1 mL/kg
For example :
a 25 kg child would required
1000 ml + 500 ml + 100 ml = 1600 ml
3. Fluid requirements to be based on BSA
1500ml / m2 BSA / day
For example :
3 kg infant : 1500 ml x 0.2 x day = 300 ml/day
Source: Holiday MA, Segar WE; The maintenance need
for water in parenteral fluid therapy padiatrics
Choice of the maintenance fluid
• Crystalloid :
Depent on the glucose and electrolyte needs
Hypotonic : D 10% 0.18 NS
D 5% 0.225 NS
D 5% 0.45 NS
• Neonate & premature or small for gestation age are at risk
for perioperative of hypoglycaemia.
• Monitoring of blood glucose concentration is recommended
II. DEFICIT
Preoperative fluid deficits :
Maintenance + fluid deficit
1. Fasting period
2. Hydration
3. Electrolyte imbalance
1. Fasting period
Fasting (NPO) guidelines for children and adults
Fasting time (Hours)
Age Solids Clear liquids
< 6 months 4 2
6-36 months 6 3
> 36 months 8 3
Replacement of fasting
Hourly fluid requirement x length of fasting (hours)
For example : a 5 kg child
5 kg x 4ml/kg/h x 4 h = 80 ml
Given : 50% in the first hour
25% in the second and third hour
Choice of fasting fluid : Crystalloid fluid
- Hypotonic solution
- Isotonic solution
2. Hydration :
Assessment of the degree of dehydration
Clinical findings Mild Moderate Severe
% body weight loss 4-5% 6-9% >10%
Estimation fluid defisit 40-50ml/kg 60-90 ml/kg 100-110 ml/kg
Pulse Normal ↑, Weak ↑↑, feeble
Blood pressure Normal Normal of low Reduced
Respiration Normal Deep Deep & rapid
Skin turgor Normal ↓ ↓↓
Mucous membranes Moist Dry Very dry
Peripheral perfusion Normal Poor Poor, cool, extremitas
Urine Reduced Oliguria Marked oliguria
Source: Nelson W
Management of dehidration
a. Estimated fluid deficit
b. Rehydration
For example : a 10 kg child is assessed to severe
dehydration with an estimated 10%
Dehydration 10%, 10 kg
EFD : 100 ml x 10 = 1000 ml
Initial fluid resusitation : 20ml/kg (20-30’)
- Respiration
Reassess the clinical state
- Circulation
- Mental status
Improved Non improvement
First 8h : 50% rest fluid deficit + Repeat : 20 ml/kg/20-30’
fluid maintenance
Second 16h : 50% rest fluid deficit + Resassess
fluid maintenance
Choice of the fluid :
Rehydration : Isotonic crystalloid
Maintenance : Hypotonic crystalloid
3. Electrolyte im balance
Electrolyte composition of stomach, small bowel and diarrhea
Stomach Small bowel Diarrhea
160
140
HCO3
120
100
H+
80 Cl+ Na+
60 Cl+ Na+ HCO3
40
20 K+ Cl+
K+ K+
Maintenance electrolyte requirement in children
Electrolytes
Sodium : 3-4 mEq/kg/day
Potassium : 2-3 mEq/kg/day
Chloride : 2-3 mEq/kg/day
Calcium : 150-500 mg/kg/day
Phosphorus : 0.5-2 mmol/kg/day
Magnesium : 0.25-0.5 mEq/kg/day
Source : J Allan Paschall
Hypo Natremia
1. Estimated fluid deficit
2. Resucitation from shock : NS / RL
3. Calculated deficit hourly IV rate
Maintenance + deficit Na- / 24 hours
mEq Na+ = (Desired Na+ - Observed Na+) x weight (kg) x 0.6
4. Infuse D5 0.45 NS or D5 NS or D5 LR
5. Add 10 – 20 mq kcl/l based on renal function and K+ level
Hypokalemia
K : 0.5 – 1 meq/kg (max.20 meq) / 2 hour
Repeat : 4- 8 hours as need
Monitoring : ECG
Hyperkalemia
CaCl : 0.1 – 0.3ml/kg a. 10% solution
CaGluconas : 0.3-1ml/kg a.10% solution
Nabic : 1-2 mEq/kg + mild to moderate hyperventilation
Glucosa + insulin : 0,5g /kg Glucose + 0.1U/kg insulin / 30-60’
III. REPLACEMENT
Intraoperative fluid management
- Maintenance
- Replacement
Replacement
- Third space lossess
- On going lossess
Guidelines for intraoperative fluids in pediatric patiens
1. First hour, hydrating solution:
Age ≤ 3 year : 25ml/kg, plus item 3
Age ≥ 4 year :15 ml/kg, plus item 3
2. All other hours basic hourly fluid plus item 3 below
Maintenance fluid = 4 mL/kg
Maintenance + trauma = basic hourly fluid
4 mL/kg + mild trauma (2 mL/kg) = 6 mL/kg
4 mL/kg + moderate trauma (4 mL/kg) = 8 mL/kg
4 mL/kg + maximal trauma (6 mL/kg) = 10 mL/kg
3. Blood replacement with 3:1 volume replacement with crystalloid
or colloid, or blood
From: Berry Reproduced
BLOOD REPLACEMENT
Estimated blood volume (EBV) in pediatric patiens
Age EBV (mL/kg)
Premature infant 90-100
Newborn 80-90
Infant < 1 y 75-80
Child > 1 y 70-75
Normal & acceptable hematocrit (Hct) values in pediatric patients
Normal hct (%)
Age Mean Range Acceptable hct (%)
Premature 45 40-45 35
Newborn 54 45-65 30-35
3 mo 36 30-42 25
1y 38 34-42 20-25
6y 38 35-43 20-25
Mean & lower normal hemoglobin levels
in pediatric patients
Normal hemoglobin (g/100mL)
Age Mean Lower limit
1 day 18 13.5
1 week 17 13
1 mo 14 13
3 mo 12.5 9
0.5 – 5 y 13 11.5
5–9y 13.5 12
12 – 14 y
girls 13.5 12
boys 14 12.5
Dallman & Siimes, Oski & Neiman, and Saarinen & Siimes
BLOOD REPLACEMENT TO USE HAEMOTOCRIT LEVEL
Hct 1 – Hct 2
1. Blood required = X EBV
Hct 3
2. Blood required (PRC) = (Hct 1 – Hct 2) x body weight (kg) x 1.5
(WB) = (Hct 1 – Hct 2) x body weight (kg) x 2.5
Hct1 : Haematocrit before transfusion, the measured
haematocrit
Hct2 : Haematocrit required after transfusion, the desired
haematocrit
Hct3 : Haematocrit of the blood to be given (60% if packed cells)
EBV : Estimated blood volume
Guidelines for red cell transfusion to neonate and premature
• Shock associated with acute blood loss
• Hb< 13g/100mL, Hct<40%, and presence of pulmonary
failure, cyanotic heart disease, or congestive heart failure
• Comulative loss of 10% or more of the blood volume
within 72 h or less if additional sampling is required
• Hb<80g/100mL, or Hct<25% in a stable neonate with clinical
manifestations of anemia, e.g. tachycardia, tachypnea,
poor feeding
Source: Kevy SV, Gorline JB, in Hemetology of infancy & childhood, 1998
Postoperative Fluid Management
• Maintenance fluid
• Replacement of fluid deficit
• Replacement of other losses
- Chest tube
- Nasogastric tube
- Weeping incision
- Continous slow bleeding
• Correction of electrolyte inbalance
• Maintenance fluid requirement on the first most operation
day are decreased to 2/3 of the usual daily amount
Conclusion
• Fluid therapy for pediatric patients must be based on the knowledge
of the fluid and electrolyte needs in healthy infants and children
on physiologic responses to the surgical procedure
• Formula for fluid therapy are guidelines that need to be revaluated
according the patients response
• Even more than in the adult, improper fluid management in
infants and children can cause life threatening consequences
• The inadverten administration of a seemingly minuscule excess
of fluid may couse problems.
For example :
100 ml fluid in full term neonate is comparable to 1 to 2
liter excess in an dault
