Perioperative Fluid

Management in Pediatrics
By: Karim Kamal, MD
Professor of Anesthesia
Cairo University
 Why is this topic important?
The numerous opinions and formulas
regarding perioperative fluid, electrolyte and
blood transfusion therapy for infants and
children can be very CONFUSING
A meticulous fluid management strategy is
required in pediatric patients because of the
extremely LIMITED MARGIN OF ERROR
Why is this topic important?

Limited Margin of
Confusing Error
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Preoperative Fasting
Prolonged Liberal Fasting
Preoperative Regimens for
Starvation Clear Fluids

Improves perioperative
Irritable uncooperative behavior
child
Maintains normoglycemia
Significant hypoglycemia
in young infants Does not increase risk of
aspiration
 Preoperative Fasting

6 hours → solids, milk (including formula feeds)

4 hours → breast feeding
2 hours → clear fluids (e.g. water, carbonated
drinks, black tea or coffee)
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Maintenance Fluids
4 - 2 - 1 rule

Holliday and Segar (Pediatrics 1957;19:823-32)

Calculated IV fluid requirements based on the
estimated metabolic requirements
Calorie expenditure:
3-10 kg: 100 kcal/kg
10-20 kg: 1000 kcal + 50 kcal/kg for each kg above 10 kg
>20 kg: 1500 kcal + 20 kcal/kg for each kg above 20 kg
Under normal conditions 1 ml of water is required to
metabolise 1 kcal
 Maintenance Fluids
4 - 2 - 1 rule

Daily maintenance electrolyte requirements:

Potassium and Chloride: 2 mEq/100 kcal/day
Sodium: 3 mEq/100 kcal/day
These requirements can theoretically be met
using D5 ½ NS
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Deficit Replacement
Children develop preoperative fluid deficits secondary
to continuing insensible losses and urine output during
the fasting hours
Furman et al (Anesthesiology 1975: 42:187-93)
Hourly maintenance requirements x Number of fasting hours
1/2 of the deficit → 1st hour
1/2 of the deficit → over the next 2 hours

Berry (Anesthetic management of difficult and routine

pediatric patients. New York: Churchill Livingstone
1986:107-35)
< 3 years → 25 ml/kg over the first hour of surgery
> 4 years → 15 ml/kg over the first hour of surgery
Both methods were based on the assumption that
patients had been NPO for at least 6-8 hours
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Third Space Losses
Refers to the sequestration of fluid to a non-functional
extracellular space that is beyond osmotic equilibrium with
the vascular space
In pediatrics: variable
Minor surgical procedure: 1 ml/kg/h
Major abdominal procedures: 15-20 ml/kg/h
Necrotising enterocolitis in premature infants: 50 ml/kg/h
The younger the child, the greater is the relative proportion of losses
because of the large ECF volume in young infants compared with
older children and adults
Should be replaced with crystalloids (NS or LR)
Large amounts of NS are responsible for hyperchloremic
metabolic acidosis, whereas this does not occur after LR
administration
 Third Space Losses
Recent adult studies:
Functional fluid space is either unchanged or expanded rather than
contracted after surgery
Substantial amounts of fluid accumulate in the interstitial space
→ volume overload with crystalloid infusions
→ deterioration of the vascular barrier
During abdominal surgeries outcomes may be improved by
conservative fluid management in the perioperative period
Pediatric studies: lacking
Future trend: Individualised goal-directed fluid management
using only the amount of crystalloid and/or colloid
necessary to optimise flow-related variables such as stroke
volume
 Blood Loss
Pediatric patients have higher oxygen consumption
than adults
Neonates
The myocardium operates at near maximum level of
performance as a baseline → unable to compensate for
a decreased oxygen carrying capacity by increasing CO
Have higher fraction of HbF, and therefore lower oxygen
delivering capacity
Congenital heart disease or lung disease → decreased
ability to oxygenate blood
 The threshold for transfusing RBCs to a neonate
should be at a higher hemoglobin trigger than an
older child
 Blood Loss
Anesthesiologist should calculate
Estimated Blood Volume (EBV)
Premature infant 90-100 ml/kg
Term infant - 3 months 80-90 ml/kg
Children older than 3 months 70 ml/kg
Very obese children 65 ml/kg
Maximal Allowable Blood Loss (MABL)
MABL = [(starting hematocrit − target hematocrit)
÷ starting hematocrit] × EBV
 Blood Loss
Example: 7 yr old child, 25 kg, Hct = 36%

EBV = 25 × 70 = 1750 ml

MABL = [(36 – 21) ÷ 36] × 1750 = 730 ml

 Blood Loss
MABL can be replaced with:
balanced salt solution (LR) in a volume of 3:1
5% albumin or hetastarch in a volume of 1:1
Once the estimated blood loss reaches this target
value (Hb 7 gm/dl), then RBC cell transfusion should
be initiated
Additional blood loss (ABL) replacement
Volume of 100% RBCs blood to be transfused =
ABL × desired hematocrit (30%)
Volume of packed RBCs (70% hematocrit) to be transfused =
ABL × desired hematocrit (30%) ÷ 0.7
This can be simplified by transfusing approximately 0.5 ml
packed RBCs for each ml of ABL
 Blood Loss
Platelet transfusion
Transfusion threshold
Bleeding patient: platelets < 40,000 – 50,000/mm3
Prophylactic: platelets < 10,000/mm3
Volume transfused
One platelet concentrate per 10 kg of body weight
Expected to raise the platelet level by 50,000/mm3
Fresh Frozen Plasma
To replace deficient clotting factors
DIC or massive blood transfusion
FFP for volume support is not an accepted indication
Volume transfused
10 to 20 mL/kg (↑ level of coagulation factors by 20%)
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Crystalloids vs Colloids
Most anesthesiologists use crystalloids
(NS or LR)
low cost
lack of effect on coagulation
no risk of anaphylactic reaction
no risk of transmission of infectious agent

There is still little evidence supporting any

particular method of volume expansion in the
pediatric population
 Crystalloids vs Colloids
The International Guidelines Conference for Neonatal
Resuscitation (2000)
Emergency volume expansion: by either
Isotonic crystalloid solution
O-ve RBCs
Dutch Pediatric Society evidence-based clinical practice
guidelines (2006)
Recommendations for volume expansion should be made based
on the solution’s:
side effects
mechanisms of action
cost
 Isotonic saline was recommended as safe, effective, and 100
times less expensive than albumin
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Dextrose

Hypoglycemia Hyperglycemia
 Dextrose
Hypoglycemia
Can have devastating effects on the CNS especially
in neonates
Low blood glucose → stress response with altered
cerebral blood flow and metabolism
Burns et al (Pediatrics 2008;122:65-74)
35 neonates with symptomatic hypoglycemia (blood glucose
level < 45 mg/dl)
MRI
 White matter abnormalities in 94% of the cases
 Severe abnormalities in 43% of the cases

Recent pediatric studies

Incidence of preoperative hypoglycemia 0% - 2.5%
Associated with 8 – 19 hours fasting
 Dextrose
Hyperglycemia
Has been recognized as detrimental for the brain
In the presence of ischemia or hypoxia
→ impaired metabolism of excess glucose
→ accumulation of lactate
→ ↓ intracellular pH
→ compromised cellular function that may
result in cell death
Can also induce osmotic diuresis
→ dehydration and electrolyte
abnormalities
 Dextrose
Current recommendations
Routine dextrose administration is no
longer advised for otherwise healthy
children receiving anesthesia
Administer intraoperative dextrose only in those
patients at greatest risk for hypoglycemia
Neonates
Children receiving hyperalimentation
Children with endocrinopathies
In such situations, to consider the use of fluids with
lower dextrose concentrations (1% or 2.5%)
 What will we talk about?
Basic Principles Controversies

Preoperative Fasting Crystalloids vs

Colloids

Maintenance
Dextrose-Containing
Solutions
Deficit

Losses Isotonic vs Hypotonic

 Isotonic vs Hypotonic
Postoperative hyponatremia is the most frequent
electrolyte disorder in the postoperative period
Due to the administration of hypotonic fluids when
capacities of free water elimination are impaired due
to increased ADH secretion as a result of
hypovolemia, stress, pain, or traction of dura mater
Severe hyponatremia (<120 mmol/l) may result in
transient or permanent brain damage (due to
osmotic movement of free water across cell
membranes from the extracellular to the intracellular
compartments)
Should be prevented by avoiding hypotonic
solutions during surgery
Where are we heading?

Weight-based
formulas
 Where are we heading?

Goal-directed
therapy (GDT)

Management of fluids such that stroke volume

is optimized is a well-validated approach that
has been shown to reduce mortality
 Where are we heading?

Anesth Analg 2011;112:1384–91

Systematically reviewed the RCTs that used a

hemodynamic protocol to maintain adequate tissue
perfusion in high-risk patients
32 RCTs including 5056 high-risk surgical patients
Significant reduction in mortality rate and in postoperative
organ dysfunction incidence
Monitoring CO resulted in the highest reduction in mortality
Pediatric studies? Still to come
Thank You