Recent guidelines regarding perioperative fluid management in children.

1. Dr Anuj Jung Karki
Consultant Anesthesiologist
Kanti Children’s Hospital
Assistant Professor
NAMS
Perioperative fluid management in
children; Is dilemma solved?

2. Perioperative fluid …
•Goal of perioperative infusion therapy is maintain
the normal physiological state in children by
normal ECFV
normal BV
normal metabolic function
normal electrolytes, and acid–base status
normal tissue perfusion

3. Historic background
•The administration of iv maintenance fluids in
children was originally described in 1957 by HOLIDAY
and SEGAR.
•Planned to match free water requirements and
energy expenditure in healthy children.

4. Wt α Energy expenditure α fluid
requirement
Easy rule of thumb: 4/2/1ml/kg/hr

5. •Sodium :3 meq/100kcal/day
•Resembles hypotonic
composition

6. Background…
• Lindahl SG.Energy expenditure and fluid and electrolyte requirements in
anesthetized infants and children.Anesthesiology:1988
•Energy expenditure in anesthetized children was
50% lower than that calculated by Holliday and
Segar
•But he calculated that 166 ml of water were
required to metabolize 100 calories under
anesthesia.
Thus, there was a good agreement in fluid
requirements between the two studies

7. Background…
Since Holiday & Segar publication
•Usual IV fluid given to children for decades was
1/3rd to 1/4th saline with 5 % dextrose (Hypotonic)

8. From around
2000/2001
•Both the composition and the volume of
maintenance fluids were challenged and reevaluated.
•Content of sodium is insufficient in many situations

9. Acute hyponatremic
encepalopathy/Death
Paut O et al
2000,France.
7 cases of
severe
hyponatremic
encepaphy
UK 2000-2006
6 Death case
International literature cites
more than 50 cases of
serious injury or child death
Administration of hypotonic solution significantly
increases the risk of hyponatremia which have
occasionally resulted in permanent neurological
damage or even death.

11. Tonicity/Na
• Eulmesekian PG et al.Hospital-acquired hyponatremia
in postoperative pediatric patients: Prospective
observational study. Pediatric Critical Care
Medicine :2010
Peri-operative hyponatremia has
been reported in as high as 31% of
surgical children with hypotonic
solution.

12. • Halberthal M et al.Acute hyponatraemia in children admitted to hospital: retrospective
analysis of factors contributing to its development and resolution. Lesson of the
week.BMJ 2001
Two factors are required for hyponatraemia to
develop
1. Source of electrolyte free water
2. Vasopressin
Causes of vasopressin release
• Low “effective” circulating volume
• Nausea, pain, anxiety
• Drugs (some act through inducing nausea)
• Afferent stimuli by way of the vagus nerve

13. Tonicity, sodium and chloride
content???

14. Tonicity/Na
• Fraser CL, Arieff AI. Epidemiology, pathophysiology, and management of
hyponatremic encephalopathy. Am J Med 1997
• Dubois MC, Gouyet I, Murat I et al. Lactated Ringer with 1% dextrose: an
appropriate solution for peri-operative fluid therapy in children. Paed Anaesth
1992
As compared to hypotonic solutions for infusion with 5% glucose ,
use of isotonic solutions for infusion results in a lower risk
of hyponatremia with possible encephalopathy, cerebral
edema, and respiratory insufficiency and the lower glucose
concentration of 1–2.5% results in a lower risk of intraoperative
hyperglycemia.

15. Tonicity/Na
• APA. Consensus guideline on perioperative fluid management in children 2007. Available at :
http://www.apagbi. org.uk. Sept 2007, reviewed in Aug 2010.
• Sümpelmann R., Becke K., Crean P., Jöhr M., Lönnqvist P. A., Strauss J. M., Veyckemans F.,
European consensus statement for intraoperative fluid therapy in children, EUR. J.
ANAESTHESIOL.2011
Recommended from hypotonic to isotonic electrolyte
solutions with lower glucose concentrations (1-2.5% instead of
5%) to avoid electrolyte and glucose imbalance .

16. Hypotonic solution
Isotonic solution
Tonicity
Seems like Dilemma is solved

17. Na Concentration
• Seumpelmann R, Becke K, Crean P et al. European consensus statement for intraoperative fluid therapy in children. Eur J
Anaesthesiol 2011
• Intraoperative background infusion in children should have an
osmolarity and sodium concentration as close to the
physiologic range as possible, should contain 1–2.5%
glucose and should also include metabolic anions (e.g., acetate,
lactate, or malate)

18. Cl Concentration
• Witt L, Osthaus WA, Bunte C et al. A novel isotonic-balanced electrolyte solution with 1% glucose for perioperative fluid
management in children – an animal experimental preauthorization study. Pediatr Anesth :2010
• Disma N, Mameli L, Pistorio A et al. A novel balanced isotonic sodium solution vs normal saline during major surgery in
children up to 36 months: multicenter RCT. Pediatr Anesth :2014
•As compared to normal saline, hyperchloremic
acidosis occur more rarely if solutions for infusion
with a lower chloride concentration.

19. Na/Cl concentration
Low Na/High Cl
Na/Cl range: as body plasma range
Seems like dilemma is solved

20. Glucose Concentration
• Hypoglycemia: Devastating as hypoxia
• Hyperglycemia : osmotic diuresis and
consequently dehydration and electrolyte
disturbances and increases risk of hypoxic-
ischemic brain or spinal cord damage

21. Perioperative Hypoglycemia
• Leelanukrom R., Cunliffe M., Intraoperative fluid and glucose management in children. Peadtric
Anesthesia.2000
•More recent studies, estimated ; 1% to max 2.5%
• Usually associated with long fast durations, beyond
the current recommended fasting guidelines.

22. Perioperative hypoglycemia
• Maekawa N et al Acta Anaesthesiol Scand. 1993 “Effects of 2-, 4- and 12-
hour fasting intervals on preoperative gastric fluid pH and volume, and
plasma glucose and lipid homeostasis in children.”
Peroperative glucose deficiency in most cases
results in a catabolic reaction with release of
ketone bodies, and/or free fatty acids, as well
as decrease in BE (ketoacidosis) .

23. Intraoperative Hyperglycemia
• Leelanukrom R, Cunliffe M .Intraoperative fluid and glucose management in children. Peadiatric
Anesthesia .2000
• Söderlind M,Salvignol G,Izard , Lönnqvist PA. Use of albumin, blood transfusion and intraoperative glucose
by APA and ADARPEF members: a postal survey. Paediatric Anesthesia. 2001
•Intra-operative administration of ≥ 2.5%
glucose solutions often resulted hyperglycemia
due to stress-induced insulin resistance and
dilutional hyponatremia.

24. Glucose concentration
• Sümpelmann R et al. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative
fluid therapy in children : results of a prospective multicentre observational post-authorization safety
study (PASS), PAEDIATR. ANAESTH.2010
•Perioperative use of infusion solutions containing no
glucose, 1%, 2.5%, 4% or 5% glucose
•Administration of 1% glucose prevents hypoglycemia,
ketogenesis and lipid mobilization and is associated
with blood glucose concentrations in the normal range
with preventing hyperglycemic episodes.

25. Glucose concentration
•No added Dextrose: Chances of hypoglycemia high
•1-2.5% Dextrose: Optimal
•>2.5%:chances of Intraoperative hyperglycemia
high
Seems like dilemma solved

26. Intraoperative rate of infusion
Maintenance: 4/2/1
Deficit: NPO period
3rd Space loss:type of Surgery
Is it too much of fluid???

27. Maintenance
•Holiday & Segar: 4 2 1 still in clinical use
•Simpler and more accurate 20 to 40 mL/kg of a
balanced salt solution.

28. Third space loss
• Murat I., Dubois M. C.Perioperative fluid therapy in pediatrics. PAEDIATR. ANAESTH.2008
• Bailey A. G., McNaull P. P., Jooste E., Tuchman J. B. Perioperative crystalloid and colloid fluid management
in children : where are we and how did we get here ?,ANESTH. ANALG. 2010
Third-space losses may vary from 1 ml·kg−1·
h−1 for a minor surgical procedure to as much
as 15–20 ml·kg−1·h−1 for major abdominal
procedures.

29. Third space loss
• Chappell D et al. A Rational Approach to Perioperative Fluid Management. Anesthesiology
2008
•Classic third space does not exist.
• Routine replacement of high insensible and third
space losses should be abolished in favor of demand-
related fluid regimens

30. Deficit
• Furman E, Roman D, Lemmer L et al. Specific therapy in water, electrolyte and blood-volume
replacement during pediatric surgery. Anesthesiology. 1975
Furman et al proposed to replace 50% of the
fasting deficit in the 1st hour and 25% in the 2nd
and 3rd hours.

31. Infusion rate/volume
•Outcomes improved by conservative and
individualized fluid management in the
perioperative period in adult.
• But little evidence regarding this topic in pediatric
patients
•Totally challenging area in daily pediatric practice
as with non invasive /inadequate monitoring tools in
children.

32. Intraoperative fluid volume
•Goal directed concept is also emerging in
pediatric patients.
•Restricted Vs liberal intraoperative fluid
Seems like dilemma is still persisting

33. Perioperative intravenous fluid therapy in
children: Guidelines from the Association of the
Scientific Medical Societies in Germany. Sumpelman R
et al 2016
Intraoperative background infusion
•A balanced isotonic electrolyte solution with 1–2.5% glucose
• Initial infusion rate of 10 ml/kg/h and be adjusted .
Replace additional fluid deficits
•A balanced isotonic electrolyte
Circulatory instability
•Balanced isotonic electrolyte solutions
• 10–20 ml/kg until the desired effect is achieved

34. Belgian recommendations on perioperative
maintenance fluid management of surgical
pediatric population(BAPA). Najafi N et al.2012
Intraoperative period
•Isotonic solution +Glucose 1%
•Full maintenance fluid volume
•Isotonic replacement fluid as needed
Postoperative period
•Isotonic fluid+ glucose 5%
•First 24 hr:
-70% of maintenance volume
•After 24 hr: Full maintenance volume
•Isotonic replacement fluid as needed
•Event of Hypovolumia: Isotonic fluids (Saline
0.9%, Plasmalyte®, Hartmann® or colloids) as a
bolus.

35. Intravenous fluid therapy in children and young
people in hospital. NICE guideline 2015
Routine maintenance
Isotonic crystalloids that contain sodium in the range 131–154
mmol/L
4/2/1
Neonate: Isotonic Cystalloids with 5-10% of dextrose
Replacement and redistribution
Consider isotonic crystalloids that contain sodium in 131–154
mmol/litre
Fluid resuscitation
Glucose-free crystalloids that contain sodium 131–154
mmol/litre, with a bolus of 10-20 ml/kg over less than 10
minutes.

36. European consensus statement for
intraoperative fluid therapy in children.
Sumpleman R et al 2011
Intraoperative background infusion in children
should have
•an osmolarity and sodium concentration as close to
the physiologic range as possible
•should contain 1–2.5% glucose
• should also include metabolic anions (e.g., acetate,
lactate, or malate)

37. Conclusion
Intraoperative
Background maintenance: Isotonic Balanced
solution with 1-2.5% dextrose.
Infusion rate:
Maintenance: children 4/2/1 (Neonate a/c to days)
Deficit: Dividing 1st 2nd 3rd Hr
3rd Space: Decide carefully
Deficit, 3rd space loss and ongoing loss: Isotonic
solution (NS,Hartman’s,Plasmalyte)
Event of Hypovolumia: Isotonic solution 10-20ml/kg

38. Conclusion
Post operative
•Fluid type
-Isotonic fluid (NS with5% dextrose avoid if Na>145)
•(NS,Hartman’s,Plasmalyte)
• Maintenance: 70% of total maintenance 1st 24 Hr
-After 24 hrs(if delay in enteral feeding): Full
maintenance
• Ongoing loss: Isotonic solution

39. Isotonic solution with 1-2.5% glucose
France: Polyionique B66
Switzerland: Ringer-Laktat mit Glucose 1%/Ringer-
Laktat mit Glucose 2%
Belgium: Hartmann’s solution with Glucose 2.5%
Austria: ELO-PAED balanced mit 1% Glucose
Germany: Elektrolyt- Infusionslosung 148 mit
Glucose 1 PAD

40. Challenges
•Recommended solutions are neither currently
commercially supported nor indeed available in nepali
market.
• Clinicians may tend to use suboptimal fluids or to
compose their own fluid mixture, which could
potentially lead to iatrogenic complications or medical
errors.

41. Finally
Recommendations are just a framework and
it is of critical importance to individualize
fluid therapy in unstable children.

42. Thank you