Fluid management in the paediatric patient anaesthetist consideration...

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Fluid management in the paediatric patient anaesthetist consideration...

  1. 1. FLUID MANAGEMENT IN THE PAEDIATRIC PATIENT Dr Riyas A
  2. 2. Water physiology  Water is the most plentiful constituent of the human body  approximately 75% of birthweight for a term infant  decreases to approximately 60% of body weight during the 1st yr of life and basically remains at this level until puberty
  3. 3. Fluid Compartments  TBW is divided between 2 main compartments  intracellular fluid (ICF)  extracellular fluid (ECF)  ECF  Plasma  Interstitial fluid  Transcellular fluid
  4. 4. Fluid compartments & volumes changes with age Compo nents Premat ure Neonat e Infant Adult ECF 50 35 30 20 ICF 30 40 40 40 Plasma 5 5 5 5 Total 85 80 75 65
  5. 5. Transcellular fluid  CSF  Synovial fluid  Digestive juices  Intraocular  Pleural  Pericardial  peritonial
  6. 6. Continu….  Plasma water is 5% of body weight  Blood volume is usually 8% of body weight  The volume of plasma water can be altered by pathologic conditions  dehydration, anemia, polycythemia, heart failure, abnormal plasma osmolality and hypoalbuminemia
  7. 7. Continu…  Interstitial fluid - normally 15% of body weight  can increase dramatically in diseases associated with edema  heart failure, protein-losing enteropathy, liver failure, nephrotic syndrome, and sepsis
  8. 8. Electrolytes  Exist as ions  Cations – positively charged  Anions – negatively cahrged  Concentrations expressed as meq/L
  9. 9. Electrolyte Content of Body Fluids
  10. 10. Electrolyte Composition in Body Fluids (Normal) Electroly te Plasma Exracellu lar Intra cellular Na+ 142 145 10 K+ 4 4 159 Mg2+ 2 2 40 Ca2+ 5 3 1 Cl- 103 117 10 HCO3 - 25 27 7
  11. 11. Daily Loss of Water Source of Loss Normal Activity and Temperature (mL) Normal Activity High Temperature (mL) Prolonged Exercise (mL) Urine 1400 1200 500 Sweat 100 1400 5000 Feces 100 100 100 Insensible losses 700 600 1000 Total 2300 3300 6600
  12. 12. Determining fluid requirement  Howland ----1911----energy consumption in children  In 1957 holliday and segar correlated calorie requirement with basal metabolism and active energy needs
  13. 13. Calorie requirement is  0-10kg=100kcal/kg/day  10-20kg=50kcal/kg/day+1000kcal  >20kg=1500kcal+20cal/kg  Mb of 1cal produces 0.2ml of water and consumes 1.2ml  On transporting this in to hourly basis
  14. 14. Continu…  0-10kg4ml/kg/hr  10-20kg40ml+2ml/kg/hr  >20kg60ml+1ml/kg/hr  Fever increses the calorie requirement by 10- 20%for every centigrade rise
  15. 15. Clinical assessment of dehydartion Symptoms&sign s Mild Mode Severe Wt loss <5 5-10 >10 General condition Alert/restless Thirsty/lethrgic Cold/thirsty Pulse Normal rate /voume Rapid/weak Rapid/feeble Respiration Normal Rapid Rapid/deep Systolic pressure N N/Low Unrecordable Anterior fonta N/sunken Sunken Very sunken Eyes n/sunken Sunken/dry Grossly sunken Skin N Decreased Markedly decresed Mucous membrane Moist Dry Very dry Urine output Adequate Less ,dark coloured Oliguria/anuria Capillary filling Normal <2sec >3sec Estimated deficit 30-50ml/kg 60-90ml/kg 100ml
  16. 16. Investigation for confirming dehydration  Serum osmolarity /serum sodium  Acid base status,serum ph and base deficit  Serum potassium compared with ph  Urine output
  17. 17. Correction of flui deficit  Done in three phases  Emergency phase20-30ml/kg over 10- 20min (intital resucitation with isotonic saline  Repletion phase 125-50ml/kg over 6-8hr(or half the deficit)  Repletion phase 2remainder of the deficit
  18. 18. Mild dehydration  Correction is with ORS  Package containing  Glucose 20gm/Lwater  Nacl 3.5gm/Lwater  Kcl4.5gm/Lwater  Trisodium citrate 2.9gm/Lwater  Sodium bocarbonate2.5gm/L water
  19. 19. Compensatory mechanism  Definite  temporary
  20. 20. Nil per oral guidlines Age Milk and fat free solids Fluids <6mnths 3-4hr (breast milk) 2hrs 6-36mnths 6hrs(formula breast feeds) 3hrs >36mnths 8hrs fatty feeds or solids 3hrs
  21. 21. Body requires  Maintenance fluid  Replacement fluid  Maintenance fluid hypotonic fluid  4 basic reason  1)evaporation  2)excretion through kidney and stools  3)through respiratory tract  4)growth
  22. 22. Fluid required to compensate for fasting  The younger child with higher basl metabolism  Prolonged fsting which occurred inadverently or out of necesssity  In the hot summer m0nth  A febrile child  In polycythemia when there is a risk of dehydration predisposing to thrombosis
  23. 23. Monitoring fluid loss an replacement  Routine monitoring pulse oxy,nibp,ecg,precordial stethescope 15-20%  Urine out put
  24. 24. Selection of fluid  Depend on condition of patient  Surgery hct
  25. 25. Intra operative fluid replacement Surgical trauma Type of surgery Fluid replacement Minimal Inguinal repair 1-2ml/kg/hr Moderate Ureter reimplantatio n 4ml/kg/hr Severe Scoliosis,intra abdominal surgery >6-8ml/kg/hr
  26. 26. heamatocrit  A normal hct means ,a hct within two standard deviation for the age  An acceptable hct is with which an infant or child can tolerate with out blood transfusion
  27. 27. Blood  The use of blood products in pediatric surgical patients has diminished greatly because of the fear of transmission of disease—particularly human immunodeficiency virus (HIV). Because HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and a number of other disease-causing viruses can be transmitted with as little as 10 mL of packed red blood cells (PRBCs), administration of any blood product requires clear, medically defensible clinical indications that are preferably recorded on the anesthetic record
  28. 28. Blood loss and replacement  In general, blood volume is approximately 100 to 120 mL/kg for a preterm infant, 90 mL/kg for a full-term infant, 80 mL/kg for a child 3 to 12 months old, and 70 mL/kg for a child older than 1 year.These are merely estimates of blood volume.The individual child's blood volume is calculated by simple proportion by multiplying the child's weight by the estimated blood volume (EBV) per kilogram
  29. 29. Maximum allowable blood loss  MABL=EBV*(Starting hct-target hct)/strting hct  Volume to be transfused=(desired hct- presenthct)8ebv/hct of prbc
  30. 30. Normal and acceptable hct value Premature 40-45 35 Newborn 45-65 30-35 3months 30-42 25
  31. 31. Composition of IV fluids (per 1000 ml) Fluid Na K Cl Glucose Others 5% dextrose - - - 50 g - 10% dextrose - - - 100 g - Normal saline 154 mEq - 154 mEq - - N/2 saline 77 mEq - 77 mEq - - N/5 saline in 5% dextrose 30 mEq - 30 mEq 40 g - 3% saline 513 mEq - 513 mEq - - Ringer’s lactate 130 mEq 4 mEq 109 mEq - Lactate 29 Isolyte P 26 mEq 19 mEq 22 mEq 50 g acetate 24, PO4 3, Mg 3
  32. 32. Some other fluids meq/L Fluid Na K Cl Glucose Others Plasmalyte A 140 5 98 Mg3 acetate 27 Albumin 5% 145+15 <2.5 100 Hexa starch 6% 154 154
  33. 33. Conclusion  Fluid therapy should be tailored to the needs of individual patient  Basal fluid and energy requirements as well as correction of derangements may be met by crystalloids  Infusion of large volume of crystalloid to correct intravascular deficit may produce tissue oedema,coagulation abnormality and organ dysfunction
  34. 34. conclusion  Intravascular correction should be made with crystalloids   thank you

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