This document discusses fluid and electrolyte management in infants and children. It covers topics such as calculating fluid requirements using the Holliday-Segar method, appropriate intravenous fluids for different age groups, and considerations in the preoperative, operative, and postoperative periods. Key points include: - Neonates greater than 32 weeks gestation and 1.5kg can use the Holliday-Segar formula of 4ml/kg/hr for daily fluid needs. - Isotonic fluids like normal saline or lactated ringers are recommended for resuscitation and maintenance in children. - Postoperative patients should receive isotonic fluids and replacement of additional fluid losses. - Postoperative diuresis generally occurs 3-4 days

1. FLUID AND ELECTROLYTE
MICHAELISKANDAR
PEMBIMBING :
DR. DR HARSALI LAMPUS SP.BA
DR. CANDY SP.B SUBPED
DR. LEO RENDY SP.B SUBPED

21. • FLUID ADMINISTRATION IS NECESSARY TO MAINTAIN ADEQUATE TISSUE PERFUSION AND
CELLULAR METABOLISM
FLUID IS OFTEN REQUIRED TO ACUTELY REPLETE GASTROINTESTINAL, RENAL, OR BLOOD
LOSSES
TO COMPENSATE FOR INSENSIBLE LOSSES SECONDARY
FEVER, HYPERVENTILATION, OR INCREASED METABOLISM.

22. CALCULATING THE FLUID AND ELECTROLYTE
REQUIREMENTS
• HOLLIDAY AND SEGAR METHOD SINCE THE 1950S
• THE HOLLIDAY AND SEGAR METHOD ALSO APPROXIMATED THE DAILY ELECTROLYTE
REQUIREMENT OF 2 MEQ/100 ML/KG AND 3 MEQ/100 ML/KG FOR POTASSIUM/CHLORIDE
AND SODIUM
• FOR INFANTS THAT ARE GREATER THEN 32 WEEKS GESTATIONAL AGE, MORE THAN ONE
WEEK IN AGE, AND GREATER THAN 1.5 KG, DAILY FLUID REQUIREMENTS CAN BE
CALCULATED USING THE HOLLIDAY AND SEGAR FORMULA AT 4 ML/KG/HR

23. THE BASIS OF SELECTION
• D5 0.45 NACL AS THE MOST COMMONLY USED INTRAVENOUS FLUID IN ILL CHILDREN
• DOES NOT MEET THE ELECTROLYTE REQUIREMENTS FOLLOWING MAJOR SURGERY OR
INJURY. D5 0.45 NACL CONTAINS ONLY 77 MEQ/L OF SODIUM
• HYPOTONIC
• ONLY PROVIDES 20% OF CALORIC REQUIREMENTS FOR UNSTRESSED CHILDREN
• THE USE OF D5 0.45 NACL IN SURGICAL PATIENTS, BASED ON THE HOLLIDAY AND SEGAR
METHOD, CAN LEAD TO FLUID OVERLOAD IN THE EXTRACELLULAR COMPARTMENT AND
DANGEROUS ELECTROLYTE DISTURBANCES ESPECIALLY HYPONATREMIA

24. BASIC SCIENCE
• TOTAL BODY WATER MAKES UP A LARGER PERCENTAGE OF BODY WEIGHT AS AGE AND
GESTATION DECREASE
• DESPITE A LOWER GLOMERULAR FILTRATION RATE, INFANTS HAVE A SIGNIFICANT
POSTNATAL DIURESIS.

25. WHAT IS THE NORMAL BODY WATER COMPOSITION
IN NEONATES AND WHAT FLUID SHIFTS TAKE PLACE
IN THE NEWBORN PERIOD?
• A SHIFT FROM THE INTRACELLULAR COMPARTMENT OVER THE NEXT TWO TO THREE DAYS
LEADS TO A DIURESIS (1 TO 3 ML/KG) THAT RESULTS IN A LOSS OF 5 TO 10% OF THE BODY
WEIGHT
• OVER THE NEXT YEAR, TBW REDUCES TO 60% OF BODY WEIGHT OF WHICH 20-25% IS
CONTAINED IN THE EXTRACELLULAR COMPARTMENT (WHICH IS SIMILAR TO ADULT LEVELS)
• THE EXTRACELLULAR COMPARTMENT IS LARGER IN PREMATURE INFANTS AND THERE IS A
GREATER DIURESIS (GREATER THAN 3 ML/KG) RESULTING IN A GREATER DROP IN WEIGHT (UP
TO 15%) IN THE FIRST WEEK OF LIFE

26. HOW DOES GLOMERULAR FILTRATION RATE,
CONCENTRATING ABILITY AND SODIUM
MANAGEMENT IN THE KIDNEY DIFFER IN THE
PRETERM AND THE FULL TERM NEWBORN?
• THE FACT THAT THE NEWBORN KIDNEY HAS A GLOMERULAR FILTRATION RATE (GFR) THAT
IS 25% OF ADULT RATES
• ADULTS NORMALLY DIRECT 16% OF THEIR CARDIAC OUTPUT TO THE KIDNEYS
• ONLY 2% OF THE CARDIAC OUTPUT IS DIRECTED TO THE KIDNEYS IN NEWBORNS
• THIS INCREASES TO 8.8% AT FIVE WEEKS AND TO 9.6% BY THE END OF THE FIRST YEAR
• DESPITE THIS LOW GFR, DIURESIS OCCURS SINCE THE INFANT CAN EXCRETE VERY
DILUTE URINE (DOWN TO AN OSMOLARITY OF 50 MOSM/KG IN COMPARISON TO A MAXIMAL
DILUTION OF 70 TO 100 MOSM/KG IN ADULTS)
• NEWBORN KIDNEYS ARE LESS ADEPT AT SODIUM RETENTION DUE TO LIMITED NA-K-
ATPASE AND NA-K EXCHANGE EXPRESSION

27. WHAT ARE THE INSENSIBLE LOSSES OF THE
NEWBORN AND INFANT?
• THE SKIN AND THE RESPIRATORY TRACT
• FULL TERM INFANTS LOSE APPROXIMATELY 50 ML/KG/DAY
• PREMATURE INFANTS CAN EASILY LOSE IN EXCESS OF 150 ML/KG/DAY

28. HOW DOES DEHYDRATION PRESENT IN
CHILDREN?
• HISTORY OF VOMITING AND/OR DIARRHEA
• LOW URINE OUTPUT
• FEVER
• WEIGHT DECREASE
• INCREASED CAPILLARY REFILL TIME (GREATER THAN TWO SECONDS)
• DRYNESS OF LIPS AND MUCOUS MEMBRANES, LACK OF TEARS
• SUNKEN FONTANEL
• MENTAL STATUS CHANGES
• HEART RATE INCREASE USUALLY WITHOUT CHANGES IN BLOOD PRESSURE

29. HOW DOES DEHYDRATION PRESENT IN
CHILDREN?
• DRY MUCOUS MEMBRANES, INCREASED THIRST AND MILDLY DIMINISHED URINE OUTPUT
MAY INDICATE A 30-50 ML/KG DEFICIT IN INFANTS AND ADOLESCENTS.
• TACHYCARDIA ASSOCIATED WITH VERY LOW OR NO URINE OUTPUT, SUNKEN EYES,
SUNKEN FONTANELS AND LOSS OF SKIN TURGOR MAY INDICATE A 60-100 ML/KG DEFICIT
• SEVERE DEFICITS (90-150 ML/KG) CAN BE MARKED BY ABSENCE OF TEARS, DELAYED
CAPILLARY REFILL, HYPOTENSION, MOTTLED SKIN AND POTENTIAL NEUROLOGICAL
CHANGES

30. WHAT ARE THE NORMAL FLUID MAINTENANCE
REQUIREMENTS OF PREMATURE AND TERM
INFANTS?
• HE MOST ACCURATE WAY TO ASSESS FLUID STATUS IS BY MONITORING URINE OUTPUT AND
AIMING FOR 1 TO 2 ML/KG/HR
• FOR INFANTS THAT ARE GREATER THEN 32 WEEKS GESTATIONAL AGE, MORE THAN ONE
WEEK IN AGE, AND GREATER THAN 1.5 KG, DAILY FLUID REQUIREMENTS CAN BE
CALCULATED USING THE HOLLIDAY AND SEGAR FORMULA AT 4 ML/KG/HR

31. WHAT ARE THE NORMAL ELECTROLYTE
REQUIREMENTS OF INFANTS, CHILDREN AND
ADOLESCENTS?

32. WHAT OPTIONS ARE AVAILABLE FOR FLUID
ADMINISTRATION?

33. WHAT IS THE RECOMMENDED TYPE OF
INTRAVENOUS FLUID FOR USE IN NEONATES,
CHILDREN AND ADOLESCENTS?
• NEONATES GREATER THAN 1500 G AND FULL TERM INFANTS IS 10% DEXTROSE IN WATER
(D10W). ON DAYS TWO THROUGH SEVEN, SODIUM AND POTASSIUM ARE ADDED.
• AFTER DAY SEVEN, D5 TO D10 WITH ONE-QUARTER NORMAL SALINE IS STARTED IF THE
INFANT HAS NOT YET BEEN PLACED ON PARENTERAL NUTRITION
• INFANTS LESS THAN 1500 G ARE STARTED ON D10W
• CHILDREN (I.E. GREATER THAN TWO MONTHS OF AGE) AND ADOLESCENTS WHO REQUIRE
FLUID RESUSCITATION SHOULD INITIALLY RECEIVE EITHER NORMAL SALINE OR LACTATED
RINGERS
• NORMAL SALINE, WITH DEXTROSE IF DESIRED, OR LACTATED RINGERS CAN THEN BE
STARTED FOR MAINTENANCE FLUID UTILIZING THE HOLLIDAY-SEGAR METHOD OF THE 4-2-
1 RULE

34. A COCHRANE REVIEW HAS DEMONSTRATED THAT HYPOTONIC FLUID SHOULD NOT
USUALLY BE GIVEN TO CHILDREN OUTSIDE OF THE NEONATAL PERIOD AS IT MAY RESULT
IN UNRECOGNIZED HYPONATREMIA AND MORBIDITY

35. WHEN SHOULD PATIENTS BE MADE NPO PRIOR
TO A PROCEDURE AND WHAT FLUIDS SHOULD
BE ADMINISTERED PREOPERATIVELY?
THE RECOMMENDED FASTING GUIDELINES, BASED ON THE EUROPEAN SOCIETY OF
ANAESTHESIA (2011) SUGGEST [40]
• TWO HOURS FOR CLEAR LIQUIDS
• FOUR HOURS FOR BREAST MILK
• SIX HOURS FOR NON-HUMAN MILK OR INFANT FORMULA
• EIGHT HOURS FOR SOLID FOOD

36. HOW MUCH AND WHAT TYPE OF INTRAVNEOUS
FLUID SHOULD BE GIVEN IN THE OPERATING
ROOM?
• INITIAL MAINTENANCE INTRAVENOUS FLUIDS IN THE OPERATING ROOM SHOULD INCLUDE
NORMAL SALINE OR LACTATED RINGERS SOLUTION
• NEONATES LESS THAN 48 HOURS OF AGE REQUIRE SUPPLEMENTAL DEXTROSE
• REPLENISHMENT OF THIRD SPACE FLUID LOSSES IS AN IMPORTANT CONSIDERATION
• MINIMAL SURGICAL LOSSES (E.G. HERNIA OPERATION), THE RATE OF FLUID REPLACEMENT
SHOULD 1 TO 2 ML/KG/HR.
• MODERATE FLUID LOSSES (E.G. CHOLECYSTECTOMY) THE RATE OF REPLACEMENT SHOULD BE
4 TO 7 ML/KG/HR
• LARGER LOSSES (E.G. ELECTIVE BOWEL RESECTION), A REPLACEMENT RATE OF 6 TO 10
ML/KG/HR IS APPROPRIATE

37. POSTOPERATIVE CARE
• POSTOPERATIVE PATIENTS SHOULD RECEIVE ISOTONIC FLUID AND REPLACEMENT OF
ADDITIONAL ABNORMAL FLUID LOSSES

38. WHAT ARE THE PATIENT RESPONSES TO AN
OPERATION?
• THE RESPONSE TO SURGICAL STRESS IS GOVERNED BY COMPLEX NEUROENDOCRINE AND
CYTOKINE INTERACTIONS.

40. WHAT FLUID SHOULD BE USED IN THE
IMMEDIATE POSTOPERATIVE PERIOD?
• ISOTONIC FLUIDS SUCH AS NORMAL SALINE OR RINGERS LACTATE SHOULD BE USED FOR
THE FIRST SEVERAL DAYS AFTER SURGERY BOTH FOR MAINTENANCE
• INTRAVENOUS SOLUTIONS SHOULD ALSO INCLUDE FIVE PERCENT DEXTROSE UNTIL HIGHER
NUTRIENT SOLUTIONS ARE INITIATED

41. WHEN DOES A POSTOPERATIVE DIURESIS
OCCUR?
• POSTOPERATIVE DIURESIS GENERALLY OCCURS AFTER THREE TO FOUR DAYS AS ADH
LEVELS BEGIN TO DECREASE
• SHOULD THIS NOT OCCUR, CONCERNS ABOUT PAIN CONTROL AND INFECTION SHOULD BE
RAISED AS POSSIBLE CAUSES FOR PROLONGED ADH SECRETION.

42. TERIMA KASIH