2. • IV fluids are drugs
• Pediatric population is heterogeneous
• So, one formula may not suffice
• Both quantitative and qualitative perspective of fluid
management
• Based on physiology and pathology of child
3. Distribution
• 50 to 80% body: composed
of water and percentage is
inversely proportional to age
• As child ages, loss of fluid is
predominantly from ECF
• Distribution of content (fluid
and ions) in these
compartment is controlled
by Donnan effect and
Starling forces
4. Components
• ECF: Major part is sodium (cation) and
chloride (anion)
• ICF: predominantly consists of potassium,
magnesium, proteins and phosphates
• Interstitium: lower proteins but otherwise has a
composition equivalent to ICF.
5. Perioperative fluid management
Objective:
• maintain normal physiological state
• normal ECF volume / blood volume
• normal tissue perfusion
• normal metabolic function
• normal electrolyte and acid–base status
6. Higher fluid requirement
• Higher metabolic rate
• Larger surface area to weight ratio
• Faster respiration
• Kidneys – lower concentrating ability
• Larger ECF and blood volume
7. Management can be broadly covered in three main
parts:
• (1) resuscitation fluid
• (2) maintenance fluid
• (3) replacement for the losses
8. Historical perspective
• Holliday and Segar - came up with the widely used
4/2/1 principle of fluid management.
• Calorie management: daily requirement of
electrolytes like sodium (3 mmol/kg) and potassium
(2 mmol/kg).
Holliday MA, Segar WE. Pediatrics 1957
9. Preoperative fasting
• Preoperative fasting is essential to reduce the risk of
aspiration.
• But it causes harmful physiological and metabolic
effects along with increased perioperative agitations
• So, it is advised to continue enteral feeding till the
recommended fasting guidelines.
• Children can be allowed to drink clear fluids until 1 hr
before the surgery safely
Thomas M, et al. Paediatr Anaesth 2018
11. Preoperative fasting
• Shortened fasting times for clear fluids improve
perioperative experience for children and parents
w/o increasing incidence of pulmonary aspiration.
• Studies have shown that the stomach empties itself
within 1 hr of clear fluids (1-3ml/kg).
Smith I, et al. Eur J Anaesthesiol 2011
Practice Guidelines for Preoperative Fasting : Anesthesiology 2017
12. Preoperative fluid resuscitation
• Holiday and Segar formula is still recommended
widely (including APA and NICE guidelines)
• Clinical assessment of dehydration
• Use of TTE for preoperative fluid assessment is
becoming a common tool in combination with
clinical parameters
Polderman KH, et al. Am J Emerg Med 2015
13. Intraoperative fluid management
• Guidelines (APA, NICE) still follow Holiday Segar
formula for maintenance therapy and recommend
infusion of isotonic solutions.
• NICE guidelines recommend restriction of fluids by
50 to 80% because of non-osmotic ADH secretion
Sümpelmann R,et al. Perioperative fluid management in children. Curr Opin Anesthesiol 2019
14. Replacement fluid
• 3rd space loss (matter of debate) because it is
difficult to account for and is roughly estimated as 2
ml/kg/h for superficial surgery, 4–7 ml/kg/h for
thoracotomy and 5–10 ml/kg/h for abdominal
surgery.
• Sumplemann et al. recommend that in patients with
circulatory instability, balanced isotonic electrolyte
solutions without glucose can be given as
repeat-dose infusions of 10–20 ml/kg until the
desired effect is obtained
Sümpelmann R, et al. Curr Opin Anesthesiol 2019
18. Hypotonic vs Isotonic
• Holiday and Segar formula: had led physicians to give
hypotonic fluids with 5% dextrose.
• In the 1990s : reports of hyponatremia induced
encephalopathy due to hypotonic fluids and stress
induced elevated ADH levels.
• Later, paradigm shift in the perioperative fluid
management both for type and volume of fluid
infused perioperatively for children.
Arieff A. Pediatr Anesth 1998
19. Hypotonic vs Isotonic
• ‘European consensus statement for intraoperative
fluid therapy in children’ (2011) stated that:
• solutions should have an osmolarity and sodium
concentration as close to physiologic range as
possible, should contain 1–2.5% glucose and should
also include metabolic anions (e.g., acetate, lactate,
or malate)
S€umpelmann R, et al. Eur J Anaesthesiol 2011
21. Glucose supplementation
• Situations with high risk of developing hypoglycemia:
preterm neonates
children receiving hyperalimentation
children with liver failure
mitochondrial diseases
Endocrinopathies
Long fasting time
Datta PK. Glucose for children during surgery: Pros, cons, and
protocols. Anesth Essays Res 2017
23. Isotonic fluids with dextrose (1-2.5%)
• Patient remains in normoglycemic range
• Reduces ketogenesis, FFA (lipolysis)
• Suppress protein catabolism
• maintains electolyte balance
• Limitation: decrease bicarbonate, BE, pH,
Insulin:glucagon ratio and increase incidence of
delayed hyperglycemia.
2017
24. Which Isotonic fluid?
• Most commonly available isotonic fluids are 0.9% NS,
RL and plasmalyte.
• None of available isotonic fluid is superior to one
another.
• Balanced crystalloids should be used which mimic
electrolyte pattern of plasma
25. Plasmalyte
Overall plasmalyte is better because:
metabolism of acetate is fast
more independent of hepatic function
with a lower increase in oxygen consumption
no interference with lactate as a marker of low tissue
perfusion
Most of anesthetic drugs are compatible with
acetate except phenytoin and diazepam
Zander PR. EJHP Practice 2006
Heiderich S, et al. Paediatr Anaesth 2016
26. Liberal vs restrictive approach
Liberal approach:
• Liberal approach has been adopted a lot for
compensating the fluid loss during major surgical
procedures.
• Most studies evaluated liberal approach and showed
many complications in the postoperative period.
Bell, E. F., (2008). Restricted versus liberal water intake for preventing morbidity
and mortality in preterm infants. Cochrane Database Syst Rev,
27. Liberal vs restrictive approach
Restrictive approach:
• Recently, it is more preferred approach because
patient outcomes, such as wound healing and
hospital stay had been improved significantly.
• Limitation – Common complication is intra and
postoperative hypovolemia which causes reduced
organ perfusion and systemic dysfunction.
Mandee, S., et al. (2015). Pediatric Anesthesia
Murat, I. (2008). Pediatric Anesthesia
Visram, A. (2016). Southern African Journal of Anaesthesia and Analgesia
28. LIBERAL VS RESTRICTIVE
• Liberal group required more intraoperative
transfusion of PRBCs, FFP, colloid
• However no differences in mean creatinine or acute
renal failure in immediate postoperative period were
observed in restrictive group
• Ideally, it should be goal directed fluid therapy.
Transplant proceedings 2014
29. Colloids vs crystalloids
• A controversial continuity is still exist in detecting
which type of fluid to be used for fluid loss
replacement in major pediatric surgeries, due to the
dearth of supporting data for typical fluid.
• According to associated complications, crystalloids
are more preferred in use in replacement.
Abraham‐Nordling, M., et al. (2012). British Journal of Surgery
Arya, V. K. (2012). Indian journal of anaesthesia
Ashes, C., & Slinger, P. (2014). Current Anesthesiology Reports
30. Colloids - guidelines
• According to a recommendation by European
Medicines Agency (EMA) and German S3 Guideline
on Volume Therapy:
• HES/artificial colloids can continue to be used for
intraoperative volume therapy in children with
healthy kidneys where treatment with crystalloids
alone is not sufficiently effective.
Marx G, et al. Eur J Anaesthesiol 2016.
EMA. 23 July, 2014
31. Colloids
Adverse effects:
• Allergic reactions
• Renal failure
• Coagulation disorders
• Decreases hemoglobin level
• Hemodilution
• Iatrogenic hypervolemia
Arya, V. K. (2012). Indian journal of anaesthesia
Bailey, A. G. (2010). Anesthesia & Analgesia
32. Colloids
• No advantage of one colloid over the other.
• Albumin remains the main colloid used in neonatal
period and early infancy.
• 5% albumin shown to be more effective than 20%
and remains the preferred colloid in young infants as
it is iso‐oncotic to plasma and very effective to
maintain blood pressure and plasma colloid
perfusion pressure.
Greenough A. Eur J Pediatr 1998
Roberton NR. Eur J Pediatr 1997
33. Blood and blood products
• When to transfuse blood in children depends on
MABL calculated as:
MABL = EBV × (H0 – H1)/H0
• Transfusion trigger is usually accepted to be around
hemoglobin of 7-8 g/dl in children.
• Volume of packed cells required is calculated as:
Body weight (kg) × desired increment in
hemoglobin (g/dl) × 5
Morley SL. Red blood cell transfusions in pediatrics. Arch Dis Child Educ Pract 2009
34.
35. Experimental group: CO, CI, oxygen delivery, oxygen
delivery index, oxygen consumption, SV, SVV, PPV,
ScVO2(mixed venous oxygen saturation), lactate
levels, oxygen extraction ratio, aortic velocity-time
integral variation, aortic flow peak velocity, aortic
flow peak velocity variation PVI (pleth variation
index), NIRS.
Control group: standard
parameters were used to monitor
haemodynamics such as mean
arterial pressure, perfusion
pressure, arterial blood pressure,
central venous pressure.
38. • PPV and CVP are not optimal parameters to guide
fluid therapy in children.
• In pediatrics, fluid responsiveness is best assessed
with aortic peak blood flow velocity variation [either
with echocardiography or an esophageal Doppler
probe (Cardio-Q)]
Gan H, et al. Anest Analg 2013
Pereira de Souza Neto E, et al. British Journal of Anaesthesia 2011
2021
39. • SVV by FloTrac/Vigileo can be used to assess fluid
responsiveness; however, this device has not yet
been validated for fluid therapy.
• GDT guided by FloTrac/Vigileo (SVV) decreased
intraoperative bleeding, blood product
requirements, ICU stay and postoperative
complications
Biais M, et al. Anest Analg 2009.
Slagt C, et al. British Journal of Anaesthesia 2014
2021
44. • Parameters such as SPV, PPV, ΔDown, and ΔUp
arterial pressure-based variables poorly predict fluid
responsiveness in children
• Both ΔPOP (pulse oximetry plethysmography) and
PVI (plethysmographic variation index) are attractive
parameters for use in pediatric because they are
measured noninvasively
45. ΔPOP and PVI
• ΔPOP% waveform is by blood volume change in
vessels,not by pressure change. Formula:
100 × (amp max – amp min) / [(amp max + ampl min)
/ 2]
• PVI: obtain the respiratory variations in
plethysmographic waveform
PVI = [perfusion index (PI) max − PI min] / PI max
• meta-analysis: PVI is a reliable predictor in children
• Threshold for responders to volume expansion 14% ±
3%.
Desgranges FP, et al. Br J Anaesth 2016
46. Respiratory variation of aortic blood
flow peak velocity
• ΔVpeak is measured at aortic annulus or LVOT by
using pulsed wave Doppler with TTE or TEE.
• Promising marker for optimization of periop fluid
therapy in pediatrics. Morparia KG, et al. J Clin Monit Comput 2018
47. Difference (adult vs children)?
• Fluid responsiveness in pediatrics is different from
adults. Reasons:
1. Characteristics and compliance of blood vessels
differ with age, becomes more stiff with age because
of calcification.
2. Respiratory compliance of children is larger than
adults. So, change in intrathoracic pressure
transmitted to vascular system is less
48. • Pediatric fluid therapy is the most critical element of
anesthesia management perioperatively.
• Suitable approach of fluid replacement in pediatrics
is still in argument because there is a rareness in
supporting data for each regimen.
• Instead of relying on single variable, use of multiple
variable significantly improves the sensitivity and
specificity
International Journal of Pharmaceutical Research | Apr - Jun 2020 | Vol 12 | Issue 2
