Title: Pediatric Liver Transplant Fluid Management: Strategies and Considerations Pediatric liver transplant surgery presents unique challenges in fluid management, necessitating careful attention to resuscitation strategies, fluid boluses, choice of fluids, and assessment of fluid responsiveness. This comprehensive review delves into the why, how, what, and when of fluid management in pediatric liver transplant surgeries, highlighting key considerations for healthcare providers. Introduction Pediatric liver transplantation is a complex surgical procedure aimed at replacing a diseased liver with a healthy one. While advancements in surgical techniques have improved outcomes, fluid management remains a critical aspect of perioperative care. The liver's central role in regulating fluid balance and the potential for significant blood loss during surgery underscore the importance of meticulous fluid management in pediatric liver transplant patients. Why Fluids in Resuscitation Fluid resuscitation serves multiple purposes in pediatric liver transplant surgery. Firstly, it aims to maintain adequate tissue perfusion and oxygen delivery, particularly to vital organs, during the surgical procedure. Secondly, fluid resuscitation helps offset fluid losses resulting from surgical bleeding and third-space losses, thereby preventing hypovolemia and its associated complications. Lastly, optimal fluid management supports hemodynamic stability, reducing the risk of perioperative morbidity and mortality. How: The Fluid Bolus Fluid boluses are a cornerstone of resuscitative efforts in pediatric liver transplant patients. These boluses are administered rapidly to restore intravascular volume and cardiac output, particularly during periods of acute hemodynamic instability. Careful attention must be paid to the volume and rate of fluid administration to avoid complications such as fluid overload, which can exacerbate perioperative edema and compromise organ function. What: Crystalloids and Colloids The choice between crystalloids and colloids is a key consideration in pediatric liver transplant fluid management. Crystalloids, such as normal saline and lactated Ringer's solution, are widely used due to their availability, low cost, and ability to restore intravascular volume. However, colloids, including albumin and synthetic colloids, offer advantages such as higher oncotic pressure and may be preferred in cases of significant fluid loss or when crystalloids alone are insufficient to maintain adequate intravascular volume. When: Fluid Responsiveness Assessing fluid responsiveness is crucial for guiding fluid management decisions in pediatric liver transplant patients. Various clinical parameters, including heart rate, blood pressure, urine output, central venous pressure, and dynamic indices (e.g., pulse pressure variation, stroke volume variation), can be utilized to assess a patient's response to fluid therapy.

1. Pediatric Liver Transplantation –
Fluid Management
Karthik Ponnappan T

2. • Why- Fluids in resuscitation
• How- The Fluid Bolus
• What- Crystalloids and colloids
• When- Fluid Responsiveness

10. Endothelial Glycocalyx
Myburgh NEJM 2013

14. When?

18. • Children have higher chest wall and lung
compliance  The variation in intrathoracic
pressure with normal tidal volume ventilation
may not cause significant circulatory changes
in children
• Children have a more compliant arterial tree
than adults  PPV doesn’t work well

19. EDM
• The most convincing predictor
was ΔVPEAK, a direct
ultrasound measurement of
variations in aortic blood flow
induced by small reversible
changes in preload due to
ventilator induced changes in
venous return.

20. PLR
• ΔCIPLR appeared to be an excellent predictor of
fluid responsiveness in children

23. What?
I don’t care what you use, as long as you use it
carefully!”

24. The Maintenance Fluid

25. Total water needs
• 50mL from insensible + 66.7mL from urine = 116.7mL water
needs/100kcal/day
• Assume water of oxidation provides 16.7mL
• 116.7-16.7 = 100mL/100kcal/day

26. Electrolyte Needs

27. Why ½ DNS
recommended 2 mEq/100 kcal/day of both potassium and chloride and 3
mEq/100 kcal/day of sodium.
These electrolyte requirements are theoretically met by the hypotonic
maintenance fluid commonly used in hospitalised children by 5%
dextrose (D5) with 0.45% normal saline (NS).
For many decades, the fluid given to children by paediatricians was
based on this concept
Arya VK IJA 2012

28. • preoperative deficits
• multiplying the hourly rate, as per 4 / 2/1 rule
method, by the hours of fasting
• Replace half of this volume during the first hour
of surgery, followed by the other half over the
next 2 h.

34. Isotonic fluids and Desalination

36. Plasmalyte vs ½ NS

37. Time to Hyponatremia

38. Perioperative Glucose
• only in those children at greatest risk for
hypoglycaemia
• Use fluids with lower dextrose concentrations
( 1% or 2.5%)
Leelanukrom Paediatric Anaesthesia 2000

39. Perioperative Glucose
• The highest risk of hypoglycaemia is
– in neonates,
– children receiving hyperalimentation, and
– endocrinopathies,
• Glucose infusion at a rate of 120–300
mg/kg/h
• Regular Monitoring

47. Tailoring the Fluid use
• Frequent Monitoring  both hemodynamics
AND electrolytes closely!!

48. Dissection Phase
• Preload crucial
• Watch Sodium!!
– Preop hyponatremia
– NS/Albumin/FFP can cause sudden spike of
Sodium Central Pontine Myelinolysis!!

49. Anhepatic Phase
• Vascular Clamping
• Children tolerate vena caval clamping better
than adults, and less hemodynamic changes
are seen

50. Reperfusion Phase
• Reperfusion is also less likely to result in
hemodynamic changes or rhythm
disturbances

51. Choice of Fluid
• Isotonic, buffered salt solutions  initial
resuscitation fluids
• Consider saline  hypovolaemia and alkalosis
• Consider albumin  sepsis
• Hydroxyethyl starch should not be used in any
patient population

52. Choice of Fluid
• Identify the fluid that is most likely to be lost
and replace the fluid lost
• Consider serum osmolality and the acid-base
status
• Consider cumulative fluid balance and actual
body weight
• Consider the early use of catecholamines

53. Paediatric solution infusions (Isolyte P,
D5%+ NS 0.45%
• Dangerous as boluses– Avoid Intraoperatively

54. Maintenance – Holliday Segar- 50% in critically
ill kids!!

55. Maintenance – Still NS!!

56. Replacing Deficit

58. Massive Transfusions
• MABL = [(starting haematocrit – target haematocrit) ÷ starting haematocrit] × EBV
• If Target is 30% Hct, and PRBC has 70% Hct, we can simplify!!
• 0.5 ml PRBCs for each millilitre of blood loss beyond the MABL
Barcelona SL, Thompson AA, Cote CJ. Intraoperative pediatric blood transfusion therapy: A
review of common issues. Paediatr Anaesth. 2005