The document discusses pediatric perioperative fluid management, emphasizing the importance of intravenous fluid therapy before, during, and after surgery to maintain circulation and electrolyte balance. It outlines types of fluids, principles of fluid therapy, and the challenges of managing fluid therapy in newborns, noting that fluid overload can lead to significant complications. A retrospective cohort study is presented, highlighting the association between fluid overload in newborns after abdominal surgery and increased duration of ventilator support.

1. PEDIATRIC PERIOPERATIVE
FLUID MANAGEMENT
PRESENTERS: Machera
Abel
FACILITATOR: Dr. Lukansola

2. Outline
• Introduction
• Types of fluid
• Preoperative fasting
• Preoperative fluid deficit
• Intraoperative fluid
• Postoperative fluid management
• Journal presentation

3. Introduction
• Intravenous fluid therapy is an integrated and lifesaving part of the
treatment of patients undergoing surgery.
• Perioperative fluid therapy It is the administration of intravenous
fluids before, during, and after surgery at the right time and in the
right amounts.
• The goal of perioperative intravenous fluid therapy is to maintain or
restore circulation with an adequate fluid and electrolyte balance,
thereby creating the preconditions for a favourable outcome for the
patient.

4. Body fluid composition
• Body fluid compartments consist of intracellular and extracellular
compartments, with the extracellular further divided into interstitial
and plasma volumes.
• IV free water distributes evenly across total body water, isotonic
crystalloids stay in the extracellular compartment, and colloid
solutions expand plasma volume when the endothelial glycocalyx is
intact.
• In fetuses and premature newborns, most of the total body water is
extracellular (60-70% of body weight), decreasing to 40% in term
babies and 30% in older infants.
• Electrolyte composition remains consistent throughout life, but the
size of fluid compartments changes with age.

5. Goals of Perioperative Fluid management
i. Maintain or correct fluid balance (dehydration, hypovolemia)
ii. Maintain or correct plasma constitution (electrolytes)
iii. Secure sufficient circulation (in combination with vasoactive and/or
cardioactive substances)
iv. Secure sufficient oxygen delivery to organs (in combination with
oxygen therapy)

6. Principles of fluid therapy
i. Replace losses or deficits
ii. Continue Maintenance
iii. Anticipate additional on-going losses.
iv. Anticipate excess fluid intake

7. TYPES OF FLUIDS
i. Crystalloid fluids
ii. Colloid fluids
iii. Blood products

8. Crystalloids
• Crystalloids are solutions containing electrolytes and other low-molecular-
weight substances.
• Crystalloids can be further sub-grouped into Isotonic, hypotonic, and
hypertonic fluids
• Fluids with ionic concentrations resembling extracellular fluid are called
balanced solutions.
• Organic anions are added to balanced solutions to reduce chloride
concentrations and the risk of iatrogenic hyperchloraemic acidosis.
• Lactate serves this purpose in lactated Ringer’s solution, also acting as a
buffer and substrate for hepatic bicarbonate synthesis. Acetate and gluconate
serve a similar purpose in Plasma-Lyte solution

9. Isotonic Solution
• They have tonicities close to that of plasma as termed ISOTONIC.
• Common examples are : 0.9% Saline, Ringer’s Lactate, D5-1/4NS and
Plasmalyte.
• Balanced electrolyte solutions- (low-[Cl–] crystalloids, which have
preserved ionic “balance” by replacing Cl– with lactate, gluconate, or
acetate) such as lactated Ringer’s solution or PlasmaLyte are most
commonly used for replacement.

10. Uses of Isotonic Solution
• ECFV depletion of any cause since hypotonic solutions can cause
dangerous hyponatremia in the setting of ECFV depletion.
• Post-operative management
• Shock from any cause
• Hemorrhage
• Burns

11. Plasmalyte Hartmann’s solution

12. Hypotonic solution
• These are solutions whose osmolarity
is LESS than the serum osmolarity.
These fluids dilute the serum.
• Examples are: 0.45% Saline, D2W,
D3W
• USES
i. Hyperosmolar states due to severe
hyperglycemia, (DKA). (0.45%
saline, not D5 0.45% Saline)
ii. Hypernatremia with ECFV
depletion. Eg. Severe Diarrhoea

13. Hypertonic solution
• These have higher osmolarity
than serum.
• Useful for - stabilizing BP,
Increasing urine output,
correcting hypotonic
hyponatremia and decreasing
Edema.
• EXAMPLES : 3%,7%, 10% Saline.
D5W and D10W are also
hypertonic solutions.

14. Colloids
• Colloids contain homogeneous non-crystalline particles suspended in
balanced crystalloid or isotonic saline.
• These particles tend to remain within the bloodstream after infusion,
thus increasing intravascular oncotic pressure and expanding plasma
volume.
• Colloids are either artificial (hydroxyethyl starch [HES], gelatins and
dextrans) or derived from donated blood (albumin and fractionated
blood products).

15. Colloids

16. CRYSTALLODS vs COLLOIDS
Crystalloids
• Cheap
• Easy to manufacture
• Short half life
• No Anaphylaxis reaction
• Large volumes required
(three to four times the volume
needed when using colloids. )
• Do not interfere with blood clotting.
Colloids
• More expensive
• Not easy to manufacture
• Long shalf life
• Small risk of Anaphylaxis
• Smaller volumes of infusion
required.(1:1 )
• May interfere with blood clotting

17. Blood
• Oxygen delivery to the tissues is primarily a function of haemoglobin
level, haemoglobin oxygen saturation and cardiac output.
• Ensuring an adequate haemoglobin level and intravascular volume is
therefore vital for oxygen delivery.
Reprinted with revisions from: Wilson CM. Perioperative fluids in children. Update in Anaesthesia
2005;

18. Selection of Fluid
• Balanced crystalloid solutions:
• Balanced electrolyte solution (eg, Ringer's lactate, Plasmalyte) rather
than normal saline or colloid to;
i. Maintain intraoperative normovolemia.
ii. Replacement of lost blood on a 1.5:1.0 volume basis until a
transfusion threshold is met.

19. CONT.
• Colloid solutions:
• During blood loss, some clinicians prefer to administer colloid (e.g. albumin) on a
1:1 volume basis until a transfusion threshold is met.
• We minimize colloid use due to insignificant hemodynamic benefits compared
with crystalloids.
• Blood transfusion:
• Red blood cells (RBCs) are used to replace blood loss when a transfusion
threshold is met.
• Decisions regarding transfusion of plasma derivatives (eg, fresh frozen plasma
[FFP]) are based on estimates of blood loss and evidence of abnormal
hemostasis.

20. Preoperative fasting
• Fasting is essential as it decreases the risk of regurgitation; aspiration;
and the associated life-threatening sequelae of airway obstruction,
chemical pneumonitis and bacterial pneumonia
• Fasting before surgery has the potential to induce dehydration and a
number of neurohumoral and metabolic responses, resulting in
ketosis and catabolism (glycogenolysis, lipolysis and proteolysis).
• Prolonged fasting can cause hunger, thirst, anxiety and distress
• Studies have shown that the stomach empties itself within 1 hr of
clear fluids without increased risk of pulmonary aspiration.

21. Preoperative fasting

22. Preoperative fluid deficits
• Euvolaemia is expected in the elective surgical setting when clear oral
fluids are promoted before surgery.
• For children undergoing emergency surgery, there may be significant
fluid deficits caused by burns, fever, sepsis, bleeding or
gastrointestinal losses (vomiting, gastric tube drainage, and diarrhea).
• The fluid deficit to be replaced is the maintenance fluid requirement
(multiplied by the hours since last oral intake) added to preoperative
external and third space losses.
• Replace 50% over the first hour, then 25% over each of the next two
hours.

23. Assessment of dehydration

24. Intraoperative fluid
• The goal of giving fluid during surgery is to provide water for basal
metabolism and to maintain circulating volume and electrolyte
homeostasis.
• Balanced isotonic crystalloids (e.g. Plasma-Lyte) are the 1st
-line fluids for
intraoperative maintenance and volume replacement.
• In infants and children beyond 4 weeks of age Holliday and Segar equation
(4/2/1) is recommended for use to calculate basal daily fluid requirements
• Adjustments need to be made to replace the additional obligatory fluid
losses of surgery. Eg. evaporation from open-cavity surgery, burns, fever
and sepsis, gastrointestinal losses and bleeding.

25. Redistribution and evaporative surgical fluid losses
Degree of Tissue Trauma Additional Fluid Requirement
Minimal (e.g. superficial surgery) 1–2 mL/kg/hr
Moderate (e.g. appendicectomy) 4–7 mL/kg/hr
Severe (e.g.open abdo surgery) 5–10 mL/kg/hr

26. Intraoperative fluid cont…
• An alternative approach is to provide 10 ml/kg/h of balanced isotonic
solution. This tends to provide both maintenance fluid and
replacement of insensible losses in one calculation.

27. Intraoperative fluid cont…
• Large volume infusion of crystalloids during surgery (>40-60 ml/kg) may
induce endothelial dysfunction, increased transfer of fluid to the interstitium
and interstitial fluid overload.
• Colloid solutions are considered as 2nd
-line fluids for volume replacement in
children setting, although there is insufficient evidence to definitively guide
this practice.
• Dilutional anaemia may manifest after the infusion of large volumes of
crystalloids.
• Use of pRBC in this setting is a common strategy to mitigate this risk. Colloid
solutions may be given in repeated doses of 5-10 ml/ kg (up to a daily
maximum of 30ml/ kg

28. Glucose containing fluids
• For normal healthy babies glucose supplementation is not routinely
necessary .
• Glucose should be supplemented in children with risk of glucose
impairment including neonate, children with malnutrition,
hypermetabolism, liver failure, hypothermia, mitochondrial disorders,
beta-blocker therapy or critical illness.
• Where glucose is provided, the addition of 1-2% glucose to intraop
maintenance fluid is sufficient to prevent hypoglycemia and ketosis,
without causing hyperglycemia.
• Routine use of 5% glucose is associated with hyperglycemia

29. Glucose additives to create 1% and 2% solutions

30. Postoperative fluid management
• Early return to oral intake and enteral hydration is encouraged after
surgery.
• IV fluid therapy is used when enteral hydration is insufficient to
maintain fluid and electrolyte balance.
• Preferred fluid: isotonic balanced salt solution Plasma-Lyte with
dextrose 5%.
• Maintenance rates calculated using the Holliday and Segar 4/2/1
formula.
• After major surgery, reduce rates by 30-50% to account for increased
ADH secretion and avoid hyponatremia.

31. Postoperative fluid management cont…
• Plasma electrolyte levels should be tested daily during IV fluid
infusions.
• Ongoing clinical assessments of volume status, fluid losses, and
electrolyte status are critical.
• Fluid administration rate, type, and additives should be adjusted
based on patient needs.
• IV fluid therapy should be as short as possible, considering nutritional
needs and potential total parenteral nutrition if enteral intake is
delayed.

32. Fluid responsiveness
• The static assessment of fluid status from clinical signs is unreliable for
predicting fluid responsiveness.
• Variables, such as HR, systolic arterial pressure, central venous pressure
and pulmonary artery occlusion pressure, have all been shown to have
low predictive value for determining the usefulness of i.v. fluids to
improve haemodynamics in children.
• Dynamic variables, such as pulse pressure variation, stroke volume
variation, respiratory variation in inferior vena cava diameter,
oesophageal Doppler indices and plethysmographic waveform
techniques, also have inconclusive or conflicting evidence, rendering their
clinical usefulness uncertain

33. Journal presentation
Overview
• Title
• Abstract
• Introduction
• Methods
• Results
• Discussion
• Conclusion
• Critique

34. Title

35. Abstract

36. Introduction
• Fluid management in newborns undergoing surgery can be
challenging due to difficulties in accurately assessing volume status in
the context of high fluid needs perioperatively and postoperative
third-space fluid loss
• Preterm infants are particularly vulnerable to fluid overload because
of their underdeveloped cardiovascular and renal systems, making
them less capable of managing large fluid volumes.
• Tools like weight, urine output, and renal function tests may not
accurately reflect intravascular and interstitial volume, especially in
newborns after abdominal surgery.

37. Introduction cont..
Problem statement
• Fluid overload (FO) after pediatric abdominal surgery can cause acute kidney
injury (AKI), increased morbidity, and complications like abdominal compartment
syndrome and mesenteric ischemia, due to fluid shifts, third spacing, and
evaporative losses, while postoperative antidiuretic hormone secretion may
exacerbate water retention and bowel edema; but there is limited literature on
fluid balance in newborns after abdominal surgery, highlighting the need for
further research on risk factors and outcomes
Objective
• To determine the burden of fluid overload and to evaluate their associations with
adverse effects among infants undergoing abdominal surgery at a tertiary
perinatal center.

38. Methodology
Study design
• Retrospective cohort study done at tertiary level NICU between January
2017 and June 2019.
• Participants
• Inclusion Criteria:
• Infants who underwent abdominal surgeries and were admitted to the NICU
for postoperative care.
• Exclusion Criteria:
• Those who had multiple congenital anomalies, including CHD or kidney
disease, and those who died <24 hours after surgery

39. Methodology cont..
• Data were extracted from paper and electronic medical charts. Fluid
management was assessed from 3 days pre-operation to 7 days post-
operation.

40. Methodology cont…
Independent variables
• Gestational age (GA) was defined as the best obstetric estimate
Dependent variables
• Primary outcome
• fluid balance at postoperative day 3 and day 7. obtained from % daily weight
change
• Secondary outcomes
• mortality, duration of mechanical ventilation, AKI, days to start enteral feeds,
post-op sepsis, length of hospital stay, bronchopulmonary dysplasia (BPD), and
high-grade intraventricular hemorrhage (IVH)

41. Methodology cont….
• Actual fluid intake (mL/kg/day) referred to the total volume of fluid the
patient received in the previous 24h, including parenteral nutrition,
fluid boluses, transfusions, flushes through intravenous (IV) lines,
medications, and fluid to keep the IV line open.
• Prescribed fluid intake referred to the amount of fluid on the
physicians’ orders on the patient records.
• the impact of fluid balance among infants with surgery performed <7
days of life (DoL) and >7 DoL was analyzed separately.

42. Methodology cont..
• Statistical analysis
• Patient demographics and clinical characteristics were reported as median
(interquartile range [IQR]) and proportion (%) for continuous and categorical
variables, respectively.
• Odds ratio and 95% confidence interval were calculated using univariate logistic
regression analyses to quantify the association between adverse outcomes and
FO.
• Multivariable logistic regression was performed after adjusting for potential
confounders and other covariates based on the findings of the univariate analysis.
• R (v.4.0.3) using R-studio (v.1.3.1073) was used for statistical analysis, with p<.05
to be considered statistically significant.

43. Results
• Between January 2017 and June 2019, 83 newborns underwent abdominal
surgery.
• Sixty patients were included in this study, with a median [IQR] gestational age
of 29 weeks [25–36] and a median [IQR] birth weight of 1240 g [721–2871].
• Surgery was conducted at a median [IQR] of 6 DoL [3–12], with 32 patients
having surgery before 7 DoL and 28 patients having surgery on or after 7 DoL
• The actual median daily fluid intake was 178 mL/kg on postoperative days 0–2
and 163 mL/kg from postoperative days 3 to 7, which were significantly higher
than the median prescribed fluid volume of 145 mL/kg (p<.01).
• The maximum median [IQR] percentage of weight change was 6% [3–13] and
11% [5–17] in postoperative days 3 and 7, respectively

46. • Analysis of the cohort when divided into surgery before 7 or after 7 DoL, we
found that there were no differences in fluid administration or max weight
change between the two groups
• Every 1% increase in weight gain within the first 3 postoperative days was
associated with the requirement of an additional 0.6 days of invasive ventilator
support (p=.012)
• This correlation remained significant after adjusting for gestational age (p=.033).
There were 32 (53%) infants requiring respiratory support at 28 DoL, and 20
(33%) developed BPD. We did not identify any correlations between max weight
gain within the first 3- or 7 days post-operation and the development of BPD and
mortality.
• Only 30 (50%) of patients had serum creatinine measured pre- and post-
operatively for comparison. Overall, we identified 4 (6.7%) infants who developed
AKI, according to the aforementioned criteria.

47. Discussion
• Fluid overload was associated with a longer duration of ventilation, and FO could
be an independent risk factor for multi-organ dysfunction rather than just a
marker of disease severity.
• The underlying mechanism of association between FO and an increase in invasive
ventilation durations could be fluid accumulation in the lungs, endothelial
dysfunction, increased risk of patent ductus arteriosus (PDA), or pulmonary
edema in the context of prematurity.
• It is also possible that an increase in circulating inflammatory cytokines due to the
stress of surgery and underlying disease could cause more injury to the lungs in
these circumstances.
• The longer duration of ventilator support could potentially lead to a further
increase in lung injury and consequently, increase the risk of BPD.

48. • The increased weight change in our patients is likely due to generous
amounts of administered fluid, which was consistently higher than
the ordered fluid intake.

49. Conclusion
• In newborns undergoing abdominal surgery, fluid overload in the first
3 postoperative days was positively associated with increased
duration of invasive ventilator support.
• Judicious post-operative fluid management may be beneficial to
improve respiratory outcomes.

50. Critique
Aspect strength Weakness
Tittle Clear
Abstract Clear
Introduction Has background, problem and objective
Methods Retrospective cohort study • Small sample size
• No details on how the sample
study was obtained
• Single-centered study
Results Well presented in tabular form
Discussion Commented on discussion of results
Conclusion clear