Pediatric Fluid Management
and
Blood Product Therapy
Joy Loy, M.D.
MetroHealth Medical Center
April, 2004
ASA Fasting Guidelines
Clear liquids
Breast Milk
Infant Formula
Neonates
Infants
Nonhuman Milk
Solids
2 hours
4 hours
4 hours
6 hours
6 hours
8 hours
Clear Liquids
• water, juice without pulp, carbonated
beverages, clear tea, black coffee
• should not contain alcohol
• type of liquid ingested important than
volume
infants < 5 mos
10 ml/kg
children and adults 15 ml/kg
Breast Milk
• is NOT a clear liquid
• does contain milk solids
• cleared from the stomach more
quickly than nonhuman milk
ASA Fasting Guidelines
• pre-op fast does not guarantee an empty stomach
• timing of last fluid ingestion has little relation to
volume of gastric contents at induction
ASA Fasting Guidelines
• gastric fluid volume and pH are independent
of duration fluid fast beyond 2 hours
• main determinant: endogenous gastric
secretion
ASA Fasting Guidelines
• reduces
the risk of pulmonary aspiration
• offering clear liquids up to 2 hours before
induction
> reduces hunger and irritability
> preserves hydration
>  risk of hypoglycemia
BODY FLUID COMPOSITION
Compartments
Total Body Water (TBW) =
Intracellular Fluid ( ICF ) +
Extracellular Fluid ( ECF
)
a) interstitial fluid ( ISF ) : no protein
b) plasma volume ( PV ) : with protein
* ISF and PV basically same electrolyte content
Body Fluid Composition
INFANT
Total Body Water 75 %
CHILD
ADULT
70 %
55-60 %
ECF
40 %
30 %
20 %
ICF
35 %
40 %
40 %
Fat
16 %
23 %
30 %
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
CVS :
• incomplete myocardial development
• immature sympathetic innervation
IMPLICATION:
neonates and young infants are more
sensitive to hypovolemia
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
RENAL:
• immature renal function at birth
 GFR
25% of adult level at term
adult level at age of 2 years
concentrating capacity of newborn kidney
term infant : max. 600-700 mOsm/kg
adult
: max. 1200 mOsm/kg
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
free H2O clearance :
excrete markedly dilute urine up to 50
mOsm / kg vs. 70-100 Osm/kg in adults
 Na reabsorption
 HCO3 /H exchange
 urinary losses of K+ and Cl-
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
IMPLICATION:
Newborn kidney has limited
capacity to compensate for volume
excess or volume depletion
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
HEPATIC :
• limited hepatic glycogen stores
> risk of hypoglycemia
> provide 5%-10% dextrose in fluid
maintenance
> supplemental insulin for sustained
hyperglycemia from dextrose
PHYSIOLOGIC CONSIDERATIONS
Metabolic and Fluid Requirements
 metabolic rate
O2 consumption
neonates: 6-9 ml/kg/min
adults: 3 ml/kg/min
growth 120 kcal/kg/day
PHYSIOLOGIC CONSIDERATIONS
Metabolic and Fluid Requirements
 fluid requirement
> greater BSA to mass ratio in infants
> other factors:
radiant warmers
fever
illness
injury
thinner skin and lack of keratinization of
stratum corneum in premature neonates
Compensatory Mechanisms
1) Temporary mechanism
2) Definitive mechanism
Compensatory Mechanisms
Temporary Mechanism
> activated to maintain normal BP and normal
fluid volume
a) endogenous vasopressors
ADH, angiotensin II, catecholamines
b) transcapillary refill: ISF  PV (skin turgor)
c) ADH :  free H2O absorption
caution : hyponatremia using hypotonic
fluids
Compensatory Mechanisms
Definitive Mechanism
> through the kidneys
> activation of renin - angiotensin aldosterone (RAA) system
>  urine output and  urine specific gravity
Maintenance Fluids
replaces water and electrolytes lost under ordinary conditions
• Evaporative / insensible water loss (ISWL)
• Urinary and stool losses
• Growth
Maintenance Fluids
1) Evaporative or Insensible Water Loss (ISWL)
• solute-free H2O losses from skin and lungs
•  30-35 % of total maintenance volume
• 1/3 of total maintenance requirement
• affected by ambient humidity and temperature
• minimum replacement : 60-100 ml/kg/day
Maintenance Fluids
2) Urinary Losses
• 280-300 mOsm /kg of H2O
specific gravity 1.008-1.015
• 2/3 of total maintenance fluids
3) Growth
Maintenance Fluids
Hourly Maintenance Fluid Requirement
1) 4 - 2 -1 rule
WEIGHT
FLUID
0 - 10 kg
4 ml/kg/hr
10 - 20 kg
2 ml/kg/hr
> 20 kg
1 ml/kg/hr
* reliable up to body weight of 80 kg
Hourly Maintenance Fluid Requirement
2) Holliday and Segar
WEIGHT
FLUID/day
0 - 10 kg
100 ml / kg /day
10 - 20 kg
1000 + 50 ml/kg/day
> 20 kg
1500 + 20 ml/kg/day
* based on caloric requirement of hospitalized patients
Maintenance Fluids
Hourly Maintenance Fluid Requirement
3) OH Method
WEIGHT
FLUID/hr
0 - 10 kg
4 ml / kg / hr
10 - 20 kg
20 + 2 ml/kg/hr
> 20 kg
40 + 1ml /kg/hr
Choice of Maintenance Fluids
• Remains controversial
• Hypotonic solution
D5 1/2 NS + 20 mEq KCl
D5 1/4 NS : may be a better choice in
neonates due to their limited ability
to handle Na + loads
• Balanced salt solution
Guide for Maintenance Fluid Therapy
Newborn Term
Day 1
50-60 ml/kg/day
D10 W
Day 2
100 ml/kg/day
D10 1/2 NS
>Day 7 100-150 ml/kg/day D5-D10 1/4 NS
Older Child
4-2-1 rule
Holliday & Segar method
Daily Electrolyte Requirements
Na
2-3 mEq /kg/day
day 2-3
K
1-2 mEq /kg/day
day 3-4
Cl
2-3 mEq /kg/day
Ca
20-100 mg/kg/day
* 1 mEq = 1 mmol
day 1
Glucose Requirements
term and preterm infants :
5 - 6 mg/kg/min
goal: maintain normoglycemia
40 - 120 mg/dl
D10W 60-80 ml/kg/day >1kg infants
D5W 100 ml/kg/day <1kg infants
Perioperative Fluid
Management
3 Phases
1. Maintenance Fluid Replacement
2. Replacement of Preop Deficit
3. Replacement of Ongoing Losses
Perioperative Fluid Management
Maintenance Fluid Replacement
4 - 2 -1 rule
WEIGHT
0 - 10 kg
FLUID
4 ml/kg/hr
+
10 - 20 kg
2 ml/kg/hr
+
> 20 kg
1 ml/kg/hr
Perioperative Fluid Management
Preoperative Deficit
DEHYDRATION
MILD (1-5 %)
history of vomiting or diarrhrea
 urine output (1st)
MODERATE (6-10%)
skin turgor
sunken eyes and fontanelles
weight loss
dry mucous membranes
lethargic
Perioperative Fluid Management
Preoperative Deficit
SEVERE (11-15%)
cardiovascular instability
 BP
mottled skin
tachycardia
anuria
sensory changes
20%
coma
shock
Perioperative Fluid Management
Preoperative Deficit Therapy
Components:
1) dehydration severity
Hx and PE
electrolyte values
serum tonicity
2) type of dehydration
isotonic hypotonic hypertonic
Perioperative Fluid Management
Preoperative Deficit Therapy
3) replacement of deficit
• goal: restore CV, CNS and renal
function
• monitor adequacy based on response
clinical condition
urine output and urine specific gravity
vital signs
Perioperative Fluid Management
Estimated Preop Fluid Deficit
number of fasting hrs x maintenance fluids
infuse 1/2 on the first hr
infuse 1/4 on the 2nd hr
infuse 1/4 on the 3rd hr
Perioperative Fluid Management
Choice of Fluids
Isotonic Crystalloids
• generally the most appropriate for preop
and intraop deficits
Hypotonic Fluids
• can cause significant hyponatremia
Perioperative Fluid Management
Lactated Ringers (LR)
reasonable for maintenance fluids
less expensive than other BSS
provide Na and K
avoid infusion with blood due to calcium content
Perioperative Fluid Management
Normal Saline (NS)
higher Na content (154)
preferred in patients high risk for cerebral edema
prolonged infusion can lead to :
hypernatremia
hyperchloremia
metabolic acidosis
Perioperative Fluid Management
Composition of IV Crystalloid Solution
SOLUTION
pH
Osm
Gluc
Na
K
mg/dl
CL
Lact
Ca
mmol/L
D5
5.0
253
500
--
--
--
--
--
LR
6.7
273
--
130
4
109
28
3
D5 LR
5.3
527
500
130
4
109
28
3
D5 0.22% NSS
4.4
330
500
38.5
--
--
--
--
D5 0.45% NSS
4.2
407
500
77
--
77
--
--
0.9% NSS
5.7
308
--
154
--
154
--
--
Normosol R
7.4
295
--
140
5
98
acetate 27
--
gluconate 23
Stoelting RK: Pharmacology and Physiology in Anesthetic Practice, ed 2, Philadelphia 1991, JB Lippincott
Perioperative Fluid Management
Composition of Colloid Solutions
Na
Cl
Osm
5% Albumin
145
100
Hespan
154
154
308 mOsm/L
Hextend
143
124
307 mOsm/L
330 mOsm/L
Is intraoperative
glucose necessary?
Perioperative Fluid Management
Intraoperative Glucose Administration
Effects :
intraop hyperglycemia
hyperosmolality
osmotic diuresis
worsen neurologic outcome during cerebral
ischemia
Perioperative Fluid Management
Intraoperative Glucose Administration
Exceptions : patients at risk for hypoglycemia
• neonates and young infants
• debilitated patients with chronic illness
• patients on parenteral nutrition
• neonates of diabetic mothers
• Beckwith-Wiedeman syndrome
• nesidioblastosis
Perioperative Fluid Management
Intraoperative Glucose Administration
Existing infusions of dextrose-containing fluid
may be continued at a reduced rate (50% of
maintenance) to compensate the effect of surgical
stress on glucose control
Perioperative Fluid Management
Replacement of Ongoing Losses
1) Real Losses
blood loss
urine output
insensible losses
drainage from various sites
2) 3rd Space Loss
trauma
peritonitis
burns
upper GI drainage
Perioperative Fluid Management
Replacement of Ongoing Losses
Degree of
Tissue Trauma
Additional Fluid
Required
Minimal Incision
3-5 cc/kg/hr
Moderate Incision
with viscus exposure
5-10 cc/kg/hr
Large Incision
with bowel exposure
8-20 cc/kg/hr
Perioperative Fluid Management
Replacement of Ongoing Losses
EBL Replacement
• crystalloid (3:1 ratio)
3 cc / 1 cc blood lost
• colloid solution (1:1 ratio)
1 cc / 1 cc blood lost
• blood products (1:1 ratio)
1 cc / 1cc blood lost
Perioperative Fluid Management
Replacement of Ongoing Losses
Albumin
• 25 % and 5% solutions
• pooled from human donors
• no ABO testing or blood filter required
• remains expensive
• in short supply
Is albumin risk-free?
Perioperative Fluid Management
Composition of Colloid Solution
New Zealand : albumin may be related to Creutz-Jacob
disease (CJD) or prion disease with long incubation period
(>5-10 yrs)
processing of human albumin does not destroy the prions
no blood screening for prion diseases
Perioperative Fluid Management
Replacement of Ongoing Losses
Determinants of Blood Transfusion
1) Estimated Blood Volume
2) Preoperative Hematocrit
3) Co-existing Illness
Perioperative Fluid Management
Replacement of Ongoing Losses
Estimated Blood Volume
Premature Neonates
95 -100 ml /kg
Full Term Neonates
85-90 ml / kg
Infants
80 ml / kg
Adults
75 ml / kg (male)
65 ml / kg (female)
Perioperative Fluid Management
Replacement of Ongoing Losses
Guidelines for Pediatric Normal & Acceptable Hematocrit
NORMAL (x)
ACCEPTABLE
premature
40-45 (45)
35
newborn
45-65 (54)
30-35
3 months
30-42 (36)
25
1 year
34-42 (38)
20-25
6 years
35-43 (38)
20-25
Perioperative Fluid Management
Blood Product Replacement
Normal Hematocrit
Hct within 2 standard deviations for age
Acceptable Hematocrit
Hct that is tolerated by infants and children without
the need for blood transfusion
Perioperative Fluid Management
Blood Product Replacement
Allowable Blood Loss (ABL)
Hct patient - Hct target
Hct patient
X
EBV
Perioperative Fluid Management
Blood Product Replacement
PRBC
10 cc/kg will  the hgb by 3 gm/dl and hct by 10%
(adult:1 unit will  the hgb by 1 gm/dl and hct by 2-3%)
Platelets and FFP
10-15 ml/kg
given when EBL > 1-2 x the patient’s blood volume
1 unit / 10 kg raises the platelet count by ~ 50,000/uL
Cryoprecipitate
1 unit/10 kg
SUMMARY
Total Intraoperative Fluid Replacement
MF + EFD + ISL + EBL
MF : Maintenance Fluid
EFD : Estimated Preop Fluid Deficit
ISL : Insensible Losses
EBL : Estimated Blood Loss
Summary
Brief Procedures ( myringotomy, PET)
replacement may be unnecessary
1-2 hr Procedures
IV placement after inhalation induction
replace 10-20 cc/kg + EBL in 1st hour
Longer and Complex Procedures
4-2-1 rule
acute intravascular loss: 10-20 cc/kg LR / NS
Summary
Meticulous fluid management is required in pediatric
patients due to limited margin of error
Liberalization of fasting guidelines compatible with
safety limits preop deficit
Crystalloid solution is the first choice to restore
intravascular volume
Summary
Limit glucose-containing solutions for patients at
risk for hypoglycemia
Tranfusion trigger points
preop hematocrit and hemodynamics
co-existing medical problems
potential for further blood loss
25% decrease in EBV