Anesthetic Implications In Neonates & Children: Intravenous fluids

1. Anesthetic Implications In Neonates & Children: Intravenous fluids Speaker: Dr VandnaArora Moderators: Dr SujataChaudhary Dr Chhavi Sharma University College of Medical Sciences & GTB Hospital, Delhi email: anaesthesia.co.in@gmail.com www.anaesthesia.co.in

2. Body composition

3. Neonatal fluid management • Renal function is immature at birth, limited ability to excrete large water load • Large volume of ECF in newborn • Therefore term newborns have reduced fluid requirements for first week of life • Daily fluid requirement for term new born after birth : day 1: 70 ml/kg day 3: 80 ml/kg day 5: 90 ml/kg day 7: 120 ml/kg • Daily fluid requirements – slightly higher for preterm • Started on 10% glucose to prevent hypoglycemia

4. Intraoperative fluid management Intravenous access and fluid administration devices • Young children : IV access is accomplished usually after inhalational induction • Older children / IV access is required before induction : use of topical anesthesia (EMLA cream) or sedation or both • Complex surgeries in sick children : atleast two large bore catheters • Preferred sites for larger catheters : antecubital and saphenous veins • Access to central circulation via femoral, subclavian or internal jugular veins • Microdrip infusion sets/ fluid infusion pumps should be used

5. Microdrip set

6. Choice of IV fluid • Isotonic solutions are preferred: -lactated ringer’s solution - 0.9 % normal saline • Children at risk for hypoglycemia : 5% dextrose in 0.45% NS co-administered at maintenance rates

7. Holliday- Segar formula for maintenance fluid requirement in healthy children

8. Deficit replacement • Calculated by multiplying the hourly maintenance rate by number of hours of restriction • 50% of the deficit is replaced in the first hour • 25% in each of the next two hours Maintenance Hourly maintenance fluid rate as calculated by holliday segar formula. Ongoing losses • Blood loss is replaced : colloids in the ratio of 1:1 crystalloids in the ratio of 3:1 • Third space losses : isotonic crystalloids range from 1-2 ml/kg/hr in minor surgical procedure to as much as 15 ml/kg/hr for abdominal procedures

9. Post operative fluid management • Replacement of fluid deficits is completed • Ongoing losses are replaced – chest tubes, surgical drains, nasogastric suction, weeping incisions, continued slow bleeding • Repeated assessment of the child until normal fluid and electrolyte homeostasis has returned- trends in vital signs , input output charting, urine specific gravity, daily weights, serum electrolytes.

10.  APA Guidelines for Perioperative fluid management in children, 2010 • During surgery the majority of children may be given fluids without dextrose. Blood glucose should be monitored if no dextrose is given. • The maintenance fluid used during surgery should be isotonic such as 0.9% sodium chloride or Ringer lactate solution. • Neonates in the first 48 hours of life should be given dextrose during surgery. • Preterm and term infants already receiving dextrose containing solutions should continue with them during surgery. • Infants and children on parenteral nutrition preoperatively should continue to receive parenteral nutrition during surgery or change to a dextrose containing maintenance fluid and blood glucose monitored during surgery.

11. Children of low body weight (less than 3rd centile) or having prolonged surgery should receive a dextrose containing maintenance fluid (1-2.5% dextrose) or have their blood glucose monitored during surgery. • All losses during surgery should be replaced with an isotonic fluid such as 0.9% sodium chloride, Ringer lactate solution, a colloid or a blood product, depending on the child’s haematocrit. • There is no evidence that the use of human albumin solution is better than use of an artificial colloid to replace blood loss. • In children over 3 months of age the haematocrit may be allowed to fall to 25%. Children with cyanotic congenital heart disease may need a higher haematocrit to maintain oxygenation.