pediatric intraoperative fluid replacement alyssa brzenski

Pediatric Intraoperative FluidReplacement

Alyssa Brzenski

Case 1

• You are awoken at 2 am to do an exploratory laparatomy and silo placement for a neonate with gastroschisis born 4 hours previously. The surgeon tells you that there are large areas of adhesions and possible ruptured liver cyst. How will you manage the fluids?

Case 2

• A 2 year old who was hit by a car is brought in by EMS to your trauma bay. How will you manage his fluid status?

Case 3

• A 1 month old male presents to the ER with 5 days of intractable nausea and vomitting. His mom tells you that she has not changed his diaper for the last day and that when he cries he doesn’t have any tears. How will you replace this infant’s fluid deficit?

The original fluid replacement

NPO guidance

• Once recommended to give 25 mL/kg for kids 3 or under and 15mL.kg for kids 4 and older.

• No longer practical given shorter NPO times

Should I add glucose?

• Hypoglycemia difficult to detect under anesthesia

• Associated with detrimental neurologic consequences

• Hyperglycemia dangerous especially with concurrent ischemia or hypoxia

Think about glucose

• NICU babies- started on dextrose containing solution(typically D10 with pre-calculated electrolytes)

• Children on Hyperal or other Dextrose solutions• Liver resections• Endocrine patients (inborn errors of

metabolism/ TCA cycle abnormalities)• Neonates of diabetic mothers

Intra-operative Replacements

Postoperative Hyponatremia

• Pediatric patients are extremely succeptible to post-operative hyponatremia

• General anesthetic predispose to inappropriate ADH secretion

Colloids - Albumin

• Ped study in menigococcal patients resusitated with albumin had lower mortality(50% vs <%5)

• Hypoalbumic neonates had fewer ventilator days and improved oxygenation

Colloids- Starches

Crystalloid vs Colloid

• No well controlled pediatric studies • No current recommendations to use only

crystalloid or colloid• Must take into consideration the cost

Cases

• What would you use for these cases?• How would you replace with blood products?

Sources• Bailey AG, McNaull P, Jooste E, Tuchman J. Perioperative Crystalloid and Colloid Fluid Management in Children: Where Are

We and How Did We Get Here? Anesthesia and Analgesia. 2010; 110: 375-90.