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 doesnt have any tears. How will you replace this infants 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
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
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: