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

Body composition

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

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

Microdrip set

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

Holliday- Segar formula for maintenance fluid requirement in healthy children WEIGHT MAINTENANCE HOURLY REQUIREMENT(ml) < 10 kg 4 ml/ kg 11-20 kg 40 ml + 2 ml/kg > 10 kg > 20 kg 60 ml + 1 ml/kg > 20 kg

Deficit replacement Maintenance Ongoing losses 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

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.

 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.

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.