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Fluid Management for the Pediatric Surgical Patient

EUEIS RESTETTY

Paradigm for Fluid Management


Fluid management is divided into 3 phases :
1.deficit

therapy 2.maintenance therapy 3.replacement therapy

1. Deficit therapy

Deficit therapy is the management of fluid and electrolyte losses that occur before the patient's presentation.

Deficit therapy has 3 components : a. estimation of the severity of dehydration b. determination of the type of fluid deficit c. repair of the deficit.

The severity of dehydration is estimated from the patient's history and physical condition. In children with mild dehydration (ie, loss of 1-5% of the body fluid volume), findings are largely based on their history (eg, vomiting, diarrhea), with minimal findings during physical examination. Children with moderate dehydration (ie, 6-10% loss) have histories of fluid losses plus physical findings that include tenting of the skin, weight loss, sunken eyes and fontanel, slight lethargy, and dry mucous membranes. Most patients with severe dehydration (ie, 11-15% loss) have cardiovascular instability (eg, skin mottling, tachycardia, hypotension) and neurologic involvement (eg, irritability, coma).

The type of fluid deficit can be estimated from the patient's history, physical findings, electrolyte values, and serum tonicity. Types of dehydration are - isotonic (ie, serum osmolarity of 270-300 mOsm/L, serum Na+ concentration of 130-150 mEq/L) - hypotonic (ie, serum osmolarity of <270 mOsm/L, serum Na+ concentration of <130 mEq/L) - hypertonic (ie, serum osmolarity of >310 mOsm/L, serum Na+ concentration of >150 mEq/L). Patients with hypertonic dehydration require special attention because complications, such as cerebral edema, may occur during rehydration.

Restoration of cardiovascular function, CNS function, and renal perfusion are the primary concerns in repair of fluid deficit. Initiate therapy with an isotonic fluid volume expander. Total fluid-deficit repair may require considerable time. In particular, potassium losses cannot be quickly replaced. After the child is producing urine, add a small amount of potassium (<40 mEq/L) to the fluid. Continually monitor the adequacy of deficit therapy by assessing the patient's clinical condition, urine output, and urine specific gravity.

Rapid rehydration therapy

In volume-depleted children, increasing importance is being given to the use of rapid replacement of ECF losses as opposed to classic deficit therapy, as described above. For example, after severe burns, patients improve and mortality rates decline with the rapid, generous expansion of ECF. The total amount of fluid given in the first 6-12 hours is often approximately 100 mL/kg of an ECF-type fluid, such as normal saline or lactated Ringer solution

In describing rapid rehydration therapy, Friedman (2005) suggests that, in children with moderate dehydration who cannot tolerate oral rehydration, ECF should be rapidly restored by administering lactated Ringer solution at a dosage of 40 mL/kg in 1-2 hours; oral rehydration should be started after the intravenous (IV) infusion is completed. In patients with severe dehydration, ECF should be rapidly restored by administering IV lactated Ringer solution, 0.9% NaCl (ie, isotonic NaCl solution, normal saline), or both at a rate of 40 mL/kg over 1-2 hours. If skin turgor, alertness, or pulse rate do not return to normal by the end of the infusion, an additional dose of 20-40 mL/kg should be infused over 1-2 hours.

Colloid versus crystalloid fluids


Both colloid and crystalloid solutions are widely used in the fluid resuscitation of critically ill children. Several choices of colloid are available, including albumin, hydroxyethyl starch (Hetastarch), and dextran.

Debate about the relative effectiveness of colloids compared with crystalloid fluids (eg, Ringer lactate solution [RL], 0.9% NaCl solution) is on going. In a recent Cochrane Database Review, investigators examined a series of randomized and quasirandomized trials of colloids compared with crystalloids in patients who required volume replacement. However, trials in neonates were excluded. No evidence suggested that resuscitation with colloids reduced the risk of death compared with resuscitation with crystalloids in patients with trauma or burns or in those who underwent surgery.

Because colloids are not associated with improved survival and because they are more expensive than crystalloids, their continued use in critically ill patients is probably not justified outside the context of randomized controlled trials

2. Maintenance therapy
The aim of maintenance therapy is to replace water and electrolytes lost under ordinary conditions. In the perioperative period, maintenance fluid administration often does not sufficiently account for the increased fluid requirements caused by third-space losses into the interstitium and gut.

Table 1. Guide for Early Postoperative and Maintenance Therapy

Age <12 h After Surgery Maintenance Fluids (mo)


<6 D10W with 0.45% NaCl at 1.5 times the maintenance rate D10W with 0.2% NaCl plus KCl 10-20 mEq/L at maintenance rate

>6

D5W with RL solution at D10W with 0.45% NaCl 1.5 times the plus KCl 10-20 mEq/L at maintenance rate maintenance rate

The fluid for maintenance therapy replaces losses from 2 processes: evaporative (ie, insensible) losses and urinary losses. Evaporative losses consisted of solute-free water losses through the skin and lungs. Under ordinary conditions, insensible losses account for approximately 30-35% of total maintenance volume, and this free water represents approximately a third of the total requirement for maintenance fluid. Ambient humidity and temperature affect insensible losses. Patients receiving humidified air have less insensible loss than those not receiving humidified air. Patients with hyperthermia or tachypnea similarly have exaggerated insensible losses.

In a euvolemic state, urinary losses are 280-300 mOsm/kg of water, with a specific gravity of 1.0081.015. In some circumstances (eg, diabetes insipidus, prematurity), the production of dilute urine is obligatory, and the volume of maintenance fluids must be appropriately increased. In other circumstances (eg, excessive ADH secretion, physiologic stress), a patient may be unable to decrease urine osmolality to 300 mOsm/kg of water, and the volume of maintenance fluids must be decreased. Under euvolemic conditions, urinary losses account for two thirds of total maintenance fluids.

Total requirements for maintenance fluid can be estimated from common formulas, such as those listed below. Frequently assess the patient's condition during maintenance therapy. If the estimate is correct, the patient's electrolyte levels should remain stable, and the patient should remain clinically euvolemic. Abnormal electrolyte levels or clinical signs of hypervolemia or hypovolemia indicate a need to reassess each component of the patient's maintenance therapy.

A guide for maintenance fluid therapy for term infants and older children is as follows:
Newborn Day 1 - D10W infused at a rate of 50-60 mL/kg/d Day 2 - D10W with 0.2% NaCl infused at a rate of 100 mL/kg/d After day 7 - D5W with 0.45% NaCl or D10W with 0.45% NaCl infused at a rate of 100-150 mL/kg/d Child infusion rates 0-10 kg - 100 mL/kg/d (4 mL/kg/h) 10-20 kg - 1000 mL/d + 50 mL/kg/d (40 mL/h + 2 mL/kg/h) Less than 20 kg - 1500 mL/d + 25 mL/kg/d (60 mL/h + 1 mL/kg/h)

3. Replacement therapy

Replacement fluid therapy is designed to replace ongoing abnormal fluid and electrolyte losses. Because the constituents of these losses often substantially differ from the composition of maintenance fluids, simply increasing the volume of maintenance fluids to compensate for these losses may be hazardous. The authors generally replace large-volume stoma or other fluid losses with a physiologic equivalent fluid, as shown in Table 2.

As an alternative, measuring the electrolyte content of these losses and replacing them milliequivalent for milliequivalent or milliliter for milliliter may be preferred in select circumstances. For the patient under severe physiologic stress or for those undergoing extensive surgery, calculate third-space losses into the interstitium, and adjust replacement therapy accordingly.

Table 2. Typical Electrolyte Composition of Body Fluids for a Child with Abnormal Fluid and Electrolyte Losses and of Common IV Fluids

Body or IV Fluid Electrolytes (mEq/L)


Gastric Pancreas Bile Ileostomy Diarrhea RL solution 0.9% NaCl 0.45% NaCl Na+ 70 140 130 130 50 130 154 77 K+ 5-15 5 5 15-20 35 4 0 0 Cl120 50-100 100 120 40 109 154 77 HCO30 100 40 25-30 50 28 0 0

Specific Clinical Scenarios

Pyloric stenosis

Hypertrophic pyloric stenosis often causes progressive nonbilious emesis in infants. This diagnosis can usually be confirmed by finding an enlarged pyloric olive during careful physical examination. Obtain further diagnostic studies (eg, typically ultrasonography) for infants whose histories indicate pyloric stenosis but who have no palpable pyloric mass.

The morbidity of pyloric stenosis closely relates to the degree of dehydration. The dehydration of a child with pyloric stenosis results from both fluid and electrolyte losses, with losses of H+ and chloride Cl- from gastric secretions. After progressive fluid losses, a hypokalemic-hypochloremic metabolic alkalosis develops.

Reports have suggested that the a substantial number of children with pyloric stenosis may have hyperkalemia, rather than hypokalemia. No obvious physiologic rationale for hyperkalemia in this setting is described, and the clinical importance of this finding on managing this condition is unclear.

Children with severe dehydration have accelerated renal K+ and H+ losses due to an attempt to retain fluid and Na+ ions. The urine pH of severely dehydrated children may demonstrate a paradoxical aciduria because the renal mechanisms for acid resorption are lost in an attempt to retain Na+ and K+ ions. As the kidneys attempt to retain Na+, an initial compensatory excretion of K+ occurs. Then, as K+ deficit develops, the kidney attempts to retain both Na+ and K+; thus, it excretes H+ instead of K+, and paradoxical aciduria then occurs. This cycle can be broken only by adequately replacing fluids and electrolytes.

In cases of clinical dehydration, children with pyloric stenosis require rehydration with IV fluid therapy before surgery. Administer D5W with 0.45% NaCl IV at 1.5 times the maintenance rate. Severely dehydrated children should receive initial deficit fluid therapy with 0.9% NaCl.

When urine output is demonstrated, KCl 10-20 mEq/L can be added to the fluids. Defer surgery for pyloric stenosis until the child is adequately rehydrated. The severity of dehydration can be estimated by physical examination and by measuring serum Cl- and HCO3 + levels. The degree of dehydration and the clinical response to fluid replacement therapy guide the duration of preoperative preparation in a child with pyloric stenosis. Optimal resuscitation is determined by normal skin turgor, moist mucous membranes, urine output of more than 1 mL/kg/h, serum HCO3 - level less than 28 mEq/dL, and Cl- level of more than 100 mEq/dL. Enteral feeds can usually be started soon after uncomplicated pyloromyotomy, and full feeds can be given within 24-48 hours. Postoperative electrolyte abnormalities are rare.

Gastroschisis

Gastroschisis is a defect of the anterior abdominal wall just lateral to the umbilicus. Unlike an omphalocele, no peritoneal sac is present in cases of gastroschisis; therefore, evisceration of the bowel occurs through the defect during intrauterine life. The irritating effect of amniotic fluid (pH, 7) on the exposed bowel wall results in a chemical form of peritonitis characterized by a thick, edematous membrane that is occasionally exudative. Fluid management for an infant with gastroschisis can be complex and requires strict attention to the rapidly changing needs of the neonate, who may be critically ill.

After birth, neonates with gastroschisis are subject to tremendously increased insensible fluid losses related to exposure of the eviscerated bowel. Hypothermia, hypovolemia, and sepsis are the major problems to prevent. To limit fluid and heat losses, the eviscerated bowel is covered in moist nonadherent sponges, and the lower half of the baby, including the eviscerated bowel, is covered in plastic bag or a bowel bag.

Fluid requirements in a neonate with gastroschisis can range up to 2.5 times that of a healthy newborn in the first 24 hours of life. As a general rule, the more matted and inflamed the exposed viscera appear, the greater the fluid requirements of the infant.

Initial resuscitation of an infant with gastroschisis is generally begun with a 10-mL to 20-mL/kg bolus of 0.9% NaCl or RL solution in addition to maintenance fluids. Additional isotonic fluid is administered until urine output is established. The infant's ongoing fluid needs are tailored to his or her specific hemodynamics, but volumes are generally 120-175 mL/kg/d of D5W with 0.45% NaCl with added potassium.

The patient's acid-base balance should be closely monitored because metabolic acidosis is common as a result of poor perfusion related to hypovolemia. An orogastric tube is placed in the stomach to prevent the patient from swallowing air and aspirating intestinal contents because an infant with gastroschisis has a prolonged, adynamic ileus. The infant is given parenteral antibiotics (ampicillin and gentamicin) and kept in a thermoneutral environment.

Omphalocele

Patients with omphalocele also have an abdominal wall defect, although it is typically covered and protrudes directly through the umbilicus. The development is felt to be due to failure of the lateral embryonic folds to fuse in the midline. Because omphalocele occurs early in gestation, other associated anomalies of midline structures are frequently present, most commonly in the heart. Pulmonary hypoplasia is also a serious associated problem and is related to the compression of the developing lungs. Because the defect is covered, fluid resuscitation is typically not as vigorous as it is in patients with gastroschisis. However, Aizenfisz et al recently demonstrated an increased fluid requirement for patients presenting with ruptured omphalocele. Patients with ruptured omphalocele had a larger fluid requirement than those with gastroschisis or an intact omphalocele sac.

Summary

Fluid management of the pediatric surgical patient represents an important aspect of medical care, particularly for initial treatment of the ill child. An understanding of the physiology of fluid requirements is essential for care of these children. Standard formulas for fluid therapy can be modified to account for the rapidly changing physiology of the pediatric surgical patient.

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