Perioperative Fluid Management In Pediatric Patient

The commonly used systems for calculating fluid needs of the pediatric patient: a

Body weight, Surface area, Caloric Multiple physiologic factors

These systems are unfortunately inadequate because their basic physiologic assumptions have inherent problems, and they are too rigid to account for the variability among pediatric MONITORING surgical patients.

WEIGHT ALONE CANNOT ACCURATELY REFLECT THE DIFFERENCES IN BODY COMPOSITION AND PHYSIOLOGIC CHARACTERISTICS OF THE WIDE SPECTRUM OF PEDIATRIC SURGICAL PATIENTS. To base fluid management on a more scientific basis : PHYSIOLOGIC ALTERATIONS / METABOLIC ACTIVITY

It was concluded that maintenance fluid requirements were directly related to the metabolic activity necessary for the body to perform its vital functions.

Physiology
- Percentage of body water exceeds that of adult. - Expanded extracellular space which contracts during first week of life : 1. Increasing glomerular filtration rate 2. Physiologic diuresis occurs with loss of about 10% of total body weight 3. Some SGA / dysmature infants may not have expanded extracelllar space - By 6 months of age, healthy infants have kidney function that is almost normal.

Composition of Body Fluid

Body weight, body surface and body fluid in children and adults
Premature Neonate Weight (kg) Surface area(m2) S/W Total water (%) ECF (%) ICF (%) 1.5 0.15 0.1 80 50 30

Newborn 3 0.2 0.07 78 45 35

1 year 3 year 9 years Adult 10 0.5 0.05 65 25 40 15 0.6 0.04 60 20 40 30 1 0.03 60 20 40 70 1.7 0.02 60 20 40

Hochman et.al. Reproduced

ECF ISF : non protein IVF : with protein

Fluid distribution
Premature/Newborn 80 70 % TBW

Child
65 60 % TBW

ICF 30-35%

ISF 40-37.5%

IVF 10-7.5%

ICF 40%

ISF 18-15%

IVF 7-5%

Composition of Body Fluid Comparison of body composition of infants & adults

Water

Blood Solids Fat

1500g

2500g

3500g

Adult

Composition of Body Fluid........

Cations (mEq/L)
Na+ K150 4 4 Ca++ 5 Mg++ 40 3 NH4+ 0.3

Amions (mEq/L)
CL103 109 77 HCO3- HPO427 28 10 3 -

Intracellular fluid
Extracellular fluid Lactated ringer solution 0.45 NaCL 0.9% NaCL 3% NaCL

10 142 130 77 154 590

154
590

Source: Herrin J, Fluid & electrolytes, 1997

Composition of Body Fluid Composition of Body Fluid

Source Na+ K+(mEq/L) CI-(mEq/L) HCO3pH Osmolality (mOsm/L)

Gastric Pancreas Bile Illeostomy Diarrhea Sweat Blood Urine

50 140 130 130 50 50 140 0-100

10-15 5 5 15-20 35 5 4-5 20-100

150 50-100 100 120 40 55 100 70-100

0 100 40 25-30 50 0 25 0

1 9 8 8 Alkaline 7.4 4.5-8.5

300 300 300 300

285-295 50-1400

Source: Herrin J, Fluid & electrolytes, 1997

Normal water losses in infants & children

Cause of Loss Output Urine Insensible loss Skin Respiratory tract Hidden intake (from burning 100 calories) Total

Volume of Loss (mL/100 kcal)

70 30 15 15

100

Perioperative fluid management

I. Maintenance II. Deficit III. Replacement

How should be given ? What kind of fluid ? How much ?

FISIOLOGY CAIRAN TUBUH BAYI & ANAK

Total Cairan Tubuh : 75-80% dari Berat Badan ( bayi Aterm ) 80% X Berat badan ( bayi Preterm) 60-65 % ( dewasa )
Cairan Ektra Seluler : 52% X BB 20 25% ( Dewasa )

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

Kehilangan Cairan : Fisiologis

lnsensible losses 500ml / m2 / 24 jam Renal loss 500-800 / m2 / 24 jam Keringat dan gastro-intestinal 200 ml/m2/24 jam ..... Total 15OOml / m2 / 24 jam

Kehilangan cairan ekstra seluler kedalam rongga yg secara fisiologis tidak ada
[ = rongga yang secara fungsional tidak ada ] - Kehilanga cairan ektrasel : peritonitis , ileus - intracellular : haemorrhagic shock ...... Keduanya ... Luka bakar luas
Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

Kehilangan Cairan ke Rongga 3 :

Mekanisme kontrol Ginjal Glomuler Filtration Rate (GFR) dan Tubular Function ( TF )

GFR bayi : 25% X dewasa .... Tumbuh ........ Umur 2 tahun ( 100% )

TF .... Osmol urine .... maksimal 600-700 ..... Bayi dehidrasi : KURANG mampu mengatur osmol urine.
mOsm/kg ( dewasa > 1200mOsm/kg )

Produksi urine .... Menggambarkan status hidrasi bayi / anak.

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

PRODUKSI URINE tiap JAM

ATLS

Kasus Bedah pada Bayi EMERGENCY: Penanganan yg baik prognose

Cepat stabilisasi RUJUK . Hati- hati bisa mengenai multi organ

A
B

JALAN NAFAS DEFINITIF

NAFAS BANTUAN, CEGAH BAROTRAUMA HILANGKAN MENGANGGU VENTILASI (PERUT KEMBUNG, HYPOTHERMI)

KOREKSI DEFISIT, JAGA PERFUSI

PERTAHANKAN FUNGSI ORGAN

CEGAH HIPOTHERMI

Poerwadi, Pediatric Surgeon Devision of Pediatric Surgery, Dr. Soetomo Hospital SURABAYA

Terapi Cairan Elektrolit pada Bedah Bayi Anak Akut HAL PERLU DIINGAT !!! :

TERAPI CAIRAN : Penting & harus dikuasai saat pra bedah,

intrabedah sampai pasca bedah Kebanyakan bayi : kelainan bawaan .. Prematur ... Operasi ... Hati- hati. Bayi sangat rentan kekurangan & kelebihan cairan. Perhatikan resusitasi cairan elektroli bay & anak

Poerwadi, Pediatric Surgeon Devision of Pediatric Surgery, Dr. Soetomo Hospital SURABAYA

3 W yang harus dijawab :

What is the deficit ? What is required to maintain the patient? What are the ongoing losses?

3 Prisip DASAR terapi cairan :

Repair of deficits Regular maintenance Replacement of losses

3R

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

1. Repair of Deficit

3D Degree of dehydration estimated

Kontrol :
Berdasar gejala klinis :

Determine type of fluid lost Develop an approach to correct deficit

a. Perkiraan derajat dehidrasi

- Dehdrasi Ringan ( 1- 5% ) - Dehidrasi Sedang ( 6 -10% ) - Dehidrasi Berat ( >10% )

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

Tidak ada pemeriksaan laboratorium yg

cocok utk menentukan derajat dehidrasi

b. Menentukan jenis cairan yang hilang

Dari perjalanan penyakit. Pemeriksaan osmolalitas serum : - Dehidrai .... Isotonic,...( serum osmolality = 270-300 or Na= 130 150 ) Hypotonic Hypertonic (serum osmolality > 310 ; Na >150 )

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

1. Koreksi defisit Cairan :

Rumus / Pedoman ..BUKAN harga mati .... PENTING : EVALUASI HASIL

Rule of thumb

Dehidrasi 5% .... Koreksi 50 cc/kg BB Dehidrasi 10% .. Koreksi 100 cc/kg BB

..... Bolus sebanyak 10 cc/kg BB

BOLUS : 10 CC / Kg BB

monitoring

DAPAT DIULANG
Malnutrition Hypertonic dehydration Chronically ill children

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

2. CAIRAN RUMATAN

a. Sesuai kehilangan cairan ..fisiologis b. Kebutuhan Elektrolit rumatan c. Kecepatan dan cara pemberian d. Macam cairan

BB

Volume Cairan Rumatan A. Rule of thumb

UMUR

Hari 1 : 60ml/kg/hr 0 - 1Okg : 100ml/kg/24jm Hari 2 : 90 ml/kg/hr 10-2Okg : 50ml/kg/24jm Hari 3 : 120 ml/kg/hr >20k : 20ml/kg/24jm

100ml 3 x age x Wt (kg)

B. Cara lain

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

b . Kebutuhan Elektrolit Rumatan :

Na, K, Cl : 3mEq / kg / 24 jm

c . Kecepatan pemberian
Harus dikontrol ..... Pakai mikrodrip : 60 tts /cc Kontrol dgn mikro buret ... Syrenge pump Pemanas infus

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

NATRIUM

Elektrolit utama tubuh. 90% utk mempertahankan tek onkotik

Partikel utama di CES. Na normal serum = 137-147 mMol/L Hiponatremia <130 mMol/L ......
....< 120 mMol/L ..... BAHAYA ..Mengancam nyawa.

Rumus koreksi hiponatremi :

Defisit Na (Mmol) = Na Normal Na terukur x 0.6x Kg BB

diberiakan 50% nya ( tidak boleh > 0,5 mmol/ L / jam )

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

KALIUM

Peran utama utk keseimbangan asam basa

tubuh. Sebanyak 50 60 mmol ada di CES

Kadar K plasma : 3.4 - 5.6 mMol/L.

Perlu diingat, K+ :

- utama didalam sel, - 2/3 di otot, - Kebutuhan rumatan K+ : 24mMol/kg/hari. Di ekresi via urine minimal : 20 mMol/ hari Pengeluaran via urine >30 mMol/day, atau kadar K serum < 3.5 ....... ...... indikasi kehilangan cairan berlebihan

KESEIMBANGAN ASAM BASA

ASIDOSIS : pH < 7,4 .... Koreksi ? NaBic ? .... HATI HATI !!! ... Sebelum koreksi dehidrasi, shok, ventilasi Bila semua sudah dikoreksi .. tetap acidosis dgn : pH <7.10 atau kadar bicarb < 5mMol/l Formula : Base excess ( deficit ) x 0.03 x body weight(kg) = mMol NaHCo3 [ 1ml 8.5% NaHCO3 = 1mMol ] Dilarang memberikan bolus.... Campur dgn cairan rehidrasi... Koreksi hanya boleh 25% / 4 hours.... Hentikan !!! bila pH >7.15 atau bicarb = 8-10mMol/l BAHAYA : memberikan NaHCO3 pada keadaan hipokalaemia,.... Edema otak dan meningkatkan pengikatan O2.... peripheral anoxia.
Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

Terapi TPN ... Hipokalemia....Tambahkan K+ Sebelum memberikan K+ ... Perhatikan apakh pasien anda TIDAK Anuria ?

Terapi K+ pada hypokalaemia : Hipokalaemia ringan .... Berikan ORAL ( bila tdk ada kontra indikasi )

Pemberian intravena...... 20-30 mMol/jam KCl ... JANGAN MELEBIHI 40 Mmol ... Dilarutkan dalam 1000 cc cairan infus. Ekresi : renal meningkat, retensi H+ & Na+ Kebutuhan K+,....K+ banyak dibuang bersama HCO3. H+ masuk sel, K+ keluar ke CES.
Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

ALKALOSIS :

Kandungan Elektrolt dalam cairan usus

Electrolyte

Na+
40 +/- 20

K+
10 +/- 5

H+
85 +/- 5

Cl135 +/- 5

HCO3_

Gastric juice

Small Intestine Bile

110 +/- 10

10 +/- 5

115 +/- 15

25 +/- 5

130 +/- 10

10 +/- 5

70 +/- 20

50 +/- 20

Ileostomy Colostomy

100 +/- 30 70 +/- 20

10 +/- 5 20 +/- 10

_ _

80 +/- 40 50 +/- 20

_ _

Zacharias Zachariou, MD, PhD PRE-AND POSTOPERATIVE CARE OF NEONATES AND CHILDREN

PENANGANAN PREOPERATIF
1. Evaluasi pasien menyeluruh : - Kemungkinan kelainan ( congenital ) lain - Alergi - Kondisi gizi / Nutrisi - Obat - Evaluasi sistemik ( jantung, paru dll ). 2. Pemeriksaan fisik menyeluruh. 3. Pemeriksaan lab dasar ( darah, faal beku, serum elektrolit, fungsi hati, ginjal, foto thorak, dll )
Louis H Alacron & Andrew B Peitzman Acute Care Surgery

I. MAINTENANCE
1. Maintenance fluid and caloric requirements of neonate / newborn Energy (KCal/kg/day) Age Vol (mL/kg/day)
Day 1 Day 2 Day 3 Day 4 Day 5 Weight (kg)
< 1ooo
1000-1500 1051-2000 Full Term

50 80 80 100 100 120 120 150 150 First 48 hours

80-140
60-100 60-80 40-60

40 50 50 70 70 -90 90 110 110 120 End of first week

150-200
140-160 110-150 100-150

Amounts are given as ml/kg/d

2. Hourly and Daily Maintenance Fluid Requirements of Children to based on weight

Maintenance fluid requirements Weight (kg) 0-10 10-20 >20 Day Hour

100mL/kg 1000mL + 50 mL/kg 1500 ml + 20 mL/kg

4mL/kg 40mL + 2 mL/kg 60 mL + 1 mL/kg

For example : a 25 kg child would required

1000 ml + 500 ml + 100 ml = 1600 ml
Holliday & Segar Method

3. Fluid requirements to be based on BSA

Average BSA values Neonate Child 2 years Child 9 years Child 10 years 0.25 m 0.5 m 1.07 m 1.14 m

Child 12-13 years 1.33 m

For men
For women

1.9
1.6

m
m

Children : 1500ml / m2 BSA / day For example : 3 kg infant : 1500 ml x 0.2 x day = 300 ml/day "Normal" BSA is generally taken to be 1.73 m for an adult.

Source: Holiday MA, Segar WE; The maintenance need for water in parenteral fluid therapy padiatrics

Choice of the maintenance fluid

Crystalloid : Depent on the glucose and electrolyte needs Hypotonic : D 10% 0.18 NS D 5% 0.225 NS D 5% 0.45 NS
Neonate & premature or small for gestation age are at risk for perioperative of hypoglycaemia. Monitoring of blood glucose concentration is recommended

Is intraoperative
glucose necessary?

Perioperative Fluid Management Intraoperative Glucose Administration

Effects : intraop hyperglycemia hyperosmolality osmotic diuresis worsen neurologic outcome during cerebral ischemia

Perioperative Fluid Management Intraoperative Glucose Administration

Exceptions : patients at risk for hypoglycemia

neonates and young infants debilitated patients with chronic illness patients on parenteral nutrition neonates of diabetic mothers Beckwith-Wiedeman syndrome nesidioblastosis

Perioperative Fluid Management Intraoperative Glucose Administration

Existing infusions of dextrose-containing fluid may be continued at a reduced rate (50% of maintenance) to compensate the effect of

surgical stress on glucose control

II. DEFICIT
Preoperative fluid deficits : Maintenance + fluid deficit 1. Fasting period 2. Hydration 3. Electrolyte imbalance 1. Fasting period Fasting (NPO) guidelines for children and adults Fasting time (Hours)

Age
< 6 months 6-36 months > 36 months

Solids
4 6 8

Clear liquids
2 3 3

2. Hydration :
Assessment of the degree of dehydration
Clinical findings % body weight loss Estimation fluid defisit Pulse Blood pressure Respiration Skin turgor Mucous membranes Peripheral perfusion Urine
Source: Nelson W

Mild 4-5% 40-50ml/kg Normal Normal Normal Normal Moist Normal Reduced

Moderate 6-9% 60-90 ml/kg , Weak Normal of low Deep Dry Poor Oliguria

Severe >10% 100-110 ml/kg , feeble Reduced Deep & rapid Very dry Poor, cool, extremitas Marked oliguria

Replacement of fasting Hourly fluid requirement x length of fasting (hours) For example : a 5 kg child 5 kg x 4ml/kg/h x 4 h = 80 ml Given : 50% in the first hour 25% in the second and third hour

Choice of fasting fluid : Crystalloid fluid - Hypotonic solution - Isotonic solution

Management of dehidration a. Estimated fluid deficit b. Rehydration For example : a 10 kg child is assessed to severe dehydration with an estimated 10%
Dehydration 10%, 10 kg EFD : 100 ml x 10 = 1000 ml
Initial fluid resusitation : 20ml/kg (20-30)

Reassess the clinical state

Improved First 8h : 50% rest fluid deficit + fluid maintenance Second 16h : 50% rest fluid deficit + fluid maintenance Non improvement

- Respiration - Circulation - Mental status

Repeat : 20 ml/kg/20-30 Resassess

Choice of the fluid : Rehydration : Isotonic crystalloid Maintenance : Hypotonic crystalloid

3. Electrolyte im balance
Electrolyte composition of stomach, small bowel and diarrhea
Stomach Small bowel Diarrhea

160 140
HCO3

120
100 80 60 40 20
K+ K+ H+ Cl+ Na+ Cl+ Na+ HCO3

K+

Cl+

Maintenance electrolyte requirement in children

Electrolytes Sodium Potassium Chloride Calcium Phosphorus Magnesium

Source : J Allan Paschall

: 3-4 mEq/kg/day : 2-3 mEq/kg/day : 2-3 mEq/kg/day : 150-500 mg/kg/day : 0.5-2 mmol/kg/day : 0.25-0.5 mEq/kg/day

DEFICIT.......

Daily Electrolyte Requirements

Na K Cl 2-3 mEq /kg/day 1-2 mEq /kg/day 2-3 mEq /kg/day day 2-3 day 3-4

Ca

20-100 mg/kg/day day 1

* 1 mEq = 1 mmol

Hypo Natremia 1. Estimated fluid deficit 2. Resucitation from shock : NS / RL 3. Calculated deficit hourly IV rate Maintenance + deficit Na- / 24 hours mEq Na+ = (Desired Na+ - Observed Na+) x weight (kg) x 0.6 4. Infuse D5 0.45 NS or D5 NS or D5 LR 5. Add 10 20 mq kcl/l based on renal function and K+ level Hypokalemia K : 0.5 1 meq/kg (max.20 meq) / 2 hour Repeat : 4- 8 hours as need Monitoring : ECG Hyperkalemia CaCl : 0.1 0.3ml/kg a. 10% solution CaGluconas : 0.3-1ml/kg a.10% solution Nabic : 1-2 mEq/kg + mild to moderate hyperventilation Glucosa + insulin : 0,5g /kg Glucose + 0.1U/kg insulin / 30-60

III. REPLACEMENT
Intraoperative fluid management - Maintenance - Replacement Replacement - Third space lossess - On going lossess

Guidelines for intraoperative fluids in pediatric patiens

1. First hour, hydrating solution: Age 3 year : 25ml/kg, plus item 3 Age 4 year : 15 ml/kg, plus item 3 2. All other hours basic hourly fluid plus item 3 below Maintenance fluid = 4 mL/kg Maintenance + trauma = basic hourly fluid 4 mL/kg + mild trauma (2 mL/kg) = 6 mL/kg 4 mL/kg + moderate trauma (4 mL/kg) = 8 mL/kg 4 mL/kg + maximal trauma (6 mL/kg) = 10 mL/kg

3. Blood replacement with 3:1 volume replacement with crystalloid or colloid, or blood
From: Berry Reproduced

BLOOD REPLACEMENT
Estimated blood volume (EBV) in pediatric patiens

Age Premature infant Newborn Infant < 1 y Child > 1 y

EBV (mL/kg)

90-100 80-90 75-80 70-75

Mean & lower normal hemoglobin levels in pediatric patients

Normal hemoglobin (g/100mL) Age 1 day 1 week 1 mo 3 mo 0.5 5 y 5 9y 12 14 y girls boys Mean 18 17 14 12.5 13 13.5 13.5 14 Lower limit 13.5 13 13 9 11.5 12 12 12.5

Dallman & Siimes, Oski & Neiman, and Saarinen & Siimes

Normal & acceptable hematocrit (Hct) values in pediatric patients Normal hct (%) Age Premature Newborn 3 mo 1y 6y Mean 45 54 36 38 38 Range 40-45 45-65 30-42 34-42 35-43 Acceptable hct (%) 35 30-35 25 20-25 20-25

BLOOD REPLACEMENT TO USE HAEMOTOCRIT LEVEL

EBV (starting Hct - target Hct)

MABL = Starting Hct

Packed Red Blood Cells:

The use has diminished because of disease transmission (HIV, Hep C,B. etc) Blood required (PRC) = (Start Hct target Hct) x body weight (kg) x 1.5 (WB) = (Start Hct target Hct) x body weight (kg) x 2.5

Packed Red Blood Cells .........

Child usually tolerates Hct ~ 20 in mature children

If: Premature, Cyanotic congenital disease O2 carrying capacity Hct ~ 30

No one formula permits a definitive decision Replace 1ml blood with 3 ml of LR Lactic acidosis is a late sing of decreased O2 carrying capacity Be aware of blood disorders (sickle cell disease)

Fresh Frozen Plasma:

Use to replenish clotting factors during massive transfusion, DIC,
congenital clotting factor deficits Usually replenished if EBL = 1-1.5 TBV A patient should be never given FFP to replace bleeding that surgical in nature is

If transfused faster than 1.0 ml/kg/min severe ionized hypocalcemia may occur If occurs - Rx. with 7.5-15 mg/kg Ca++ gluconate Ionized hypocalcemia can occur in neonates frequently because of decreased ability to mobilize Ca++ and metabolize citrate

Platelets:
Find etiology - TTP, ITP, HIT, DIC, hemodilution after massive blood transfusion Consider transfusion if Platelets < 50.000 In certain hospitals platelet function test is available If Platelets < 100.000 and EBL = 1-2 TBV transfusion more likely If Platelets > 150.000 and EBL > 2 TBV transfusion more likely

Guidelines for red cell transfusion to neonate and premature Shock associated with acute blood loss Hb< 13g/100mL, Hct<40%, and presence of pulmonary failure, cyanotic heart disease, or congestive heart failure Comulative loss of 10% or more of the blood volume within 72 h or less if additional sampling is required Hb<80g/100mL, or Hct<25% in a stable neonate with clinical manifestations of anemia, e.g. tachycardia, tachypnea, poor feeding
Source: Kevy SV, Gorline JB, in Hemetology of infancy & childhood, 1998

Postoperative Fluid Management Maintenance fluid Replacement of fluid deficit Replacement of other losses - Chest tube - Nasogastric tube - Weeping incision - Continous slow bleeding Correction of electrolyte inbalance Maintenance fluid requirement on the first most operation day are decreased to 2/3 of the usual daily amount

Fluid restriction:
Situation which require fluid restriction include patiens with cerebral edema congestive heart failure renal failure SIADH PDA Pulmonary disorders

Calculated : as a percent of maintenance fluids ( e.g 2/3 or 3/4 maintenance ) as insensible loss ( 300-400 ml/m) plus urine

Conclusion
Fluid therapy for pediatric patients must be based on the knowledge of the fluid and electrolyte needs in healthy infants and children on physiologic responses to the surgical procedure
Formula for fluid therapy are guidelines that need to be revaluated according the patients response Even more than in the adult, improper fluid management in infants and children can cause life threatening consequences The inadverten administration of a seemingly minuscule excess of fluid may couse problems. For example : 100 ml fluid in full term neonate is comparable to 1 to 2 liter excess in an dault

Etiology and Outcome of Neonatal NE

Hypoxemia Acidosis Low cardiac output Decrease splanchnic Blood flow

Hipertonic feeding
Absence of normal colostrum Immature gut immunity

mucosal edema and ulceration invasive infection by bowel flora

Bacterial invation Of portal system And bowel lymphatics

Pneumatosis intestinalis Portal gas Septicemia Transmural Bowel necrosis

Endotoxin release DIC

Sepsis

Perforation

Vasomotor Collapse