1. Presenter-Dr. Bunty Sirkek Moderator-Prof. Dr. Ajay Sood

2. TOTAL BODY WATER  ECF compartment  ICF compartment Vary with age Osmolarity remains constant, only fluid fraction changes

3. TOTAL BODY WATER ( 28 wk – 80 % INFANTS – 70 – 75 % OLDER CHILDREN & ADULTS – 60 -65 %) ICF- 2/3 rd OF TBW 30 – 40 % OF wt ECF -1/3 rd OF TBW 50 % OF wt AT BIRTH 20 – 25 % OF wt IN ADULTS PLASMA- 4-5% OF wt INTERSTITIAL FLUID-16 % OF wt TRANSCELLULAR FLUID 1 – 3% OF wt CSF AQ. & VITREOUS HUMOR SYNOVIALFLUID PERITONEAL FLUID PLEURAL FLUID

5.  To supply water and thereby create enough urine volume to excrete solutes  To replace insensible fluid losses  To replace electrolytes lost from urine, skin,or gut  To satisfy caloric needs,reducing tissue catabolism and providing a more normal ratio of carb,fat,and protein for energy  To supply necessary vitamins and minerals

6.  RATE OF CALORIC EXPENDITURE & GROWTH  RATIO OF SURFACE AREA TO BODY WEIGHT  DEGREE OF RENAL FUNCTION MATURATION &REDUCED RENAL CONC. ABILITY  AMOUNT OF TOTAL BODY WATER

7. BASED ON  BODY S.A.  BODY WEIGHT  CALORIC CONSUMPTION  CALORIMETRY

8.  BODY SURFACE AREA- CALORIC EXPENDITURE IS PROPORTIONAL TO BSA  BODY WEIGHT- WEIGHT HRLY 24 HRLY <10 Kg 4ml/Kg 100ml/Kg 11 -20 40ml+2ml/Kg>10 1000ml + 50ml/kg>10 >20 Kg 60ml+1ml/Kg>20 1500+20ml/Kg>20

9.  BASED ON CALORIC CONSUMPTION (HOLLIDAY &SEGAR) WEIGHT CALORIC EXPENDITURE 0 -10 100kcal/kg/day 10-20 1000+50kcal/kg above10kg >20 1500+20kcal/kg above 20kg FOR EVERY 100 CALORIES CONSUMED 67 ml of water for solute excretion 50 ml/100 kcal for insensible loss 17 ml produced by oxidation

10. THUS 67+50-17=100 100ml of water for 100 kcal OR 1ml fluid per 1kcal requirement BODY WEIGHT FLUID REQUIREMENT (HOLLIDAY & SEGAR) 0 -10 Kg : 4 ml / Kg /hr 10 -20 Kg : 40ml +2ml/Kg/hr above 10 kg >20 Kg : 60 ml+1ml/Kg/hr above 20 kg

11.  CALORIMETRY-LINDAHL FORMULA CALORIE REQUIRED-1.5 * kg +5 (kcal/hr) FLUID REQUIRED – 2.5 * kg +10 (ml/hr) Na+ REQUIRED – 0.045*k+0.16(mEq/hr) K+ REQUIRED – 0.03 * kg +0.1 (mEq/hr)

12. NORMAL LOSSES AND MAINTENANCE REQUIREMENTS FOR FLUID,ELECTROLYTES, AND DEXTROSE IN INFANTS AND CHILDREN H 2 O = 100 TO 125 mL/100kcal EXPENDED COMPONENTS: INSENSIBLE LOSS (mL) 45 SWEAT (mL) 0 TO 25 URINE (mL) 50 TO 75 STOOL (mL) 5 TO 10 FOOD OXIDATION (mL) 12 Na + = 2.5 mmol/100 kcal EXPENDED COMPONENTS: BODY GROWTH SWEAT VARIABLE URINE VARIABLE STOOL VARIABLE K + = 2.5 mmol/100 kcal EXPENDED COMPONENTS: AS FOR Na + Cl - = 5 mmol/100 kcal EXPENDED COMPONENTS: AS FOR Na + DEXTROSE = 25g/100 kcal EXPENDED COMPONENTS: BASAL METABOLIC RATE GROWTH AND TISSUE REPAIR PHYSICAL ACTIVITY MAINTENANCE SOLUTION (PER LITRE OF WATER) DEXTROSE (g) 50 K + (mmol) 25 Na + (mmol) 25 Cl - (mmol) 50

13.  Fluid management is divided into 3 phases- o Deficit therapy o Maintenance therapy o Replacement therapy

14.  Management of fluid & electrolyte losses before pts. presentation for surgery  Fluid deficits due to overnight fasting  3 components 1.severity of dehydration 2.type of fluid deficit 3.repair of deficit

15. Signs and symptoms MildModerateSevere Weight loss (%)51015 Deficit (ml /kg)50100150 AppearanceThirsty,restless, alert Thirsty,restless, lethargic,but arousable Drowsy to comatose,cold,li mp,cyanosed Skin turgornormaldecreasedMarkedly,decrea sed Mucous membranes MoistdryVery dry Anterior fontanelle normalsunkenVery sunken PulsenormalRapid & weakRapid& feeble BPnormalNormal/lowlow RespirationnormaldeepDeep & rapid Urine output (ml /kg/ h) <2<1<.5

16.  TYPE OF DEHYDRATION ISOTONIC HYPOTONIC HYPERTONIC  ISOTONIC DEHYDRATION- S.Na+ LEVELS-NORMAL RESULT IN ECF DEFECIT CAUSES-GI LOSSES,PLEURAL EFFUSION Rx – BSS  HYPOTONIC DEHYDRATION- INAPPROPRIATE SELECTION OF I/V FLUIDS /HYPOTONIC FLUID OVERLOADING Rx – MILD- ISOTONIC SALINE SOL. SEVERE- 3% SALINE

17.  ABNORMAL LOSSES-  DI  OSMOTIC DIURESIS  EXCESSIVE SWEATING  VOMITING  INADEQUATE INTAKE OF WATER  VOMITING  DISEASES OF PHARYNX,ESOPHAGUS,CNS

18. ALL DEGREE OF DEGREE OF DEHYDRATION / HYPOVOLEMIA MUST BE CORRECTED BEFORE INDUCTION OF ANAESTHESIA UNLESS THE NATURE OF ILLNESS & OPERATION PRECLUDE THIS REPLACEMENT VOLUME (L) % DEHYDRATION * TBW +DAILY MAINTENANCE FLUID % DEHYDRATION = IDEAL WT – PRESENT WT IDEAL WT FOR AGE

19.  HYPOVOLEMIA (LOSSES FROM IV SPACES) BOLUSES OF ISOTONIC SALINE/COLLOID BLOOD IF- Hb IS LOW & >40 ml/Kg OF FLUID IS REQUIRED  DEHYDRATION(TOTAL BODY WATER LOSS) SHOULD BE CORRECTED SLOWLY PREFERABLY BY ORAL ROUTE IF TOLERATED & TIME ALLOWS,OTHERWISE I/V RAPID REHYDRATION TECHINQUE- (ASSADI & COPELOVITCH) INITIAL RAPID INFUSION OF NS TO CORRECT HYPOVOLEMIA SLOWER CORRECTION OF DEHYDRATION OVER 24-72 hrs WITH 0.9%,0.45%,OR 0.25% SALINE

20.  REPLACE FOR  NPO DEFICIT  MAINTENANCE FLUID  ONGOING LOSSES & THIRD SPACE LOSSES NPO GUIDELINES FOR PAEDIATRIC PATIENT SOLID FOOD 6HRS MILK 4HRS CLEAR FLUIDS 2HRS

21.  ESTIMATED FLUID DEFICIT hrs of NPO * hourly fluid requirement  FLUID INFUSION RATE 1 st hr =1/2 of EFD + maintenance fluid + losses 2 nd hr =1/4 of EFD + ” 3 rd hr = ¼ of EFD + ”  EFD & Losses are replaced with balanced salt solution  Maintenance Fluid--5%D IN N/2 –N/5 2.5% IN N/2 – N/5

22. CHO Prot. Cal/L Na + K + Cl - HCO 3 - Ca 2+ OSM LIQUID (g/100mL) (mEq/L) (mg/dL) D 5 W 5 -- 170 -- -- -- -- -- 255 D 10 W 10 -- 340 -- -- -- -- -- -- NORMAL SALINE -- -- -- 154 -- 154 -- -- 308 (0.9%NaCl) ½ NORMAL -- -- -- 77 -- 77 -- -- -- SALINE(0.45% NaCl) D 5 (0.2%NaCl) 5 -- 170 34 -- 34 -- -- -- 3%SALINE -- -- -- 513 -- 513 -- -- -- 8.4% SODIUM -- -- -- 1000 -- -- 1000 -- -- BICARBONATE (1 mEq/mL) RINGER’S 0 to 10 -- 0 to 340 147 4 155.5 -- 4.5 273 RINGER’S LACTATE 0 to 10 -- 0 to 340 130 4 109 28 3 -- AMINO ACID -- 8.5 340 3 -- 34 52 -- -- 8.5%(TRAVASOL) PLASMANATE -- 5 200 110 2 50 29 -- -- ALBUMIN -- 25 1000 150 to 160 -- <120 -- -- -- 25%(SALT POOR) INTRALIPID 2.25 -- 1100 2.5 0.5 4.0 -- -- --

23.  Acute sequestration of fluid to a nonfunctional compartment  Occurs in –surgical trauma blunt trauma burns infections  Vary with surgical proceedures TYPE OF SURGERY 3 rd SPACE LOSS Intra abdominal. 6-10ml/Kg/hr Intra thoracic 4-7ml/Kg/hr Superficial/eye surg 1-2ml/Kg/hr neurosurgery

24.  It is important to have a plan for blood-loss replacement based on the child’s preoperative condition, haematocrit and nature of the surgery.  ABL = weight x EBV x (H0 – H1)/Ha Where H0 = patient’s original haematocrit, H1 = lowest acceptable haematocrit, and  Ha = the average haematocrit =(H0 +H1)/2

25.  IN CHILDREN ALL BLOOD LOSS SHOULD BE REPLACED  WITH PRBC,WB,COLLOID CRYSTALLOIDS  IF CRYSTALLOID IS USED- EACH 1ml OF BLOOD LOST TO BE REPLACED BY 3 ml OF FLUID  DAVENPORT’S LAW- FOR <10% BLOOD LOSS- NO BLOOD REQUIRED >20% LOSSES MUST BE REPLACED BY PACKED CELLLS OR WB 10-20% CONSIDER CASE BY CASE

26.  Skin color, mucus membrane, nail beds-anaemia, low cardiac output, hypothermia,hypoxia  Blood Pressure  Pulse Rate  CRITICALLY ILL/COMPLEX PROCEDURE INVASIVE BP MONITORING BLOOD GASES Hct, RBS S.ELECTROLYTES &PROTEINS  Urine output& Urine Na+ levels  CVP Monitoring

27.  Maintain iv drip till child is NPO  Loss of ECF due to Ryle’s tube,fistula drainage to be replaced by BSS  Blood loss monitored and replaced if necessary  Maintain U.O >0.8 ml/kg /hr

28.  FEVER ↑ CALORIE REQURIMENT BY 12% FOR EACH 1ºC RISE IN TEMP  HYPOTHERMIA ↓ FLUID REQUIREMENT  HYPERMETABOLIC STATES ↑ CALORIE REQUIREMENT BY 25 -75%  HYPOMETABOLIC STATES ↓ REQUIREMENT BY 10- 25%  STOOL WATER LOSS DOUBLED BY PHOTOTHERAPY  RADIANT WARMERS ↑TRANS EPITHELIAL LOSS BY 50-140%  PLASTIC COVERING↓LOSS BY 50-70%  IF VENTILATION WITH NONHUMIDIFIED GASES ADD 5ml/Kg/hr FOR RESPIRATOY FLUID LOSS

29.  MAJORITY OF FIT PAEDIATRIC PATIENT UNDERGOING MINOR SURGERY RE-ESTABLISH ORAL INTAKE IN EARLY POSTOP.PHASE AND NOT NEED ROUTINE I/V FLUIDS  HYPOTONIC FLUIDS SHOULD BE USED WITH CARE & MUST NOT BE INFUSED IN LARGE VOLUMES OR AT GREATER THAN MAINTENANCE RATES  HYPOVOLEMIA SHOULD BE CORRECTED WITH RAPID INFUSION OF SALINE WHILE DEHYDRATION CORRECTED SLOWLY  ONGOING LOSSES SHOULD BE MEASURED & REPLACED  PLASMA ELECTROLYTES & GLUCOSE SHOULD BE MEASURED REGULARLY IN ANY CHILD REQUIRING LARGE VOLUMES OF FLUID OR WHO IS ON I/V FLUIDS FOR >24HRS