Perioperative fluid management N. Najafi Department of Pediatric Intensive Care Department of Anesthesiology UZBrussel BAPA Annual Symposium 25 April 2014
Perioperative fluid management
N. Najafi Department of Pediatric Intensive Care Department of Anesthesiology UZBrussel
BAPA Annual Symposium
25 April 2014
Objectives The objectives of this talk are: To give you a brief overview of the
importance of administrating iv fluid in perioperative period in children
To guide you through a short flow chart the
rationales in choosing the desired fluid
To improve the care and safety of all children
Introduction
Holliday and Segar. Pediatrics 1957.
Introduction
From Holliday MA and Segar WE. Pediatrics 1975
Maintenance requirements
Electrolyte composition
Daily needs of 2 mEq/100 kcal K+ and Cl–
Daily needs of 3 mEq/100 kcal Na+ Needs of glucose 5%
Maintenance fluid requirements
¼th of daily fluid = 5% glucose in 0.9% NaCl + ¾th of daily fluid = 5% glucose in water
BUT
Association between maintenance fluid tonicity, postoperative deaths or significant neurological damage and hospital-acquired hyponatremia in previously healthy surgical children
Potentially hazardous iatrogenic complications in our current practice ???
Carandang F et al. Association between maintenance fluid tonicity and hospital-acquired hyponatremia. J Pediatr. 2013,
Surgical children
Original population
Described by Holliday and Segar
Breastfed small babies
Dilemma
Enteral based argumentation iv fluid ??
Differences in needs
Where are the differences ?
What are the needs?
What are we afraid of ?
How we can prevent the complications ?
Complications
Hypoglycemia Hyponatremia
Hypo- and hyperglycemia
Hypo- and hyperglycemia: detrimental to brain Hypoglycemia due to higher metabolic rate ? Hyperglycemia due to stress- induced insulin
resistance and high glucose intake ≥ 2.5 %
Hypoglycemia < < Hyperglycemia
Hirshberg E, et al. Alterations in glucose homeostasis in the pediatric intensive care unit; hyperglycemia and glucose variability are associated with increased mortality and morbidity. Pediatr Crit Care Med 2008
Glucose concentration
Perioperative use of infusion solutions containing No glucose 1% glucose 2.5% glucose 4% glucose 5% glucose
Sümpelmann R et al. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children, Paediatr Anaesth 2010
Glucose concentration Perioperative use of infusion solutions containing No glucose 1% glucose Normal blood gluc conc 2.5% glucose 4% glucose Hyperglycemia, 5% glucose Dilutional hypoNa
Sümpelmann R et al. A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children, Paediatr Anaesth 2010 Au A et al. Incidence of postoperative hyponatremia and complications in critically ill children treated with hypotonic and normotonic solutions. J Pediatr 2008
Perioperative hyponatremia
Prevalence of up to 31% in surgical children
Perioperative hypoNa
Increased ADH
secretion
Extracellular compartment
Intracellular compartment
Na molecules
Belgian recommendations of perioperative iv fluid
Najafi et al. Belgian recommendations on perioperative maintenance fluid management of surgical pediatric population. Acta Anaesth Belg 2012,
Minor surgery Or
Day- case surgery
Intra- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume
Post- operative period Isotonic fluid + Glucose 5% First 24 h post op: - 70% of the maintenance volume - Isotonic replacement fluids as needed After 24h: full maintenance volume
Intra- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume Isotonic replacement fluids as needed
Post- operative period Isotonic fluid + Glucose 1% Full maintenance fluid volume Allow to drink and to eat ASAP
Major surgery Or
Nil- by- mouth ≥ 24 h post op
Take home messages
Considering iv. fluids as medications Prescribing fluid volume and composition appropriately Using isotonic solutions instead of hypotonic solutions
during the intraoperative and postoperative period Restricting the administration of hypotonic solutions to
very specialized clinical areas based on careful monitoring of plasma electrolytes
Take home messages
Administering isotonic fluids as a bolus in the event of hypovolemia
Monitoring plasma electrolytes and glucose concentration regularly
Considering these recommendations as a framework that
should be adapted to clinical situations of each child