A presentation I gave on Pediatric Fluid Therapy, with the main focus around perioperative fluid therapy in the Pediatric population. This lecture was delivered to my colleagues in the department of Anesthesia, and it was invigilated by consultant Anesthetist, Dr. Anatolly Kravchenko at the Intermediate Hospital Katutura.

1. Dr. Nghitukuhamba T.E Kalipi
BSChB, MBChB
1st Year Medical Intern
Pediatric Fluid Therapy

2. Outline
1. Introduction
2. Pediatric fluid physiology
3. Types of fluids
4. Calculations used and administration of fluids
5. Complications of overhydration
6. Conclusion
7. References
8. Questions and answer session
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3. Introduction
 Pediatric fluid therapy is a topic of importance to every clinician's
encounter with a pediatric patient, today's discussion will however be
limited to peri-operative fluid management of pediatric patients.
 Meticulous attention to fluid intake and loss is required in younger
patients as these patients have limited margins of error, and fluid
overload and underhydration are not uncommon.
 Ensuring considered fluid and hemodynamic management is central
to peri-operative patient care.
 The goal of perioperative fluid administration is to maintain an
adequate intravascular volume and avoid fluid overload or
hypovolemia 3

4. Pediatric fluid physiology
 Water is the most plentiful constituent of the human body
 It makes up approximately 75% of the total body weight of a full term infant,
decreasing to approximately 60% of the total body weight during the 1st year
of life, which remains so until puberty.
Fluid compartments
The total body water is divided into two main compartments:
 Intracellular fluid (ICF): 2/3 of TBW
 Extracellular fluid (ECF): 1/3 of TBW
- Plasma
- Interstitial fluid
- Transcellular fluid (eg, CSF)
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7. Types of fluids
 The choice of fluids to use in peri-operative fluid therapy remains
controversial, the APA and NICE guidelines however recommend infusion of
isotonic solutions, so called balance crystalloids.
 By definition, balanced crystalloids should ideally mimic the electrolyte
pattern of that of plasma.
Recommended isotonic fluids:
 0.9% Normal saline
 Ringer's lactate
 Plasmalyte
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9. Advantages and disadvantages of
crystalloids
Advantages
 Inexpensive, and hypoallergic
 Efficient at replacing ECF
 Reduced risk of infection transmission, coagulation impairment or cross
matching.
Disadvantages
 Exert short lived hemodynamic effects in comparison to colloids
 Can invariably produce peripheral edema and pulmonary edema in large
volumes
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10. Calculations and administration of
fluids
 Fluid requirements can be divided into maintenance, deficit, and
replacements.
Maintenance requirements
 In 1957, Holiday and Segar published a paper "The maintenance need for
water in parenteral fluid therapy".
 This birthed the common 4/2/1 principle which is still widely used today.
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12. Deficit requirements
 In addition to a maintenance infusion, pre-operative fluid deficits must be
replaced.
 In contrast to adults, infants and children respond to dehydration with
hypotension without an increased heart rate
 Fluid deficit in a starved pediatric patient in calculated by multiplying the
weight with the hourly maintenance requirement and by the number of hours
starved as per 4/2/1 rule
e.g. 5 kg x 4ml/kg/h x 6 hours starved
 Fluid deficits are administered with hourly maintenance requirements in
aliquots of 50% in the 1st hour, and 25% in the 2nd and 3rd hours.
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13. Replacement requirements
 This can be subdivided into blood loss and third-space losses.
Blood loss
The average blood volumes per age
 Premature infants: 100 ml/kg
 Full-term neonates: 85-90 ml/kg
 Infants: 80 ml/kg
 Adults: 65-75 ml/kg
To avoid excessive fluid administration, blood loss is replaced by either colloids
(eg, albumin) or packed red blood cells once the intraoperative blood loss
exceeds the allowable blood loss.
Allowable blood loss = [(Initial Hb — Hb trigger) ÷ Initial Hb)] × EBV 13

14. Third-space loss requirements
 These losses are impossible to measure
 They must be estimated by the extent of the surgical procedure
 Third-space loss is usually replaced with Ringer's lactate.
Third-space losses based on the type surgery
 Small, atraumatic procedures (eg, limbs, hernia repair): 4 ml/kg/h
 Intermediate procedures (eg, open cholecystectomy): 6 ml/kg/h
 Major procedures (eg, open peritoneum, hemicolectomy): 8 mL/kg/h
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15. Signs of balanced volume status
 Urine output ( 1 – 2 ml/kg/h)
 Pulse rate with reference to age
 Other signs include sunken eyes, mucous membrane hydration status, skin
turgor and capillary refill, which are somewhat difficult to assess
intraoperatively.
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16. Is there a need for dextrose in
perioperative pediatric fluid therapy?
 A low concentration of dextrose (1% - 2%) should be used if dextrose is
required for a child at risk of hypoglycaemia during surgery, especially with
prolonged fasting periods.
 Children up to 8 years require 6mg/kg/min of glucose to maintain
euglycemia, premature neonates require 6-8mg/kg/min, and are therefore at
risk of developing intraoperative hypoglycaemia.
 Hartmann's 1% dextrose (10 mL of 50% dextrose added to 500 mL of
Hartmann's solution) or Hartmann's 2.5% dextrose (25 ml of 50% dextrose
added to 500 mL of Hartmann's solution) can be used in such an instance.
 After surgery, all pediatric patients should receive maintenance fluids
containing dextrose. 16

17. Complications associated with Pediatric
fluid therapy
 Hyponatramaemic encephalopathy
 SIADH leading to dilutional hyponatremia
 Hypoglycaemia
 Fluid overload
 Electrolyte disturbances (eg, hyperchloremia
 Interstitial and cellelular edema
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19. Conclusion
 Meticulous fluid administration is vital for adequate tissue perfusion and
homeostasis by maintaining euvolemia, and it should be tailored to
the physiology and pathology of the child along with their perioperative
needs.
 It is important to ensure that the fluid deficits, blood losses and third-space
losses as well as maintenance fluid requirements are administered
appropriately, and that the right type of fluids are used.
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21. References
Butterworth, J.F., Mackey, D.C., Wasnick, D., (2022). Morgan & Mikail's Clinical
Anesthesiology.
Lee, H., Kim, J.T., (2023). Pediatric Perioperative Fluid Management. Available
on
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10718623/
Wilson, C.M., Walker, I.A., (2005). Perioperative Fluids in Children. Available
on https://resources.wfsahq.org/wp-content/uploads/uia30-Perioperative-fluids-
in-children.pdf
Ved, S., (2023). Ace. Available
on https://accessanesthesiology.mhmedical.com/content.aspx?bookid=1750&sect
ionid=117322156
Open Anesthesia, (2023). Perioperative Fluid Administration in Children. Available
on https://www.openanesthesia.org/keywords/perioperative-fluid-
administration-in-children/
Farkas, J, (2019). Fluid Selection & pH-guided Fluid Resuscitation. Available
on https://emcrit.org/ibcc/fluid/
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22. Mathew, A., Rai, E., (2021). Pediatric Perioperative Fluid Management. Available
on https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477784/
Slideshare, (2014). Fluid Management in the Paediatric Patient Anaesthetist
Consideration. Available on https://www.slideshare.net/drriyas03/fluid-
management-in-the-paediatric-patient-anaesthetist-consideration
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