Fluid Therapy In Children

Maintenance and
Resuscitation
in Children

Introduction ( 1 )
Hypovolemia and hypovolemic shock
: very often occurred in PICU
Initial assessment and prompt /
accurate fluid therapy is important
If it is not treat properly, has a high
mortality
Fluid therapy has a pivotal role to
decrease mortality

Introduction (2)

VOLUME
RESUSCITATION
IN CRIT. ILL.PATIENTS

PATHOGENESIS
PATHOPHYSIOLOGY
UNDERLYING
DISEASES
IVV,Na,water.and
Plasma protein

Introduction (3)
Fluid management in children :
1.Maintenance: Maintain fluid and nutrition within
normal equilibrium
2.Volume replacement: To replace any disturbances
of body fluids
3.Volume resuscitation : To restore intravolume deficit

Factors Influences Fluid Therapy

Increased :

Decreased: :

Fever

Hypotermia

(12 % every 1oC >

37oC)
Hyperventilation

(12 % every 1oC <

37oC)
High humidity

Increase
Oliguria atau anuria
environmental temp. No activity
High activities
Fluid retention (CHF)
Abnormal fluid loss

Endpoint of fluid
resuscitation
Morbidity
Length of ICU stay

HEXTEND OR
HESPAN
WITH
CRYSTALOID

COLLOID GROUP:
POST-OP PAIN
EDEMA, NAUSEA
DOUBLE VISSION
ARE LESS THAN
CRYSTALOID

Figure 1. Age related changes in compartment fluid

volumes

Table 1. Maintenance fluid requirements for children

Fluid regime/adjustment
Baseline

1 day of age

50 ml kg-1day-1

2 days of age

75 ml kg-1day-1

3 days of age

100 ml kg-1day-1

< 10 kg

100 ml kg-1day-1

10-20 kg

1000 ml day-1 + 50 ml kg-1day-1 for

every kg over 10 kg
1500 ml day-1 + 20 ml kg-1day-1 for
every kg over 20 kg

> 20 kg
Factors
that
decrease
requirem
ent

Humidified gases

X 0.75

Paralyzed

X 0.7

High ADH (e.g. IPPV or

coma)
Hypothermia

X 0.7

High ambient humidity

X 0.7

-12% per 0C core temp is < 370C

Table 1. Maintenance fluid requirements for children

(contd)
Fluid regime/adjustment

Factors
that
increase
requirem
ent

Full activity and oral

feeds

X 1.5/free fluids

Fever

+ 12% per 0C core temp is > 37

Room temp over 31 0C

+ 30% per 0C

Hyperventilation

X 1.2

Preterm neonate (< 1.5

kg)
Radiant heater

X 1.2

Phototherapy

X 1.5

Burns day 1

+ 4% per 1% of body surface

area affected
+ 2% per 1% of body surface
area affected

Burns day 2 +

X 1.5

Tabel 2. Fluid composition in the Neonates

Kompartemen
tubuh
Ekstraselular

Intravaskul
ar

Preterm
neonat
us

Dewas
a (pria)

Dewas
a
(wanita
)

Infant

Manul
a

60%

29%

15%

15%

20%

4%

4%

5%

6%

25%

11%

10%

15%

Interstitial
Intraselular

30%

48%

45%

35%

25%

Total cairan
tubuh

90%

77%

60%

50%

45%

Daily Fluid and Electrolyte

Requirement in Infant & Children
BW
Up to 10 kg
11 20 kg
> 20 kg

Fluid (daily)
100 ml/kgBW
1000 ml/kgBW + 50ml/kg
(Every kg over 10 kg)
1500 ml/kgBB + 20ml/kg
(every kg over 20 kg)

Body Fluid Hemeostasis

Intake & Output
always the same .
Intake

Output

Equilibrium
Body Fluid

Homeostasis
disturbances
must be directly
corrected

Volume replacement

Fluid
management

target: intravascular space

indication: plasma and blood losses
colloid + crystalloid

crystalloid
Fluid replacement
target: tissues, interstitium
indication: dehydration, maintenance

Fluid management

The Fluid
Management
Concept

14

Fluid Therapy
Crystalloids

Colloids

Electrolyte
solutions
like:

Albumin

Glucose 5%

Dextran

Mannitol

Gelatin

Electrolyte
concentrate
s
etc.

NaCl 0.9%/
0,45%
Ringers
solution
Lactated
Ringers
Ringerfundin

HES
(Hydroxye

Other
fluids

thyl
starch)
15

Evolution
of
Crystalloids
Saline

Ringers

Ringer
s
Lactate

?
1850

1890

1950

2005
16

Advantages/ disadvantages of
crystalloid fluid resuscitation
Advantages

Disadvantages

l Balanced electrolyte l Poor plasma volume

composition
support
l Buffering capacity,
lactate/ acetate

l Large quantities
needed

l No risk of adverse
reactions

l Reduced plasma
COP

l No disturbance of
hemostasis

l Risk of
overhydration

l Promoting diuresis

l Risk of edema

Boldt et al. (2004), Table 3.1

18

Crystalloid
Solutions are

distributed over the

entire

Extracellular

Colloids
They remain largely within
the Intravascular Space.
Therefore, colloids are
most effective
in hypovolemic patients.

Colloid and Crystaloid

Controversies
Pro-Colloid Colloid maintain
colloid osmotic pressure,
minimized interstitial fluid
accumulation; Crystaloid
decrease colloid osmotic
pressure and caused lung edema
Pro-Crystaloid High cost and
high risk of complication

Volume Replacement Therapy

Crystalloids

Colloids

Lactated Ringer's
Normal Saline

Albumin
PPL

Gelatin
solutions

Dextran
solutions

HES
solutions

Macrocirculation:

END-POINT
FLUID RES.
IN
HYPOVOL
SHOCK

Conciousness,
BP,
PP/MAP/CVP:8-12mmHg
SaO2 >92%, SvcO2 >70%,
Cap.refill time <2,
Diuresis
Data B : t = 38oC; HR= 120 x/min;
MAP= 60 mmHg

Microcirculation:
Lactate serum < 2mmol/l

Data A : t = 36,8 oC; HR= 65 x/min;

MAP= 82 mmHg

Microcircula
tion
Hypoperfusion

deBaker, Am J Respir Crit Care Med 166:98104,2002

Reperfusion

Choice of
Fluid Resuscitation
CRYSTALOID:
RL
RA
NaCl 0.9%

Not effective for iv

Pro-coagulant effect
DVT effect/ emboli

Effective for iv
HES: Sealing
HES: Makro+
Mikrosirkulasi

COLLOID:
GELATIN
DEXTRAN
HES
Albumin

Zornow, MH et al.: Fluid Management In

Patients With Traumatic Brain Injury. New
Horizons 3:488-498, 1995
(added by presenter)

Increased PV
(ml)

Infused volume
(ml)

5% Albumin

1,000

1,000

25%
Albumin

1,000

250

Increase
d
ISS (ml)

-750

5%
Dextrose

1,000

14,000

3,700

RL

1,000

4,700

3,700

HES 200/0.5 6%

1,000

1,000

MFG 4%

1,000

1,000

Increase
d
ICV (ml)

9,300

PV plasma volume;ISS interstitial fluid volume;ICV intracellular volume;RL lactated Ringers

The relative distribution of crystalloid and colloid

solutions in the intra- and extravascular fluid space at
equilibrium (within 30 min to 1 hour of infusion)
Fluid

Intravascular

Extravascular

Normal capillary permeability

Crystallo 20%
80%
id
70%
30%
Colloid
Increased capillary permeability
Crystalloi 15-20%
80-85%
d
60-70%
30-45%
Colloid
Increased capillary permeability + cell
membrane dysfunction
Crystalloi 10-15%
85-90%
d
50-60%
40-50%

Effects of Synthetic Colloids

Retaining of fluid
in the IVS
increased IV
volume
Venous flow back
(preload)

Cardiac
output
CO

Oncotic
pressure
Hemodilution

Improved
rheology

Flow
resistance
DO2

Hematocrit

Arterial oxygen
concentration
CaO2

Ideal Colloid
Less coagulopathy, hemolysis, red cell
hemolysis, cross-match disturbances
Rapid volume replacement
Good hemodynamic restoration
Improvement of Microcirculation
Improvement of plasma oncotic
pressure
Increase DO2 and organ function
Fast metabolism / excretion and good
tolerance

Problems in Colloid
Therapy

We are just giving colloid to the patient!

What should happen?

Possible side effects amongst others can

be:
Influence on Renal Function
Influence on coagulation
Anaphylaxis reaction
Tissue accumulation
Acid base balance disturbances

29

Intra venous fluid replacement

Fluid Resuscitation

Advantages of Colloid
Refilling IVF faster than
crystalloids
Shock time becomes shorter

Remains in IVF longer than

crystalloids
No intersitial edema

Preserves oncotic pressure effect

No intersitial edema

Colloid Disadvantages
Gelatin

HES

Dextran

Anaphyl.R No
x
Coag.effec No
t
Renal
No

No

Severe

Liver

May be

No

Yes (HMW) Yes

Yes (HMW) High dose
No

Tissue Acc No

Yes (HMW) No

Dose
restriction
in RF

Yes (HMW
and MMW)

No

No

Effects of PVR solutions

on haemostasis and coagulation
Gelatins
Factor VIII, vWF

No effect

Platelets
Adhesion
Aggregation

No effect

Thrombus
formation
Blood typing

HMW- HES

Dextran
s

No clinical
effect
No effect

In emergency
situation blood typing
prior to infusion

Hydroxethylstarch (HES) Classification

(Based on the degree of substitution)
Tetrastarch (0.4)

Pentastarch

Hetastarch

(0.5)

(0.7)

HES 130 /0.4

HES 130/0.42

HES 200 /0.5

HES 450 /

(Based on In Vitro Molecular weight)

0.7
High molecular weight

Medium Molecular weight

Low molecular weight

HES

HES

HES

HES 450 / 0.7

HES 470 /0.7

HES 200 /0.5

HES 200 /0.62

HES 40 /0.5
HES 70 /0,5

HES 110 /0.5

widahes,

HES 130 /0.4

HES 130/0.42

Effects of colloids on kidney function

Gelatins:

No negative effect! Improved kidney function!

Dextrans:
Dextrans Renal insufficiency is possible after Dextran 40
HES:
HES

Acute renal failure after HES is possible

Decrease of glomerular
filtration
Dextran
concentration
in proximal
tubuli

Latent
increase of
urine viscosity

Enhanced
flow
resistance

Stop of
filtration

36

 FLUID MANAGEMENT
FLUID CHALENGE
NO
HEMODYNAMIC
STABIL??

GOOD PERIPHERAL
PERFUSION
HR AND MAP( N)
Sao2 > 92%

NON-SHOCK
YES

MANAGEMENT

FLUID - CHALENGE
RESPONSIVE TO FLUID
CHALENGE (20ml/kg <10 min)
Crystalloid or Colloid
STABIL
1. YES

FLUID REPLACEMENT
/ RESUSCITATION
(Shock management)

RONKHI
CVP

FLUID RESTR
FUROSEMIDE

RESPONSE TO FLUID
CHALENGE

2.

NO

COLD
EXTREMITY

INOTROPIC
NO

VASOPRESOR

Fluid Resuscitation in
Shock
Compensated shock: Crystalloid
or Colloid 10ml/kg/20 30 min,
until 3x
Decompensated shock: Colloid
and or Crystalloid 20 ml/kg/ < 10
min, 3x
PERIPHERAL PERFUSION, Hb, Ht, platelet,

Peripheral Perfusion:
Bad
HEMORRHAGE
SEVERE VASC.
LEAKAGE

REFFERAL HOSPITAL
WITH PICU FACILITY

INVASIVE HEMODYNAMIC MONITORING : cvp, SvcO2

LACTATE SERUM, BGA, ELECTROLYTE,ECHOCADIOGRAM
CHEST- X RAY

Take Home Messages

Early Diagnosis of Compensated Shock
Early Aggressive Fluid Therapy for
Hypovolemic Shock in Children with
colloid and or crystaloid
Early Refferal in Prolonged
Hypovolemic Shock ( After 3x Fluid
Resuscitation )