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Updated:
20 September, 2024
Fluid therapy is a fundamental part of perioperative care for surgical patients and other critically ill patients. This section describes preoperative, intraoperative, and postoperative fluid management. Available crystalloid and colloid solutions are also covered. Additionally, fluid therapy for children is described.
Perioperative Fluid Therapy
Fluid therapy in anesthesia and intensive care is commonly divided into preoperative, intraoperative, and postoperative fluid administration, collectively termed perioperative fluid therapy. In intensive care, fluid therapy is also administered to non-surgical patients. The goal of fluid therapy is to maintain or restore a normal fluid balance and tissue perfusion as much as possible. The choice of infusion fluid must be based on a solid understanding of the individual patient’s needs and the various compositions of the fluids. The basic fluid requirement is approximately 30 ml/kg/day. A healthy adult has a daily water requirement of about 1500-2500 ml. The basic electrolyte requirement is about 80 mmol Sodium, 40 mmol Potassium, 20 mmol Magnesium, and 20 mmol Phosphate.
In selecting fluid for volume replacement, consider the following;
- Volume status and tissue perfusion – replacement aims for normovolemia, which can be understood as the intravascular volume needed to achieve adequate cardiac output and perfusion pressure in peripheral tissues.
- Oxygen transport – the target hemoglobin level is set based on age and cardiovascular status.
- Coagulation – any coagulation defect should be considered and corrected.
- Colloid osmotic effect – the desired plasma level must be weighed against possible side effects of hyperoncotic fluids.
- Normothermia for optimal physiology and coagulation.
It is important to consider known risks and side effects of fluid therapy, especially with large volumes (> 3 L) and in cases of SIRS. Note that synthetic colloids have not been shown to positively affect survival compared to crystalloids in controlled clinical studies. Any allergies should always be investigated. All fluid therapy carries potential side effects, even naturally occurring substances. In cases of hypothermia, infused fluids should be warmed.
Note that:
- Saline solutions can cause edema and impaired microcirculation if given in large volumes.
- All colloids can cause kidney effects with impaired renal function in cases of hypovolemia or hypoperfusion.
- Hydroxyethyl starch should not be used in severe sepsis, in cases of significant risk of renal failure, or in critically ill patients (ICU patients).
- Albumin is preferred as a colloid solution in cases of sepsis, head injuries, and liver failure.
- Gelatins provide a relatively short-lasting plasma volume-expanding effect.
- Dextran administration should be preceded by a hapten (Promiten), which must be specifically prescribed.
- Plasma and platelets are indicated only in cases of volume deficit with expected coagulation impairment.
Electrolyte content in losses of various body fluids in mmoll
| Body fluid | Na (mmol/l) | K (mmol/l) | Cl (mmol/l) | HCO3 (mmol/l) | H (mmol/l) |
|---|---|---|---|---|---|
| Stomach (Gastric content) | 20–60 | 14 | 140 | 60–80 | |
| Bile | 145 | 5 | 105 | 30 | |
| Diarrhea / colostomy losses | 30–140 | 30–70 | 20–80 | ||
| Losses from the ileum at high flows | 100–140 | 4–5 | 75–125 | 0–30 | |
| Losses from the ileum at low flows | 50–100 | 4–5 | 25–75 | 0–30 | |
| Drainage or fistula from the pancreas | 125–138 | 8 | 56 | 85 | |
| Losses from the jejunum | 140 | 5 | 135 | 8 | |
| Polyuria | Varies | Varies | |||
| Ref: Neilson J, O’Neill F, Dawoud D, Crean P, Guideline Development G. Intravenous fluids in children and young people: summary of NICE guidance. BMJ (Clinical research ed). 2015;351:h6388 | |||||
Clinical signs of dehydration
| Symptoms / signs | Mild | Moderate | Severe |
|---|---|---|---|
| Weight loss | < 5 % | 5–10 % | > 10 % |
| Deficit (ml/kg) | < 50 | 50–100 | > 100 |
| General condition | Thirsty and worried | Thirsty, anxious or lethargic, halonated | Very sluggish to comatose, cold, gray, cyanotic |
| Mucous membranes | Normal, moisty | Dry | Very dry |
| Skin turgor | Normal | Reduced | Pronounced impaired |
| Pulse | Normal | Tachycardia | Tachycardia, weak pulse |
| Capillary refill | < 2 sec | Slow > 2 sec | Very slow |
| Blood pressure (systolic) | Normal | Normal / low | Low |
| Breathing | Normal | Deep | Deep and fast |
| Diuresis (urinary output) | < 2 ml/kg/h | < 1 ml/kg/h | < 0,5 ml/kg/h |
| NOTE! Higher dehydration can be used without all the characters being met. In hyperosmolar conditions with dehydration, the symptoms may appear different. Drops in blood pressure will often be late and are ominous. | |||
Preoperative Fluid Therapy
Preoperatively, fluids are usually administered to fasting patients waiting for surgery for more than 6 hours. This fluid administration is preferably given orally until 2 hours before the procedure. Alternatively, a balanced electrolyte solution with glucose can be administered. A common regimen for patients waiting for more than 6 hours is Glucose 2.5-5% (25-50 mg/ml) with electrolyte supplements, sodium 40-80 mmol/l, and potassium 20-40 mmol/l. The glucose solution can be given at a rate of 1 liter per 12 hours, which corresponds to about 80 ml/h.
Basic Fluid Needs
| Daily requirement | Daily requirement at body weight 70 kg | |
|---|---|---|
| Water | 30 ml/kg/day | 2100 ml |
| Sodium | 1,1-1,4 mmol/kg | 80-100 mmol |
| Potassium | 0,6-0,7 mmol/kg | 40-50 mmol |
| Glucose | 2 g/kg | 140 g |
| Calories (kcal) | 25 kcal/kg | 1750 kcal |
Patients scheduled for surgery during the day may also be given Ringer’s acetate preoperatively at an infusion rate of about 100 ml/h or 1.5 ml/kg/hour. The preoperative fluid administration must take into account the patient’s current fluid status and acid-base balance.
Intraoperative Fluid Therapy
Intraoperatively, balanced electrolyte solutions are typically administered at a rate of 3-5 ml/kg/hour without glucose. This is usually administered manually through an IV set with a clamp, without a volume pump. The rate compensates for minimal surgical bleeding of 50-100 ml. If bleeding exceeds this, the rate should be increased.
Examples of common intraoperative fluids include Ringer’s acetate or Plasmalyte. Isotonic sodium chloride is reserved for patients with hyponatremia or metabolic alkalosis due to vomiting. Blood sugar should always be monitored during major or prolonged surgery over 3 hours. Normally, glucose solutions are not administered intraoperatively. For hypoglycemia, glucose is given in the form of 5% or 10% solution. In cases of severe hypoglycemia under 3.5 mmol/l, glucose can be administered as a bolus in a 20% or 30% solution, followed by a 10% solution.
Ringer’s acetate or sodium chloride can be administered intraoperatively in a volume that is 2-3 times the lost blood volume. The administration of crystalloid solutions replaces lost blood volume by approximately 20%. These solutions are distributed from the blood volume to the interstitial fluid (ISF) over about 30 minutes, providing a reasonably good initial expansion of the blood volume.
If, during surgery, the patient is assessed as hypovolemic despite administering more than 3 liters of Ringer’s acetate, a colloid solution should be added in the form of dextran, albumin, hydroxyethyl starch, gelatin, or plasma. Colloids with hydroxyethyl starch can be administered up to 20 ml/kg body weight per hour (equivalent to 0.33 ml/kg/min or 1.2 g hydroxyethyl starch/kg body weight per hour), but not to critically ill patients, patients with sepsis, or renal failure. The administration of hydroxyethyl starch should be restricted and stopped as soon as possible. The colloid osmotic effect of human albumin 20% (such as Albumin 200 g/l) is about four times greater than that of blood plasma. In healthy subjects, less than 10% of infused albumin leaves the intravascular space within the first 2 hours after infusion.
Fluid therapy in dehydration
| Percentual deficit of total body weight | Symptom | Exampel at body weight 70 kg | 4 hours (2/3 of need) |
|---|---|---|---|
| Two percent deficit | Dry mucous membranes, thirst | 1,4 liter | 0,9 liter |
| Five percent deficit | Tachycardia, pronounced thirst, oliguria | 3,5 liter | 2,3 liter |
| Ten percent deficit | Hypotension, vasoconstriction, cognitive impairment, pronounced orthostatism | 7 liter | 5 liter |
The assessment of hypovolemia during surgery is challenging as the inhibitory effect of anesthetic agents on the autonomic nervous system causes hypotension. Signs of hypovolemia may include sudden blood pressure drop, weak pulse, weak arterial pressure curve with low filling, positional blood pressure drop (orthostasis), low central filling pressures, positive leg-raise test, low cardiac output (if measured), high EVF or Hb, and circulatory instability when administering anesthetic agents.
Check the blood pressure response to leg elevation if possible. If not, administer 500 ml Ringer’s acetate as a fluid bolus and do not repeat if no effect is seen.
Be particularly careful with positioning and transfers of anesthetized and hypovolemic patients as this can easily cause significant blood pressure drops. Elderly hypovolemic patients are particularly sensitive. A simple fluid balance calculation intraoperatively is to count the amount of fluid administered in the form of colloids and crystalloids, including blood replacement, minus urine and intraoperative blood loss. Hourly urine output is needed during major surgery or prolonged surgery over 3 hours, aiming for an hourly urine output of over 0.5 ml/kg/h, although this low flow does not seem to cause kidney damage. The drop in arterial pressure during anesthesia greatly inhibits urine production, which should be taken into account in the assessment. During minor surgery or procedures lasting less than 3 hours, hourly urine output is usually not required. In cases of intraoperative fluid overload without good urine output, diuretics can be used intravenously as usual, e.g., furosemide 5-10 mg IV.
Intraoperative fluid therapy always results in hemodilution. An Hb of 100-110 and an EVF of 30-35% is considered beneficial for microcirculation, but the optimal Hb is controversial. Younger and stronger patients tolerate hemodilution better than older and weaker patients. Dilution to an Hb value below 80 g/l may impair blood coagulation and oxygen delivery, which depends on Hb and cardiac output, may become insufficient. At an Hb below 50, immediate transfusion is needed, and myocardial ischemia is common, as seen on EKG changes. Note that when administering colloids with dextran, platelet adhesiveness decreases, and bleeding tendency may increase, especially when administering more than one liter of Macrodex to a normal-weight adult.
Postoperative Fluid Therapy
Postoperatively, a combination of crystalloid solutions and glucose solutions is usually administered. To provide the patient with a basic energy requirement during the surgery day, glucose solution is typically given postoperatively in the form of 2.5% or 5% glucose with electrolyte supplements. Continued administration can be given at a rate of about 100 ml/h (80-120 ml/h) or 1.5 ml/kg/hour. Glucose solutions should not be administered faster than 10 ml/kg/hour, meaning a 70 kg patient should never receive 2.5% glucose faster than 700 ml/hour.
Electrolytes are typically added to glucose solutions in the form of sodium 80 mmol/l (40-120) and potassium 40 mmol/l (20-40). Sodium and potassium supplements are adjusted based on current lab results. Normal values are usually optimal, but not always. Severe electrolyte imbalances should not be corrected too quickly. Potassium should never be given in a peripheral vein at a concentration higher than 40 mmol/l as it is irritating to the veins and can be painful. When a large amount of potassium is needed (> 80 mmol/day), it is best administered in concentrated solution through a central venous catheter (5-20 mmol/hour, 1 mmol/ml). Potassium should not be administered faster than 10 mmol/hour, but this can be increased to 20 mmol/hour if ECG is monitored. Blood sugar should be maintained between 5 and 10 mmol/l. In cases of large urine output (> 3 liters), serum osmolality, urine osmolality, and serum and urine electrolytes should be monitored. In cases of severe head injury, diabetes insipidus is not uncommon, requiring additional fluids.
Postoperative fluid administration is guided by the patient’s blood volume, metabolism, and current losses. Normal hourly urine output is 80-200 ml/hour. Urine production should be at least 1000-1500 ml/day. Insensible losses (fluid losses through sweating and breathing) normally amount to about 700 ml/day. A patient on a respirator with humidified air has lower insensible losses, about 400-600 ml/day. At a temperature above or below 37º, insensible losses increase or decrease by 25% per degree of temperature.
Postoperative fluid administration should replace current losses. In the case of fever, extra fluid should be administered, usually 200-300 ml extra per degree above 38 degrees. Vomiting, diarrhea, and drain losses must be compensated. Vomiting and diarrhea can usually be compensated with an extra liter of crystalloid fluid, such as Ringer’s acetate. Drain losses can be compensated with colloids, such as Voluven, in the same volume as the loss.
If the patient is assessed as normovolemic, a fluid balance of minus 500 ml may constitute a good fluid balance. This is checked against body weight. It is common for body weight to increase significantly on the first postoperative day due to intraoperatively administered fluid. This weight gain can amount to several kilos. A weight gain of 0-3 kg can be considered normal after major surgery, a weight gain of 3-5 kg is considered large, while a weight gain of 5-10 kg is considered very large and more than 10 kg as extraordinary and dangerous. A weight gain of more than 10 kg often leads to fluid leakage into the lungs and other vital organs, threatening breathing, microcirculation, and organ function. A weight gain of less than 3 kg usually does not require active measures, but small amounts of diuretics may be given. A weight gain of 3-5 kg can normalize within a couple of days; in this case, a negative fluid balance should be sought through treatment with diuretics, such as furosemide 10 mg x 3. The entire weight gain should not normally be restored in a day, so do not rush.
For a weight gain of 5-10 kg, this should be treated actively through the administration of diuretics, such as intermittent or continuous infusion of furosemide. Fluid administration should be restricted. Glucose should be given in more concentrated solutions to limit fluid administration.
For a weight gain of more than 10 kg, treatment must be active and immediate. Diuretics are usually not sufficient, and dialysis, such as venovenous continuous renal replacement therapy (CRRT) via a dialysis catheter (CDK), is needed.
Postoperative fluid therapy can involve glucose solutions for up to three days. Glucose administration should be evenly distributed throughout the day to avoid hyperglycemia. In addition to sodium and potassium administration, magnesium (20 mmol/day), phosphate (20 mmol/day), and sometimes zinc supplements are needed. Three liters of 5% glucose contains only 600 kcal, so caloric and nutritional administration should become more adequate after the third day by switching to parenteral nutrition, which also includes intravenous amino acids and fats (see this chapter).
Colloid Infusion Solutions
| Solution | Active substance | Sodium content (mmol/l) | Potassium content (mmol/l) | Chloride content (mmol/l) | Acetate content (mmol/l) | Osmolality (mosm/l) |
|---|---|---|---|---|---|---|
| Macrodex 60 mg/ml | Dextrane 70 | 154 | 0 | 154 | 0 | 300 |
| Rheomacrodex | Dextrane 40 | 154 | 0 | 154 | 0 | 350 |
| Ringer-Dextran | Dextrane 60 | 130 | 4 | 110 | 30 | 270 |
| Plasmodex | Dextrane 60 | 130 | 4 | 110 | 30 | 270 |
| RescueFlow | Dextrane 70 | 1280 | 0 | 1280 | 0 | 1580 |
| Hesra | HES 130/0,4 | 130 | 5,3 | 112 | 27 | 277 |
| HyperHAES | HES 200/0,5 | 1232 | 0 | 1232 | 0 | 2464 |
| Tetraspan 60 mg/ml | HES 130/0,4 | 140 | 4 | 118 | 24 | 310 |
| Volulyte | HES 130/0,4 | 154 | 4 | 118 | 24 | 310 |
| Voluven 60 mg/ml | HES 130/0,4 | 154 | 0 | 154 | 0 | 310 |
| Venofundin 60 mg/ml | HES 130/0,42 | 154 | 0 | 154 | 0 | 310 |
| Gelofusine | Gelatine | 154 | 0 | 120 | 0 | 274 |
| Gelaspan | Gelatine | 151 | 4 | 103 | 24 | 274 |
| Albumine 4% 40 g/l | Human albumine | 83 | < 2 | (?) | 0 | 310 |
| Albumine 20% 200 g/l | Human albumine | 125 | < 2 | 100 (?) | 0 |
Crystalloid Infusion Solutions
| Solution | Sodium Content (mmol/l) | Potassium Content (mmol/l) | Chloride Content (mmol/l) | Acetate Content (mmol/l) | Energy Content (kcal/l) |
|---|---|---|---|---|---|
| Sodium Chloride 0,9 % (9 mg/ml) | 154 | 0 | 154 | 0 | 0 |
| Benelyte | 140 | 4 | 118 | 30 | 40 |
| Ringer's Acetate | 131 | 4 | 110 | 30 | 0 |
| Glucose Buffered 2.5 % (25 mg/ml) | 70 | 0 | 45 | 25 | 100 |
| Ringer-glucose 2.5 % (25 mg/ml) | 73 | 2 | 78 | 30 | 100 |
| Glucose 5% (50 mg/ml) | 0 | 0 | 0 | 0 | 200 |
| Glucose 10% (100 mg/ml) | 0 | 0 | 0 | 0 | 400 |
| Glucose 20% (200 mg/ml) | 0 | 0 | 0 | 0 | 800 |
| Glucose 5 % with sodium and potassium (50 mg/ml) | 40 | 20 | 60 | 1 | 200 |
| Glucose 10 % with sodium and potassium (100 mg/ml) | 40 | 20 | 60 | 1 | 400 |
| Glucose 2,5 % buffered (25 mg/ml) | 70 | 0 | 45 | 25 | 100 |
| Glucose 5 % buffered (50 mg/ml) | 70 | 0 | 45 | 25 | 200 |
| Rehydrex with Glucose 2,5 % (25 mg/ml) | 70 | 0 | 45 | 25 | 100 |
| Plasmalyte | 140 | 5 | 98 | 27 | 0 |
| Plasmalyte Glucose | 140 | 5 | 98 | 27 | 200 |
Expansion Effect of Fluid Therapy
The expansion effect on blood volume diminishes over time at different rates for crystalloid and colloid solutions. The effect also varies depending on the patient’s condition. Increased capillary permeability and a lesser degree of retention in plasma are mainly seen in sepsis and inflammatory conditions (SIRS) but can also be seen in trauma and other severe conditions. The expansion effect can change significantly in severe conditions with increased capillary permeability, such as in sepsis and SIRS. Initially, blood volume increases as follows.
Volume-Expanding Effect of Various Infusion Solutions
- 1000 ml crystalloid solution increases plasma volume by 180-330 ml. Initial volume expansion is 500 ml, but it decreases within 30 minutes due to distribution to the interstitial space.
- 500 ml dextran increases plasma volume by about 400-500 ml, with a volume-expanding effect lasting 6-24 hours.
- 500 ml hydroxyethyl starch increases blood volume by 375-500 ml, with a volume-expanding effect lasting 4-6 hours.
- 500 ml albumin 4% increases blood volume by 375-400 ml, with a volume-expanding effect lasting 4-6 hours.
- 100 ml albumin 20% increases blood volume by 300 ml, with a volume-expanding effect lasting 6-8 hours.
- 500 ml gelatin increases plasma volume by about 400-500 ml. Gelatin has a volume-expanding effect lasting 2-3 hours.
To expand blood volume by one liter in an adult patient (70 kg), the following fluid volumes are required
- Crystalloid solution: about 3000 ml.
- Dextran solution: 1000-1250 ml.
- Hydroxyethyl starch: 1000-1330 ml.
- 4% albumin: 1250-1420 ml.
- 20% albumin: 333 ml.
- Gelatin solution: 1000-1250 ml.
Fluid Therapy for Children
- Albumin 5% is standard for volume requirements
- Ringer’s Acetate works in most situations
- Blood, platelets, etc., based on need
- All fluids can be given in boluses of 10 ml/kg over 1-4 hours
- If urgent, it is easiest to give volume directly with a syringe (quickly for small children < 10 kg)
- Hb limits are debated for heart-healthy children but should cope with Hb 80-90 g/L
Basic Fluid Requirements (Use the 4/2/1 Rule)
- 0 – 10 kg → 4 ml/kg/hour
- 10 – 20 kg → 40 ml/hour + 2 ml/kg/hour for weight > 10 kg
- > 20 kg → 60 ml/hour + 1 ml/kg/hour for weight > 20 kg
Clinical signs of dehydration in Children
| Symptoms / signs | Mild | Moderate | Severe |
|---|---|---|---|
| Weight loss | < 5 % | 5–10 % | > 10 % |
| Deficit (ml/kg) | < 50 | 50–100 | > 100 |
| General condition | Thirsty and worried | Thirsty, anxious or lethargic, halonated | Very sluggish to comatose, cold, gray, cyanotic |
| Mucous membranes | Normal, moisty | Dry | Very dry |
| Skin turgor | Normal | Reduced | Pronounced impaired |
| Fontanelle | Normal | Sunken | Very sunken |
| Pulse | Normal | Tachycardia | Tachycardia, weak pulse |
| Capillary refill | < 2 sec | Slow > 2 sec | Very slow |
| Blood pressure (systolic) | Normal | Normal / low | Low |
| Breathing | Normal | Deep | Deep and fast |
| Diuresis (urinary output) | < 2 ml/kg/h | < 1 ml/kg/h | < 0,5 ml/kg/h |
| NOTE! Higher dehydration can be used without all the characters being met. In hyperosmolar conditions with dehydration, the symptoms may appear different. Drops in blood pressure will often be late and are ominous. | |||
The child's total fluid needs
Fluid requirements per kg of body weight (Holliday-Segar)
| Weight (kg) | Quantity per day |
|---|---|
| Children born before w.37 and during the neonatal period | See PM for patients at Neonatal |
| < 5 kg | 150 ml/kg |
| 5 -10 kg | 100 ml/kg |
| 11 - 20 kg | 1000 ml + 50 ml for every kg over 10 kg |
| > 20 | 1500 ml + 20 ml for every kg over 20 kg |
Intraoperative Fluid Requirements (Ringer’s Acetate = Standard)
- Children < 10 kg: 10 ml/kg/hour for the first 1-2 hours
- Children > 10 kg: 3 – 5 ml/kg/hour for the first 1-2 hours
- Then 1-2 ml/kg/hour + measured/estimated losses
- Third space loss: 1-10 ml/kg/hour depending on the type of surgery
If Fluid Boluses Are Needed
- Ringer’s Acetate: 5 – 10 – 20 ml/kg
- Albumin 5% 5 – 10 – 20 ml/kg
- Blood products: 5 – 10 – 20 ml/kg
Recommendations for Children During Massive Bleeding
- Red blood cell concentrate 10 ml/kg in repeated doses
- Plasma 10–20 ml/kg
- Platelet concentrate 5–10 ml/kg
- Cryoprecipitate 5 ml/kg
- Fibrinogen concentrate 30 mg/kg
- Tranexamic acid 10–15 mg/kg
- Recombinant factor VIIa 90 μg/kg
Glucose Administration Intraoperatively
- Glucose 10% + 40 Na/20 K
- 3 ml/kg/h → monitor based on blood glucose levels!
- Indications
- Children < 1 week if ongoing glucose infusion preoperatively
- Metabolic disorders
- Growth-restricted newborns
Postoperative Fluid Requirements
- Give 75% of the 4/2/1 rule on the first postoperative day (due to elevated ADH)
- Ringer’s Acetate
- Glucose 10% + 120 Na/20 K (Reduce electrolytes for children < 6 months)
Electrolyte content in losses of various body fluids in mmoll
| Body fluid | Na (mmol/l) | K (mmol/l) | Cl (mmol/l) | HCO3 (mmol/l) | H (mmol/l) |
|---|---|---|---|---|---|
| Stomach (Gastric content) | 20–60 | 14 | 140 | 60–80 | |
| Bile | 145 | 5 | 105 | 30 | |
| Diarrhea / colostomy losses | 30–140 | 30–70 | 20–80 | ||
| Losses from the ileum at high flows | 100–140 | 4–5 | 75–125 | 0–30 | |
| Losses from the ileum at low flows | 50–100 | 4–5 | 25–75 | 0–30 | |
| Drainage or fistula from the pancreas | 125–138 | 8 | 56 | 85 | |
| Losses from the jejunum | 140 | 5 | 135 | 8 | |
| Polyuria | Varies | Varies | |||
| Ref: Neilson J, O’Neill F, Dawoud D, Crean P, Guideline Development G. Intravenous fluids in children and young people: summary of NICE guidance. BMJ (Clinical research ed). 2015;351:h6388 | |||||
Total intravenous fluid supply to be assumed during the first days of life
| Age | Volume |
|---|---|
| Day of life 1 | 60–70 ml/kg/day |
| Day of life 2 | 70–80 ml/kg/day |
| Day of life 3 | 80–100 ml/kg/day |
| From four days old | 100 ml/kg/day |
Estimated fluid needs for intravenous maintenance treatment of children and adolescents
| Weight | Daily fluid needs(ml/24 h) | Fluid demand per hour (ml/h) |
|---|---|---|
| < 10 kg | 100 ml/kg/24 hours | 4 ml/kg/h |
| 10–20 kg | 1,000 ml + (50 ml/kg/24 h for each kg more than 10 kg) | 40 ml/h + (2 ml/kg/h for each kg more than 10 kg) |
| > 20 kg | 1 500 ml + (20 ml/kg/24 tim för varje kg över 20 kg*) | 60 ml/tim + (1 ml/kg/tim för varje kg över 20 kg)* |
| * Girls rarely need more than 2,000 ml / day and boys rarely need more than 2,500 ml / day as maintenance treatment even at weights exceeding 45 and 70 kg respectively. | ||
Preoperative supply of maintenance fluid volume
| Patient weight | Volume requirement according to Holliday and Segar/day | Example basal supply (ml/day) | Preoperative maintenance fluid (ml/day) |
|---|---|---|---|
| ≤ 10 kg | 100 ml/kg | 8 kg 8 × 100 = 800 | 800 × 0,8 = 640 |
| 10–20 kg | 1,000 ml + 50 ml/kg for every kg over 10 kg | 15 kg 1 000 + 5 × 50 = 1 250 | 1 250 × 0,8 = 1 000 |
| ≥ 20 kg | 1,500 ml + 20 ml/kg for every kg over 20 kg | 25 kg 1 500 + 5 × 20 = 1 600 | 1 600 × 0,8 = 1 280 |
Peroperative fluid requirement
| Patient weight | Basic volume requirement | After 1-2 hours | Add for 3rd room loss: |
|---|---|---|---|
| ≤ 10 kg | 10 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-10 ml/kg/h depending on type of surgery |
| 10–20 kg | 3-5 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-2 ml/kg/h + measured/estimated losses |
| ≥ 20 kg | 3-5 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-2 ml/kg/h + measured/estimated losses |
Volume of postoperative maintenance fluid
| Patient weight | Basal volume requirement, /day | Example basal supply (ml/day) | After postoperative reduction (ml/day) |
|---|---|---|---|
| ≤ 10 kg | 100 ml/kg | 8 kg 8 × 100 = 800 | 800 × 0,7 = 560 |
| 10–20 kg | 1,000 ml + 50 ml/kg for every kg over 10 kg | 15 kg 1 000 + 5 × 50 = 1 250 | 1 250 × 0,7 = 875 |
| ≥ 20 kg | 1,500 ml + 20 ml/kg for every kg over 20 kg | 25 kg 1 500 + 5 x 20 = 1 600 | 1 600 × 0,7 = 1 120 |
Bleeding
Blood Volume: 70-90 ml/kg
Bleeding is replaced according to the percentage of blood volume lost
- 5-10 % Ringer’s Acetate
- > 10 % + Albumin 5%
- > 20 % + Blood
- > 50 % + Plasma
Massive Bleeding:
- Guide by thromboelastogram!
- Without thromboelastogram:
- Administer Blood/Plasma/Platelets in the ratio: 1:1:0.5
In Case of Coagulation Disorder
- + Platelets 5-10 ml/kg
- + Fibrinogen 30-70 mg/kg
- + Cyklokapron 15 mg/kg
Note
- Temperature > 36.5°C
- pH > 7.2
- Monitor s-Ca
- Hb > 90 g/L
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