MANAJEMEN CAIRAN

Nazir/Mohan/Nasrul

Fluid management of the pediatric surgery patient is a critical element of care. Basic concept that net balance is equivalent to the amount of fluid and electrolytes lost subtracted from the total intake during a specific reference period.

In most surgical patients, intake is controlled by the caregiver and should be governed by calculating expected losses and the homeostatic requirements of each individual child

Assessment of fluid status

1.

Assessment of fluid status is a clinical exercise and is only supported (but not replaced) by laboratory values. Important variables to assess include recent weight change, history of factors predisposing to fluid loss (fever, diarrhea, vomiting, etc.), medications (diuretics), renal status, use of enteral or parenteral catheters, and duration of illness.

2.

3.

Important physical findings include skin turgor, mucous membranes, capillary refill, heart rate and any orthostatic changes, or sunken fontanel in infants.

4. The goals for fluid therapy are to maintain or return to a euvolemic state as evidenced by adequate peripheral perfusion, maintenance of normal urine output (1 to 2 cc/kg/hour), and correction of any metabolic acidosis.

5. Patients who are on IV fluids, TPN, or enteral nutrition should have daily weights and strict Is and Os recorded and available for discussion on rounds.

Fluid replacement
1. 2.

3.

4.

Losses should be replaced on a cc for cc basis using an electrolyte solution of a similar content. Massive ongoing losses will require analysis of the electrolyte content of the fluid lost, with replacement of a similar fluid on a volume for volume basis. Replacement of intraoperative fluids should consider the amount of measured losses as well as unmeasured losses. For example, unmeasured (insensible) volume loss during laparotomy can be estimated at 10-15 cc/kg/hour of operative time, and should have been included in the intraoperative fluids given. The most important aspect of fluid and electrolyte replacement and fluid resuscitation is continuous clinical reassessment and adjustment of replacement fluids as needed.

Perioperative Fluid Management

The standard practice in perioperative fluid management

has been to replace intravascular volume loss with blood or colloid solutions and to use electrolyte solutions to provide for ongoing fluid requirements.

Intraoperative fluid management

Compared with adult and older childern, neonatus and

infant have greater fluids needs because of higher rates of metabolism and growth. (they have a surface area 3 times greater than adult). Neonates who drink nothing for a day may lose 10% of their weight. The goals of intraoperative fluid management are to restore intravascular volume, maintain cardiac output, and, ultimately, ensure provision of oxygen to the tissues.

Postoperative fluids
should be based on the individual patients need for water

and electrolytes. The wise assumption is that every postoperative patient will have nonphysiological secretion of ADH and will therefore be able to excrete dilute (hypotonic) urine.
Maintenance fluid for patients who are unable to take oral

fluids should be an isotonic or near-isotonic solution, with added potassium to replace urinary losses.

dehydration
Severe dehydration is characterized by a state of

hypovolemic shock requiring rapid treatment.

Initial management includes placement of an intravenous

or intraosseous line and rapid administration of 20 mL/kg of an isotonic crystalloid

The child should be frequently reassessed to determine

the response to treatment

If improvement is not observed after 60 mL/kg of fluid

administration, other etiologies of shock

 Next phase focuses on deficit replacement, provision of

maintenance fluids, and replacement of ongoing losses. Maintenance fluid requirements are equal to measured fluid losses (urine, stool) plus insensible fluid losses. Severe dehydration by clinical examination suggests a fluid deficit of 10-15% of body weight in infants and 6-9% of body weight in older children.

 Error in pediatric fluid management ussually occur in 2

areas : error calculating fluid requirements or the choice of the fluid fluids.
Urine output is a standard measurement of volume status

in most pediatric patients, even in the face of technical diffulties in the smallest patients. Am output 1.5 to 2.0 mL/kg per hour reflects adequate volume restitution.

 Fluid management is divided into 3 phases: - deficit therapy, - maintenance therapy and, - replacement therapy.