Paediatric Surgery Fluids Tutorial

Case 1

8 year old boy 3 day history of nausea, vomiting, anorexia, pyrexia, acute abdomen Marked peritonism in right iliac fossa Lethargic with dry mucosa and furred tongue Capill.refill 1,5 sec. PR 140, RR 30, BP 105/65 Temp 38.5 C

What is the most likely diagnosis?

a) b) c) d) e) Appendicitis Gastroenteritis Perforated peptic ulcer Pyelonephritis Acute Hepatitis A infection

List ways in which this boy has lost fluid

Vomiting Inadequate oral intake due to anorexia Evaporative losses due to pyrexia Increased metabolism due to pyrexia & infection Fluid sequestration into peritoneal cavity due to infectious process

Estimate the percentage dehydration

a) 0% b) 2.5% c) 5% d)7.5% e) 10%

Tips:
Are his vital signs within normal ranges for his age? (Check on the table inside one of the ward patients files if you are unsure) Is he shocked or not?

What type of fluid was lost?

Rough guide!! Gastric juice Bile
Na+ 60 148 K+ 10 5 Cl120 100 35 HCO3H+ 65

Pancreatic juice Small bowel drainage Diarrhoeal stools

140
110 120

5
5 25

75
105 90

80
30 45

Based on the type of fluid lost, which of the following would you use as resuscitation fluid, and why?
Resuscitation fluid:
0.9% NaCl SHS Plasmalyte B Ringers Lactate Na 154 130 130 131 3.5 4 5.4 K Cl 154 130 109 111 2 1.2 1.5 60 28 29 Ca Mg Lact/ Dex pH HCO3 5.5 7.5 7.4 6.5

Haemacel

145

5.1

145

6.25

7.3

How much fluid (ml) would you give to resuscitate the child with?
Use both formulae and compare amount calculated: (Weight= 25kg)

[(%dehydration)x10 -(%dehydration)]/kg 10-20ml/kg bolus repeat every 20-30 minutes as necessary

When would you start maintenance fluids in this child?

a) Straight away b) After resuscitating with initial resuscitation fluids c) In theatre d) After theatre e) Not necessary- only needs resuscitation f) Encourage oral intake once pyrexia resolved

Calculate maintenance fluid requirements using both formulae

WEIGHT
2-10kg 10-20kg

DAILY RATE
100ml/kg/d 1000ml/d +50ml/kg/d

HOURLY RATE
(4ml/kg/hr) (40ml/hr + 2ml per kg over 10kg/hr) (60ml/hr + 1ml per kg over 20kg/hr)

>20kg

1500ml/d +20ml/kg/d

Which of the following is the best maintenance fluid for this boy?
Maintenance fluid// mmol Na K 25 12 Ca Mg Cl 2.5 65 47 HCO3 Dextrose 50-100 50g/L Maintelyte 35 Paediatric 35 Maintenance Solution (PMS) Neonatalyte 5%DW &0.2% NaCl Extra-cellular fluid 20 34 142 4 5 3

15

2.5

.5

21 34

20

100 50

103 27

Replacement of ongoing losses

The child continues to vomit and you put in a nasogastric tube. It drains small bowel contents.

What electrolyte disturbances would you expect to develop if you do not replace these losses (see table on next slide )?

What type of fluid was lost?

Rough guide!! Gastric juice Bile
Na+ 60 148 K+ 10 5 Cl120 100 35 HCO3H+ 65

Pancreatic juice Small bowel drainage Diarrhoeal stools

140
110 120

5
5 25

75
105 90

80
30 45

What fluid would you use to replace these ongoing losses?

Fetch all the different vaculitres you can find from the procedure room in the ward. Compare the following with respect to content: Ringers lactate/ Hartmanns solution; 0.9% NaCl; 0.45% NaCl & 5% dextrose; Paediatric Maintenance solution; Neonatalyte; Plasmalyte; etc. Ask the nursing sister for an ampoule of potassium and see how much KCl is in one amp.

Paediatric vital signs

What is the normal urine output for a child? (ml/kg) What is the problem with using blood pressure as an indicator of haemodynamic stability in a child?
a) Inaccurate as difficult to find right size cuff b) Usually lower in children than adults, so need to know age-appropriate levels c) Drops late child as pulse rate usually increases to maintain BP until decompensation occurs d) Nurses dont routinely check blood pressure in kids

Re-evaluation: which parameters would you use to decide if the child is adequately resuscitated for surgery?
PR pulse deficit urine output pH capillary refill Lactate peripheral perfusion base deficit BP serum Na, K, Cl, Urea, level of consciousness Creatinine Haematocrit skin turgor

Case 2
6 week old infant Presents with hypertrophic pyloric stenosis

What is the usual age of presentation of HPS?

a) b) c) d) e) Any time after birth until 3 years As early as 1 week after birth in term babies Rare after 3 months of age Usually between 4-8 weeks after birth Congenital aetiology, thus child starts vomiting from birth

What biochemical picture is typical of HPS?

pH? Na? Cl? K+?

Does this abnormality develop acutely, subacutely or is it a chronic condition?

What would your initial management (resuscitation) be for this child (with HPS)?

HPS

IV line Resuscitate with 0.9% NaCl bolus (10-20ml/kg) till passing urine Then cont. resuscitation with 0.45% NaCl & 5% dextrose (adding KCl as necessary) till pH<7.5 NGT on free drainage NPO Dextrose water per os if NGT draining well

Why is 0.45% NaCl used for resuscitation in HPS?

a) It is cheaper than other fluids b) It is actually a maintenance fluid and thus not ideal for resuscitation c) The electrolyte abnormalities in HPS developed over several days (>48h) and should thus be corrected slowly to avoid rapid fluid shifts d) Extra potassium may need to be added, so rather use something like Ringers lactate

Central pontine myelinolysis

Neurologic disease caused by severe damage of the myelin sheath of nerve cells in the pons Characterized by acute paralysis, dysphagia (difficulty swallowing), and dysarthria (diffuculty speaking), and other neurological symptoms. Complication of treatment of patients with profound, lifethreatening hyponatremia (low sodium) Consequence of a rapid rise in serum tonicity following treatment in individuals with chronic, severe hyponatraemia who have made intracellular adaptations to the prevailing hypotonicity Individuals with hyponatremia should receive no more than 8-10 mmol/L of sodium per day to prevent central pontine myelinosis. From Wikipedia, the free encyclopedia

On urine dipstick:
You find this baby with HPS has a low urine-pH Is this expected? Why do you think this has happened? What is the most important extracellular ion? And intracellular ion? What are the implications for management of this urine pH?

Mechanisms of paradoxical aciduria:

1. Nasogastric suction or refractory vomiting results in loss of gastric acid. 2. Physiologic stress and hypovolemia promote renal retention of sodium and water 3. To retain sodium, the renin-angiotensin-aldosterone is activated, the kidney must release other cations (potassium and hydrogen) for exchange with Na 4. The body tries to maintain adequate potassium level as the priority, so instead of using Na/K pump in the distal tubule which would result in further loss of K, the Na/H pump is favored. Sodium is then reabsorbed as hydrogen ions are excreted, making the urine acidic. Therefore this situation aggravates the state of metabolic alkalosis.

Surgery for HPS

Does this baby necessarily need an operation?
a) No , as it is a self-limiting condition and after a few months of TPN or very thin feeds, it will resolve b) Yes; medical therapy against nitric oxide receptors is experimental only

If so, when?
a) b) c) d) Immediately (after a few saline boluses) Once the serum pH<7.5 Once the urine pH is normal Once the serum chloride >95 and s-HCO3<30

What is the name of this operation?

Case 3
Newborn with gastroschisis What extra fluid losses are expected? What is the emergency management for this condition?