![]() Holiday and Segar formula is still recommended widely to calculate the deficit and maintenance fluid requirements including the APA and NICE guidelines. This has created a paradigm shift in the perioperative fluid management both for type and volume of fluid infused perioperatively for children. In the 1990s there were reports of hyponatremia induced encephalopathy secondary to hypotonic fluids infused perioperatively and stress induced ADH levels being elevated leading to cerebral edema and respiratory insufficiency. Their calculation considered the daily requirement of electrolytes like sodium requirement of 3 mmol/kg and a potassium requirement of 2 mmol/kg which had led physicians to give hypotonic fluids with 5% dextrose. Holiday and Segar published their paper “ The maintenance need for water in parentral fluid therapy” and came up with the widely used 4/2/1 principle of fluid and calorie management in 1957. The type and volume of fluid that a child receives perioperatively has been widely studied over the last 75 years. The concentrating ability is low at birth and with further water deprivation, urine concentrates to only 600–700 mOsm/kg because of hypotonicity of renal medulla.įluid therapy is as important as any other medication that a child receives in the perioperative period. The low GFR is because of decreased capillary surface area for filtration, low systemic arterial pressure, high renal vascular resistance resulting in low ultrafiltration pressure. Glomerular filtration rate (GFR) in a term neonate reaches adult levels only by two years of age. Physiologically the amount of fluid filtering outward from the arterial ends of the capillaries equals almost exactly the fluid returned to the circulation by absorption. The Starling hypothesis says that the fluid movement due to filtration across the capillary wall is dependent on the balance between the hydrostatic and the oncotic pressure gradient across the capillary wall. At equilibrium the product of molar concentration of diffusible ions on either side of membrane will equal, maintaining the electrical neutrality. By definition Donnan effect states that when a semipermeable membrane separates a solution of non-diffusible ions from another solution of diffusible ions, equilibrium is attained with unequal distribution of diffusible ions across the semipermeable membrane due to presence of proteins. The distribution of content (fluid and ions) in ECF and ICF compartment is controlled by the Donnan effect and Starling forces. Interstitial fluid has lower proteins but otherwise has a composition equivalent to ICF. Intracellular compartment predominantly consists of potassium (K), magnesium (Mg), proteins, and phosphates. ![]() ![]() Sodium (Na +) is the primary cation and chloride (Cl -) the major anion in plasma which is part of extracellular compartment. The Intracellular fluid accounts for two-thirds of body water and around 24 weeks gestation, close 80% of total body weight of the fetus is made up of water, which reduces to around 60% at the age of one year of age and in adults it is between 50% and 60%. We performed a PUBMED search for articles using keywords including ‘children’, ‘intravenous fluid therapy’, ‘crystalloids’, ‘colloids’, ‘fluid homeostasis’, ‘blood loss’, ‘estimation of blood loss’, ‘blood loss management’, ‘perioperative fluid ‘ to get our source articles.ĭistribution of Body water in a 30 kg child This review is an attempt to provide a historical perspective and current evidence-based approach to peri-operative pediatric fluid management. Recently, there has been a lot of debate about this concept, especially as there are serious concerns regarding the development of complications like hyponatremia and hyperglycemia, both of which can result in neurological damage or even mortality in a sick child. Anesthetists have always followed pediatric maintenance fluid calculations based on Holiday and Segar formula based on studies conducted on healthy children more than 70 years ago. In perioperative setup, the fluid is administered to meet fluid deficits (fasting, and other daily based losses), blood losses and third space losses. Pediatric population is heterogeneous so one formula may not suffice and hence both the quantitative and qualitative perspective of fluid management should be based on physiology and pathology of the child along with their perioperative needs. Appropriate fluid management is vital for adequate tissue perfusion and balancing the internal milieu especially in perioperative settings and critically ill children.
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