Calculation formula 4.2.1 for infusion therapy. Solutions for administration
| CHILDREN'S AGE | WEIGHT IN KG | TOTAL FLUID REQUIREMENT | |
| PER DAY (ML) | PER 1 KG OF WEIGHT | ||
| 3 days | 3,0 | 250 — 300 | 80 – 100 |
| 10 days | 3,2 | 400 — 500 | 125 – 150 |
| 3 months | 5,4 | 750 — 850 | 140 – 160 |
| 6 months | 7,3 | 950 — 1100 | 130 – 155 |
| 9 months | 8,6 | 1100 — 1250 | 125 – 145 |
| 1 year | 9,5 | 1300 — 1500 | 120 – 135 |
| 2 years | 11,8 | 1350 — 1500 | 115 – 125 |
| 4 years | 16,2 | 1600 — 1800 | 100 – 110 |
| 6 years | 20,0 | 1800 — 2000 | 90 – 100 |
| 10 years | 28,7 | 2000 — 2500 | 70 – 80 |
| 14 years | 45,0 | 2200 — 2700 | 40 — 50 |
The constancy of water-electrolyte metabolism is maintained by osmotic and oncotic pressure. Osmotic pressure in the extracellular space is provided mainly by sodium and chlorine, in the intracellular space by potassium, oncotic pressure created in the vascular bed and in the cell is supported by proteins.
The main electrolytes of the cell are potassium, calcium, magnesium; the extracellular space predominantly contains sodium and chlorine.
Sodium (normal – 135 – 155 mmol/l in plasma) is the main ion on which the osmotic pressure of the internal environment depends.
Potassium (norm – 3.5 – 6.5 mmol/l in plasma) is indispensable in performing intracellular functions. It is involved in protein and carbohydrate metabolism and in neuromuscular conduction. In the cell membrane there is a potassium-sodium pump, which pushes sodium ions out of the cell in exchange for potassium ions carried into the cell. The rhythm of operation of this pump strictly depends on the energy potential of the cell.
BCC in an adult is 70 ml/kg or 5–8% of body weight; in infants this figure varies from 75 to 110 ml/kg, averaging 10–12% of body weight.
Ensuring the balance of water-electrolyte metabolism is a complex neurohumoral mechanism, which involves:
- central nervous system
- endocrine system, kidneys, skin, gastrointestinal tract, other organs.
The state of osmotic pressure is controlled osmo receptors,- and oncotic - by volume receptors, which transmit information to the central nervous system about the state of osmotic pressure and tissue hydration, fluctuations in bcc.
Osmo- and volumetric receptors are located in the vessels, interstitial space, in the form of islands in the right atrium and the cranium.
In the area of the hypothalamus there is a center for thirst and antidiuresis, the latter is associated with the posterior lobe of the pituitary gland, where the antidiuretic hormone (ADH) - vasopressin - is produced. ADH controls isotonia by conserving water volume; aldosterone - by regulating salt concentration.
Already with a loss of 1.5 - 2% of water, osmotic hypertension develops as a result of which:
- there is an immediate release of water from the tissues
- the thirst center is stimulated
- impulses from osmoreceptors enter the antidiuretic center of the hypothalamic region, and ADH secretion increases, diuresis decreases
This is the body’s stereotypical reaction to any increase in the osmotic pressure of the extracellular fluid. As a result, salts are diluted and isotonicity is restored.
On the other hand, a decrease in BCC during hypovolemia is perceived by receptors that, through the system renin-angiotensin leads to vasoconstructions and stimulation of secretion aldosterone– hormone of the adrenal cortex. Vasospasm causes a decrease in fluid filtration. Aldosterone promotes reabsorption sodium in the renal tubules and potassium excretion. As a result, blood osmolarity increases, water is retained in the body, and hypovolemia decreases. Internal environment returns to isotonia. Excess water causes inhibition of aldosterone secretion. This results in decreased sodium reabsorption and increased excretion of sodium and water. In turn, a decrease in sodium concentration in the blood inhibits the secretion of ADH - excess water is released.
The lability of water-electrolyte metabolism, the predominance of extracellular fluid and its rapid loss, high permeability of renal vessels in infants for a number of other reasons explains the ease of dehydration.
Infusion therapy is a therapeutic method consisting in the parenteral introduction into the patient’s body of the necessary components of vital activity, distributed in the aqueous phase. Infusion-transfusion therapy (Isakov Yu. F., Mikhelson V. A., Shtatnov M. K. 1985)
Indications for infusion therapy Reimbursement of blood volume Improvement of tissue perfusion Reimbursement of fluid deficiency during dehydration Maintaining physiological needs Reimbursement of losses (bleeding, burns, diarrhea) Forced diuresis during exotoxicosis Support during surgery Transfusion of blood components Nutritional support (TPN, PPN) (Mensach IVECCS, 2005)
- transfusion therapy - transfusion of blood products - infusion therapy - administration of simple and complex solutions, synthetic drugs, emulsions and PP preparations
Processes that determine approaches to infusion therapy (Isakov Yu. F., Mikhelson V. A., Shtatnov M. K., 1985) Water content in the body as a whole Characteristics of the body’s water spaces State of exchange of water and electrolytes between the body and the external environment State of interspatial water exchange
Water spaces of the body (classification by J. S. Edelman, J. Leibman 1959) Intracellular fluid (space) Extracellular fluid (space) ï intravascular ï intercellular fluid (actually interstitial) ï transcellular fluid - water in the secretions of the gastrointestinal tract, digestive and other glands, urine, cerebrospinal fluid, fluid from the eye cavity, discharge from serous membranes, synovial fluid Infusion therapy and parenteral nutrition
Third space An abstract sector in which fluid is sequestered from both the extracellular and intracellular spaces. Temporarily, the fluid of this space is not available for exchange, which leads to clinical manifestations of fluid deficiency in the corresponding sectors
Third space Intestinal contents with intestinal paresis Edema fluid with ascites, exudate with peritonitis Soft tissue swelling with a burn Traumatic surgical interventions (evaporation from the surface)
Third space The volume of the third space cannot be reduced by limiting the administration of fluids and salts. On the contrary, to maintain an adequate level of hydrobalance (intracellular and extracellular fluid), infusion is required in a volume exceeding the physiological need
TYPES OF SEMI-PERMEABLE MEMBRANES The fluid sectors of the body are separated from each other by a selectively permeable membrane through which water and some substrates dissolved in it move. 1. Cell membranes, which consist of lipids and proteins and separate intracellular and interstitial fluid. 2. Capillary membranes separate intravascular fluid from transcellular fluid. 3. Epithelial membranes, which are the epithelium of the mucous membranes of the stomach, intestines, synovial membranes and renal tubules. Epithelial membranes separate interstitial and intravascular fluid from transcellular fluid.
Changes in the water content in the body depending on age (Friis., 1957, Groer M.W. 1981) Age The proportion of fluid in body weight, % Premature. newborn 80 Full-term newborn 1 -10 days 1 -3 months 6 -12 months 1 -2 years 2 -3 years 3 -5 years 5 -10 years 10 -16 years 75 74 79, 3 70 60 60, 4 58, 7 63 5 62, 2 61, 5 58
Relative values water content in the extra- and intracellular space in children of various ages(Friis N.V., 1951) age 0 -1 day 1 -10 days 1 -3 months 3 -6 months 6 -12 months 1 -2 years 2 -3 years 3 -5 years 5 -10 years 10 -16 years ECF content, % 43, 9 39, 7 32, 2 30, 1 27, 4 25, 6 25. 7 21, 4 22 18. 7 ICF content, % 35, 1 34, 4 40, 1 40 33 33, 1 36, 8 40, 8 39 39, 3
Physiology of water balance Osmolality - the number of osmotically active particles in 1000 g of water in solution (unit of measurement - mOsm/kg) Osmolarity - the number of osmotically active particles per unit volume of solution (unit of measurement - mOsm/l) Infusion therapy and parenteral nutrition
PLASMA OSMOLALITY True normoosmia - 285 ± 5 mOsm/kg H 2 O Compensated normoosmolality - from 280 to 310 mOsm/kg H 2 O Colloid-oncotic pressure from 18 to 25 mm. rt. Art.
Hydration and osmolarity disorders: GENERAL RULES Everything always starts with the extracellular sector! It also determines the type of osmolarity disorder. It also determines the overall fluid balance. He is the leader, and the cell is the slave sector! Osmolarity inside the cell is considered normal! Osmolarity losses are the opposite of the total! Water moves towards higher osmolarity. Dehydration does not exclude edema!
Need for intravenous fluid in children 20 kg 1500 ml + (20 ml/kg for each kg over 20 kg) Weight 10 12 14 1 6 18 20 30 35 40 50 60 70 ml/h ac 40 45 50 5 5 60 65 70 75 80 90 95 100
Fluid requirement in children 0 -10 kg = 4 ml/kg/hour 11 -20 kg = 40 ml/hour + 2 ml/kg/over 10 20 -40 kg = 60 ml/hour +1 ml/kg/over 20 FP (ml/kg/day) = 100 – (3*age (year) Vallachi formula
Choice of vascular access Peripheral veins – infusion requirement 1-3 days; no need to administer hyperosmolar solutions Central vein– the need for infusion for 3 days or more; Parenteral nutrition; Administration of hyperosmolar solutions Intraosseous needle - Antishock therapy
Emergency fluid replacement Ø A bolus is performed in phase 1 of volume resuscitation Saline solution Na. Cl or Ringer's Lactate In a volume of 10 -20 ml/kg over 30 minutes Ø A repeated bolus of fluid may be required until hemodynamic stabilization
Albumin vs Phys. solution There are no significant differences: Mortality Time of hospitalization in the intensive care unit Time of hospitalization in the hospital Duration of mechanical ventilation Therefore... we use crystalloids
How big is the deficit? Fluid deficit = weight before illness (kg) - actual weight % dehydration = (weight before illness - actual weight) weight before illness x 100%
signs Loss of body weight (%) Liquid deficiency. (ml/kg) Vital signs Pulse BP Breathing Children under 1 year Skin - color - cold - capillary refill (sec) Over 1 year mild 5 50 moderate 10 100 severe 15 150 N N N Thirst, restlessness, anxiety rapid From N to low Deep To same, or lethargy Very frequent, threads. Shock Deep and frequent drowsiness to coma, lethargy, sweating. pale Down from the middle of the forearm/shin 3 -4 grayish From the middle of the forearm/thigh 4 -5 spotted Whole limb Same as above Usually coma, cyanosis 5 Skin turgor Anterior fontanel N N The same, and postural hypertension is reduced Sunken Eyeballs N Sunken Tears Yes +/- Significantly reduced Significantly sunken Significantly sunken Absent Mucous Under the armpit Urine Diuresis (ml/kg/hour) Spec. density Acidosis Wet Yes Dry no Very dry no ↓ 2 1,020 - ↓ 1 1.020 -1,030 +/- ↓ 0.5 1,030 + Increased blood urea nitrogen - + ++
Calculation of infusion for 24 hours 1 -8 hours - 50% of the calculated volume 8 -24 hours - 50% of the calculated volume Resuscitation fluid is not included in the total volume
signs Iso Hyper Serum Na (mol/l) 130 -150 ↓ 130 150 and N Osmolarity N ↓N N Avg. Volume er. (MCV)N N N or ↓N Average in er-ts. (MSN)N ↓N N Consciousness Lethargy Coma/convulsions. Thirst Moderate Weak Excitability/judgment Strong Skin turgor Poor Adequate Palpable skin Dry Very poor Sticky Skin temperature N Low Increased Mucous membranes Dry Sticky Tachycardia ++ ++ + Hypotension ++ + Oligouria ++ + History Loss through the gastrointestinal tract and kidneys, blood loss, plasma loss. Deficiency or loss of salts Deficiency or loss of water Dense doughy
Is hematocrit relevant? Yes! For isotonic disorders No! For hypo or hypertensive disorders
Isoosmolar dehydration Calculation of fluid deficiency: Eliminating the cause! Volume replacement with isotonic media (Na.Cl 0.9%, Sterofundin) Control by Ht is possible
Hyperosmolar dehydration Water deficiency Hyperventilation Profuse sweat Hypo- or isosthenuria Danger of damage to the central nervous system (rupture of perforating veins, subdural hematoma)
Hyperosmolar dehydration Calculation of free water deficiency is inaccurate: Elimination of the cause! Replenish the deficiency with 0.45% Na. Cl or 5% glucose “Titration” of the effect is necessary!
Hyperosmolar dehydration Starting solution Ringer-Lactate / saline. solution Monitor Na level every 2-4 hours – Proper rate of Na reduction 0.5 -1 mmol/l/hour (10 mmol/l/day) – Do not reduce more than 15 mmol/l/day If Na is not corrected: – Go to ratio 5% glucose/physical. solution 1/4 Sodium is not corrected – Calculation of total body water deficit (TBWD) TBWD = 4 ml/kg x weight x (patient’s sodium - 145) – Reimbursement of fluid deficiency within 48 hours Glucose 5%/sodium chloride 0.9% 1 /2
Hypoosmolar dehydration Calculation of Na+ deficiency is unreliable: Elimination of the cause! Replenishment of Na+ deficiency 5.85% or 7.2% Na. Cl + KCl Caution: pontine myelinolysis! Monitor Na every 2 hours. The rate of increase in Na is not more than 2 mmol/l/hour
Hyponatremic seizures Increase sodium level by 5 mmol/l by administering 6 ml/kg 3% Na. Cl – Inject 3% Na. Cl (0.5 mEq Na.Cl/ml) IV over 1 hour – Administer 3% Na. Cl at a rate of 6 ml/kg/hour until the seizures are relieved. Seizures occur as a result of cerebral edema. It is possible to use Na. HCO 3 8% 1 ml/kg
Hypoosmolar overhydration Heart failure Excess hypotonic solutions Pain (via ADH) Syndrome of inappropriate ADH secretion (SIADH)
Composition of infusion therapy -Izoosmolar dehydration with glucose-salt in a ratio of 1/1 -1/2 -Hypo-osmolar dehydration with glucose-salt in a ratio of 1/2-1/4 (up to some saline solutions) -Hyperosmolar dehydration with glucose-salt in a ratio of 2: 1 (up to the infusion of one 5 -10% Glucose under sugar control, with possible application insulin
Fluid Load Mode (FLR) FLR = FP + PP FLR is the primary rehydration regimen in most cases. Pathological losses (PP) 1. Obvious losses are measured by compensation. 1: 1 (vomiting, discharge through a tube, stool, etc.) 2. Fever +10 ml/kg/day for every degree 10 above normal. 3. Shortness of breath +10 ml/kg/day for every 10 breaths. above normal! 4. Paresis 1st degree. -10 ml/kg/day. 2 tbsp. -20 ml/kg/day; 3 tbsp. -30 ml/kg/day. 5. Phototherapy 10 ml/kg/day.
Fluid loading regime (LNG) Volume of infusion therapy according to the degree of dehydration (Denis’s table) age I degree III wall 0 – 3 months 200 ml/kg 220 -240 ml/kg 250 -300 ml/kg 3 – 6 months 170 -180 200 - 220 220 -250 6 – 12 months 150 -170 170 -200 200 -220 1 – 3 years 130 -150 Up to 170 Up to 200 3 – 5 years 110 -130 Up to 150 Up to 180
Fluid load mode (RLG) RGG = 1.7 FP + PP 1.7 FP = 1.0 FP+ 0.7 daily diuresis (on average 70% of FP) Indications - toxicosis of various origins Contraindications to RGG - Age up to 1 year (high tissue hydrophilicity, immaturity of systems for removing excess fluid) - Renal and postrenal acute renal failure - Prerenal cardiogenic acute renal failure - Heart failure - Cerebral edema
Fluid load mode (RLG) Hyperhydration mode for acute poisoning Mild degree - if possible, enteral load, enterosorption. If it is not possible, the method of forced diuresis (FD) = 7.5 ml/kg/hour for no more than 4 hours with a transition to physical. need. Moderate degree - PD = 10 -15 ml/kg/hour Severe degree - PD = 15 -20 ml/kg/hour Composition: polyionic solutions, saline. solution, Ringer solution, 10% glucose solution
Fluid load mode (RDG) RDG = 2/3 – 1/3 of RNG Indications: -Heart failure (SSN-1 st. 2/3 from RNG; SSN-2 st. 1/2 from RNG; SSN-3 st. 1/3) - Cerebral edema (2/3 from RNG to the full volume of RNG with stabilization of hemodynamics to maintain ICP.) - Acute pneumonia, RDS (from 1/3 to 2/3 AF) - Renal, postrenal and cardiogenic prerenal acute renal failure (1/3 AF + diuresis correction every 6 -8 hours.)
Correction of protein-electrolyte and metabolic disorders Electrolyte content in mmol preparations 1 g Na. Cl 1 g KCl 1 g Ca. Cl 2 1 g Mq. SO 4 Electrolyte content in mmol 17.2 mmol Na 13.4 mmol K 2.3 mol Ca 4.5 mmol Ca 4.0 mmol Mq Correction of decompensated met. acidosis. Volume of 4% soda (ml) = BE x weight/2 It is used only if the ability and function of breathing to compensate is preserved.
Perioperative Fluid Therapy Goal: Maintain fluid and electrolyte balance Correction of hypovolemia Ensuring adequate tissue perfusion
Perioperative Fluid Therapy Pediatrics 1957 Recommended 5% glucose/0.2% Na. Cl for basic infusion therapy Based on the amount of human milk electrolytes
First publication – 16 healthy children – All underwent elective surgery – Severe Hyponatremia and Brain Edema death/permanent neurological impairment – All received Hypotonic Hyponatremic solution
. . . Oct. 1, 2006 The risk of developing hyponatremia after receiving hypotonic solutions is 17.2 times greater Prescribing hypotonic solutions is not reliable/harmful
Perioperative fluid therapy National Guidelines 2007 (UK GOVERNMENT SAFETY AGENCY) 4% glucose solution and 0.18% sodium chloride solution should not be used in routine practice Intra- and postoperatively use only isotonic solutions
Intraoperative Fluid Therapy - ECF Tonicity Na & Cl Bicarbonate, Ca, K – Lactated Ringer – Phys. Solution (Normal saline) Na (154) Large quantities- hyperchloremic metabolic acidosis - without complications (adults)
Intraoperative fluid therapy - glucose Hypoglycemia Stress hormones Autoregulation cerebral blood flow(300%) Transition to the Krebs cycle with disruption of homeostasis Hyperglycemia Autoregulation of cerebral blood flow Mortality (3 -6) Osmotic diuresis
Control randomized blind studies of LR with 0.9% or 1% dextrose Without hypoglycemia 1 hour after surgery Glucose level at the end of surgery increased (stress) Norm in the group without dextrose
Intraoperative fluid therapy - Glucose Phys. solution (0.3% and 0.4%) and dextrose (5% and 2.5%) Hongnat J. M., et al. Evaluation of current pediatric guidelines for fluid therapy using two different dextrose hydrating solutions. Paediatr. Anaesth. 1991: 1: 95 -100 Lactated Ringer and dextrose (1% and 2.5%) Dubois M. C. Lactated Ringer with 1% dextrose: an appropriate solution for peri-operative fluid therapy in children. Paediatr. Anaesth. 1992; 2: 99 -104 1. Less concentrated solutions With high content dextrose - greater risk of hyperglycemia and hyponatremia 2. Optimum-Lactated Ringer and dextrose 1%
Recommendations Crystalloids - solution of choice D 5% 0.45 Na. Cl, D 5% 33 Na. CL…. should not be used routinely in healthy children LR - with low risk of hypoglycemia LR 1% - solution for hypo/hyperglycemia
Polyionique B 66 and B 26 Composition (mmol/l) Lactated Polyionique B 66 Ringer Polyionique B 26 Na 130 120 68 K 4. 0 4. 2 27 Ca 1. 5 2. 8 0 Cl 109 108. 3 95 Lactate 28 20. 7 0 Dextrose 0 50. 5 277 > 3 years Add. I/O losses; HP and younger age P/O Normovolemia
Recommendations (France) Polyionique B 66 - for routine intraoperative fluid therapy in children - Reduces the risk of severe hyponatremia - % glucose - a compromise solution to prevent hypo/hyperglycemia
Recommendations Crystalloids are the solution of choice Short operations (myringotomy, ...) – No need Operations 1 -2 hours – 5 -10 ml/kg + blood loss ml/kg Long complex operations – Rule 4 -2 -1 – 10 -20 ml/kg LR/physical solution + blood loss
Perioperative fluid therapy Number of hours of fasting x hourly exercise. need – 50% - 1st hour – 25% - 2nd hour – 25% - 3rd hour Furman E., Anesthesiology 1975; 42: 187 -193
Intraoperative fluid therapy - Volume Recommendations according to age and severity of injury 1st hour – 25 ml/kg ≤ 3 years, 15 ml/kg ≥ 4 years Further time (Physical requirement 4 ml/kg/hour + injury) – Mild - 6 ml/kg/h – Moderate - 8 ml/kg/h – Severe -10 ml/kg/h + blood loss Berry F., ed. Anesthetic Management of Difficult and Routine Pediatric Patients. , pp. 107 -135. (1986). ,
Intraoperative fluid therapy - Tonicity Isotonic transfer of fluid from the ECF to the non-functional 3rd space >50 ml/kg/h - NEC in premature infants § IVF § ECF 1 ml/kg/h - minor operations fetus NR 4 -6 months 15 -20 ml /kg/chabdominal
Recommendations Dependence on surgical trauma Minimum 3 -5 ml/kg/h Moderate 5 -10 ml/kg/h Large 8 -20 ml/kg/h
Blood loss Calculation of the maximum permissible volume of blood loss MDOC = Weight (kg) x BCC (ml/kg) x (Ht out – 25) Ht medium Ht out – initial hematocrit; Ht avg – average of Ht ref and 25%. Circulating blood volume: Premature newborn 90 – 100 ml/kg; Full-term newborn 80 – 90 ml/kg; Children
Infusion therapy For small losses, isotonic crystalloids (Ringer, 0.9% Na. Cl, sterofundin) For large losses in the third space, a deficiency of bcc, plasma substitutes (HES, gelofusin) 10 -20 ml/kg are included in the IT composition. If blood loss is > 20% (in newborns > 10%) of the blood volume, blood transfusion is performed. For blood loss > 30% of blood volume, FFP is included in the composition
Indications for infusion therapy in children with burns Damage to more than 10% of the body surface area Age up to 2 years
Emergency measures Liquid Volemic load up to 20 -30 ml/kg/hour Control: diuresis, blood pressure, level of consciousness
Parkland formula In the first 24 hours V=4 x body weight x % burn Ringer-Lactate solution, Sterofundin, Ionosteril 50% in the first 8 hours 50% in the next 16 hours
Composition of infusion therapy: Saline solutions (ringer, sterofundin, 0.9% Na. Cl) + plasma expanders. 10% Albumin is prescribed when the albumin fraction in the blood decreases to less than 25 g/l. PSZ: Fibrinogen up to 0.8 g/l; PTI less than 60%; Prolongation of TV or APTT by more than 1.8 times the control
Colloids vs Crystalloids Isotonic solutions of crystalloids Require a lot, easily pass from the third space to the intravascular Colloids can be prescribed on the second day of therapy, when capillary permeability decreases - will not go into edema Perel P, Roberts I, Pearson M. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2007, Issue 4
Signs of adequate fluid load Decreased tachycardia Warm, pink skin outside the burn surface (SBP 2 -2.5 sec) Diuresis not less than 1 ml/kg/hour Normal indicators R. H, BE +/-2
Hemorrhagic shock Develops as a result of blood loss associated with injury, surgery, gastrointestinal bleeding, hemolysis; Determining the volume of blood loss is difficult due to the small volume of blood volume; The clinical symptoms of shock are mild (pallor, cold sweat, tachycardia, tachypnea) and appear when the loss of blood volume is > 20 – 25%; Newborns compensate for hypovolemia worse - a 10% decrease in blood volume leads to a decrease in LV SV, without an increase in heart rate. Hb. F
Objectives of ITT for blood loss Restoration and maintenance of blood volume; Stabilization of hemodynamics and central venous pressure; Normalization of rheology and blood microcirculation; Restoration of WWTP and VEB; Restoration of coagulation factor deficiency; Restoring the oxygen transport function of the blood.
Tactics intensive care For blood loss of 15 - 20% of the volume of blood volume, only saline solutions; Blood loss of more than 20 - 25% of the volume of blood volume is accompanied by SLN and symptoms of hypovolemic shock and is compensated with saline solutions, plasma substitutes (gelofusin, HES), erythromass; If blood loss exceeds 30–40% of the blood volume, FFP 10–15 ml/kg is included in the IT program. These recommendations are indicative only. In a specific clinical situation it is necessary to focus on blood pressure, central venous pressure, red blood cell indicators Hb, Ht, coagulogram.
Principles of blood transfusion therapy in children The main document regulating the use of blood components in children is order No. 363; The basic principles of blood transfusions are not fundamentally different from those in adult patients, except for the neonatal period;
Transfusion of erythrocyte-containing components. The main goal is to restore the oxygen transport function of the blood as a result of a decrease in the number of red blood cells. Indications. Acute anemia due to developed bleeding due to injuries, surgical operations, diseases of the gastrointestinal tract. Blood transfusion is indicated when acute blood loss> 20% bcc. Nutritional anemia, occurring in severe form and associated with deficiency of iron, vitamin B 12, folic acid; Anemia, with depression of hematopoiesis (hemoblastosis, aplastic syndrome, acute and chronic leukemia, renal failure, etc.), leading to hypoxemia. Anemia due to hemoglobinopathy (thalassemia, sickle cell anemia). Hemolytic anemia (autoimmune, HUS)
Transfusion of erythrocyte-containing components. In the presence of anemia not associated with o. blood loss, the solution to the issue is based on the following factors: 1. The presence of signs of hypoxemia (shortness of breath, tachycardia) and tissue hypoxia (lactate, metabolic acidosis); 2. The child has cardiopulmonary pathology; 3. Ineffectiveness of conservative therapy methods. Indications in the presence of tissue hypoxia Hb
Normal Hb values At birth 140 - 240 g/l 3 months 80 -140 g/l 6 months-6 years 100 -140 g/l 7 -12 years 110 -160 g/l Adults 115 -180 g/l Anaesth Intensive Care Med. 2012; 13:20 -27
Indications for blood transfusion Up to 4 months less than 120 g/l for premature or full-term infants with anemia; 110 g/l for children with chronic oxygen dependence; 120 -140 g/l for severe lung pathology; 70 g/l for late anemia in stable children; 120 g/l for acute blood loss of more than 10% of the blood volume. Anaesth Intensive Care Med. 2012; 13:20 -27
Indications for blood transfusion Over 4 months 70 g/l for stable children; 70 -80 g/l for critically ill children; 80 g/l for perioperative bleeding; 90 g/l for blue heart defects; Thalassemia (with insufficient activity bone marrow) 90 g/l. Hemolytic anemia 70 -90 g/l or more than 90 g/l during a crisis. For surgical interventions 90 -110 g/l. The amount of pathological Hb is no more than 30% and less than 20% in thoracic neurosurgery Anaesth Intensive Care Med. 2012; 13:20 -27
Reduce blood transfusions Maximize hemoglobin Acute normovolemic hemodilution Prevention of high venous pressure Use tourniquets where possible Surgical technique(diathermy, adhesives) Hypervolemic hemodilution Tranexamic acid Use of Cellsavers Anaesth Intensive Care Med. 2012; 13:20 -27
Indications for PSZ transfusion: DIC syndrome; acute massive blood loss of more than 30% of the circulating blood volume with the development hemorrhagic shock; liver diseases accompanied by a decrease in the production of plasma coagulation factors, if there is bleeding, or before surgery; burn disease accompanied by plasma loss and DIC syndrome; exchange plasmapheresis. Coagulogram: - when fibrinogen decreases to 0.8 g/l; - when the PTI decreases to less than 60%; - when the TV or APTT is prolonged by more than 1.8 times the control.
Features of PSZ transfusion. PSZ dose 10 – 15 ml/kg; For DIC with hemorrhagic syndrome, 20 ml/kg; About liver diseases with a decrease in the level of coagulation factors and bleeding 15 ml/kg, followed by repeated transfusion h/w 4 - 8 hours 5 - 10 ml/kg; Preparation of PSZ in a defrost T 37 o. C After defrosting d.b. used within an hour.
Transfusion of platelet concentrate. Platelets less than 5 x 109 l with or without bleeding and bleeding; Platelets less than 20 x 109 l if the patient has a septic condition, disseminated intravascular coagulation; Platelets less than 50 x 109 l with severe hemorrhagic syndrome, the need for surgery or other invasive diagnostic procedures. Platelets less than 10 x 109 l in patients with acute leukemia during chemotherapy. Prophylactic transfusion of platelet concentrate with deep thrombocytopenia (20 -30 x 109/l) of amegakaryocytic nature without signs of spontaneous bleeding is indicated in the presence of sepsis against the background of agranulocytosis and disseminated intravascular coagulation.
Transfusion of platelet concentrate with increased destruction of platelets of immune origin is not indicated. In case of thrombocytopathies, transfusion of platelet concentrate is indicated only in urgent situations - in case of massive bleeding, operations.
Blood transfusion therapy in newborns. In the neonatal period, anemia is predisposed by: 1. Anatomical and physiological features: Change of Hb synthesis from fetal to adult; Short cycle life of an erythrocyte (12 – 70 days); Low erythropoietin levels; Red blood cells have reduced filterability (increased destruction). 2. Prematurity (more than low performance red blood and more severe development anemia); 3. Iatrogenic anemia due to repeated blood sampling for research.
Indications. at birth Ht 10% of bcc (↓ SV without heart rate); in the presence of clinical signs severe anemia– hypoxemia (tachycardia > 180 and/or tachypnea > 80) or more high rates Ht.
Rules for blood transfusions in newborns: All transfusions in newborns are considered massive. Only filtered or washed red blood cells are transfused according to individual selection. The rate of red blood cell transfusion is 2-5 ml/kg body weight per hour under mandatory monitoring of hemodynamics and respiration. For rapid transfusions (0.5 ml/kg body weight per minute), it is necessary to pre-warm the erythromass. ABO testing is performed only on the recipient's red blood cells, using anti-A and anti-B reagents, since natural antibodies are usually not detected at an early age. For HDN caused by anti-D antibodies, only Rh is transfused - negative blood. If the pathogenic antibodies are not anti-D antibodies, the newborn can be transfused with Rh-positive blood.
See Also – Pediatric Dehydration Replace Phase 1 Acute Resuscitation – Give LR OR NS at 10 -20 ml/kg IV over 30 -60 minutes – May repeat bolus until circulation stable Calculate 24 hour maintenance requirements – Formula First 10 kg: 4 cc/kg /hour (100 cc/kg/24 hours) Second 10 kg: 2 cc/kg/hour (50 cc/kg/24 hours) Remainder: 1 cc/kg/hour (20 cc/kg/24 hours) – Example: 35 Kilogram Child Hourly: 40 cc/h + 20 cc/h + 15 cc/h = 75 cc/hour Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day Calculate Deficit (See Pediatric Dehydration) – Mild Dehydration: 4% deficit (40 ml/kg) – Moderate Dehydration: 8% deficit (80 ml/kg) – Severe Dehydration: 12% deficit (120 ml/kg) Calculate remaining deficit – Subtract fluid resucitation given in Phase 1 Calculate Replacement over 24 hours – First 8 hours: 50% Deficit + Maintenance – Next 16 hours: 50% Deficit + Maintenance Determine Serum Sodium Concentration – Pediatric Hypertonic Dehydration (Serum Sodium > 150) – Pediatric Isotonic Dehydration – Pediatric Hypotonic Dehydration (Serum Sodium
All doctors and printed publications talk about the benefits of water for the human body, but few people specify how much water we need for a normal life.
Quite often, parents are faced with two opposite situations: the child drinks a lot of water - and the child drinks almost no water. Mothers of such children are concerned about this problem and begin to limit their water consumption or, conversely, try to force them to drink. So where is she? golden mean“And how much water should a child drink?
To begin with, it is worth noting that we include ordinary water as water - spring, bottled, boiled, filtered, etc. Juices, compotes, sweet water, carbonated drinks, milkshakes, fruit drinks, tea, herbal decoctions, infusions - do not belong to the concept of “water”.
What is the best water to give to a child?
Proper drinking water is essential for normal height and child development, must comply with the hygienic standards set out in SanPiN No. 2.1.4.1116-02. Definitely, the water that flows from the tap in the apartment is unlikely to meet these standards and should not be given to children to drink. If you have a well or borehole, this water may be more suitable for drinking. But to find out, take the water samples to the laboratory, where they will test special study and they will give you professional opinion. It is best to give children bottled drinking water. This water must be labeled "water highest category"or "baby water".
Requirements for “baby water”:
Balanced mineral composition. Remember, the amount of salts and their concentration in baby water is much lower than in regular water.
Should not contain preservatives, including carbon dioxide and silver, microorganisms.
Baby water should not be treated with chemicals.
Child water consumption standards
Consumption rates depend on the child’s age, nutrition, lifestyle, and time of year. It must be remembered that water enters the child’s body not only with clean water, but also with porridge, soup, vegetables and fruits.
Children under one year old
Located only on breastfeeding, do not need water (WHO recommendations). If the child is bottle-fed or complementary foods are introduced, then the child needs to be supplemented with 100-150 ml of water per day. In the hot season or at elevated body temperatures, the volume of water can be increased, provided that the baby drinks it and does not spit it out. As soon as it appears in the diet solid food, then the child must be given water at the rate of: child’s weight X 50 ml – volume of liquid food (soup or milk) X 0.75.
For example, your baby weighs 10 kg and eats 300 ml of milk per day:
1. 10 kg. X 50ml. =500 ml.
2. 300 ml. X 0.75=225ml.
3. 500ml. – 225ml. =275 ml.
225 ml is the amount of water that your baby should drink per day.
Children from one to 3 years old
At this age, children can already walk, run and actively play outdoor games. Therefore, at this age the amount of water required reaches 800 ml. Don't forget that all children are different. If your child prefers to stand next to you and watch other children play rather than participate, then 500 ml per day may be enough for him. But if your child runs actively, then the need for water may increase to 1.5 liters.
Water should be drunk strictly between meals, 20 minutes before meals or 20 minutes after. It is not recommended to drink water with food, as this will worsen the digestion process.
Children from 3 to 7 years old
The consumption rate at this age will be from 1.5 to 1.7 liters. The normal limits may vary depending on the child’s activity and gender.
Children over 7 years old should drink water at the adult norm - 1.7-2 liters. We increase the amount of water if the child plays sports or is sick.
The method of administering fluid depends on the severity of the child’s condition. Not the entire calculated volume of daily fluid requirements is administered parenterally; the other part of the fluid is given per os.
At I degree exicosis, oral rehydration and, if necessary, infusion therapy in a volume of no more than 1/3 of the patient’s daily fluid requirements are used. The need for IT arises if it is not possible to feed the child, and signs of toxicosis with exicosis increase.
At II degree exicosis is indicated for IT in an amount of no more than 1/2 depending on the patient’s daily fluid needs. The amount of liquid missing from daily requirements is given per os.
At IIIdegrees exicosis is indicated for IT in a volume of no more than 2/3 of the patient’s daily fluid requirements.
Types of solutions
The following types of solutions are used for infusion therapy:
« Aqueous solutions - 5% and 10% glucose. 5% glucose solution is isotonic, leaves quickly vascular bed and gets inside the cell, so its use is indicated for intracellular dehydration. A 10% glucose solution is hyperosmolar, due to which it has a volemic effect, in addition, it has a detoxification effect. The use of 10% glucose requires the addition of insulin at the rate of 1 unit per 50 ml of 10% glucose. ^ y
Crystalloids, saline solutions - Ringer's solution, disol, trteol, quadrasol, lactosol, saline. They quickly leave the vascular bed, moving into the interstitial space, which can cause edema in children in the first months of life who have an unstable Na* balance. younger child, the smaller the volume of saline solutions is introduced, which is reflected in the table. 3. For children in the first months of life, saline solutions are administered in a volume of no more than 1/3 of the volume of IT. Single dosage no more than 10 ml/kg per day.
In practice, Ringer-Locke solution is often used; it contains 9 g of sodium chloride, 0.2 g of calcium chloride, potassium chloride, sodium bicarbonate, 1 g of glucose, and water for injection up to 1 liter. This solution is more physiological than isotonic sodium chloride solution.
ъГ/ig ■/&&-/£&"
/O /i-G"(?£> /1&f£> C> * /*£s)
Colloidal solutions medium molecular weight - infucol, reopolyglucin,
reogluman, reomacrodex, rondex, volecam, plasma, gelatinol, 10%
albumen. L ^/Н^сР y £ -
/(/ g V,
Low molecular weight (hemodez, polydes) and high molecular weight (polyUlyukin)
Colloids are used very rarely for exicosis in children.
Colloidal solutions usually make up no more than 1/3 of the total volume of IT.
It is recommended to use infucol HES, a 2nd generation hydroxyethylstarch preparation. It causes the transition of fluid from the interstitial space to the intravascular space, binds and retains water in the bloodstream, thereby ensuring a long-term volemic effect (up to 6 hours). Has no age restrictions. Available in the form of 6% and 10% solutions.
A 6% solution is prescribed at a dose of 10-20 ml/kg per day, up to a maximum of 33 ml/kg.
A 10% solution is prescribed at a dose of 8-15 ml/kg per day, up to a maximum of 20 ml/kg.
Among the new drugs, reamberin should be noted. It has detoxification, antihypoxic effects, and has a slight diuretic effect. Available as a 1.5% solution in bottles of 200 and 400 ml. It is administered to children at a dose of 10 ml/kg intravenously at a rate of no more than 60 drops per minute, once a day, for a course of 2-10 days.
Solutions for parenteral nutrition - infezol, lipofundin, intralipid, alvesin, aminon. They are rarely used for exicosis in children.
Table 3
The ratio of aqueous and colloidal-saline solutions used for infusion therapy, depending on the type of exicosis.
Example. When calculating using the first method, the patient’s daily fluid requirements are 9 months. equal to 1760 ml. With exicosis of the second degree, the volume of IT will be 1/2 of this amount, i.e. 880 ml. We will give the remaining 880 ml to the child per os in the form of rehydron, raisin decoction, kefir. Let’s say that, according to the conditions of the problem, the child has an isotonic type of exicosis. We choose the ratio of aqueous and colloidal-saline solutions 1:1, then from 880 ml we take 440 ml of 5% glucose
(aqueous solution), 280 ml of rheopolyglucin (colloid - no more than 1/3 of the total volume of IT) and 160 ml of Ringer's solution (saline solution).
When carrying out IT, the injected solutions are divided into portions volume 100-150 ml depending on the age of the patient. The younger the child, the smaller the volume of a single serving.
During IT, you should alternate portions of aqueous and colloidal saline solutions - this is the “layer cake” rule.
Selecting a starting solution
Determined by the type of dehydration. In water-deficient exicosis, 5% glucose is administered first; in other types of exicosis, IT most often begins with a colloidal solution, sometimes with saline.
Example. 440 ml of 5% glucose can be divided into 4 servings (14i, 100,100 ^ and 100 ml); 280 ml of rheopolyglucin - for 2 servings of 140 ml; 160 ml of Ringer's solution - for 2 servings of 80 ml. The starting solution is rheopolyglucin.
serving - reopolyglucin 140 ml
serving - 5% glucose 140 ml
serving - 5% glucose 100 ml
serving - rheopolyglucin 140 ml
serving - 5% glucose 100 ml
portion - Ringer's solution 80 ml
serving - 5% glucose 100 ml
Using corrector solutions
In infusion therapy, corrector solutions are used, which include, first of all, various electrolyte supplements. For IT, daily allowances must be provided physiological needs child in them, and the identified deficit was compensated (Table 4).
Typical clinical manifestations hypokalemia are weakness of the muscles of the limbs and trunk, weakness respiratory muscles, areflexia, bloating, intestinal paresis Hypokalemia contributes to a decrease in the concentrating ability of the kidneys, resulting in the development of polyuria and polydipsia. The ECG shows a decrease in the voltage of the T wave, a U wave is recorded, the S-T segment moves below the isoline, and the Q-T interval lengthens. Severe hypokalemia leads to expansion of the QRS complex, the development of various types of heart rhythm disturbances, atrial fibrillation, and cardiac arrest in systole.
Needs for K+ children early age are 2-3 mmol/kg per day, over 3 years - 1-2 mmol/kg per day. In practice, a 7.5% solution of KS1 is used, 1 ml of which contains 1 mmol K+, less often 4% KS1, the K+ content of which is approximately 2 times less.
Rules for administering K+ solutions:
they must be administered in a concentration of no more than 1%, i.e. A 7.5% solution of KS1 should be diluted approximately 8 times;
jet and fast drip administration Potassium solutions are strictly prohibited, as they can cause hyperkalemia and cardiac arrest. It is recommended to administer potassium solutions intravenously slowly at a rate of no more than 30 drops/min, i.e. no more than 0.5 mmol/kg per hour;
administration of K+ is contraindicated for oliguria and anuria;
Example calculating the introduction of K+. If a child weighs 8 kg, his daily requirement for K+ is 2 mmol/kg x 8 kg = 16 mmol, which is 16 ml of a 7.5% KS1 solution. You can divide these 16 ml into 4 parts of 4 ml and add to IT portions containing 5% glucose.
K+def. = (K+normal - K+patient) x 2t.
where m is mass in kg,
K - coefficient, which for newborns is 2, for children under 1 year - 3,
for children 2-3 years old - 4, over 5 years old - 5.
In isotonic and salt-deficient exicosis, K+ deficiency can be calculated by the hematocrit value:
K+def. = Htnorm -Htsick x sch/5,
YuO-Ht norm
where Ht norm is the hematocrit of a healthy child of the appropriate age (%). In newborns this is an average of 55%, at 1-2 months. - 45%, at 3 months. - 3 years - 35% (see appendix).
Expressed hypocalcemia manifested by disturbances in neuromuscular excitability, cardiac activity and convulsions.
Ca+ requirements average 0.5 mmol/kg per day. In practice, a 10% calcium chloride solution is used, 1 ml of which contains 1 mmol Ca+, or a 10% solution of calcium gluconate, 1 ml of which contains 0.25 mmol Ca+. Calcium gluconate can be administered intravenously or intramuscularly, calcium chloride - only intravenously (!).
Example calculating the introduction of Ca+. If a child weighs 8 kg, his daily requirement for Ca+ is 0.5 mmol/kg x 8 kg = 4 mmol, which is 16 ml
10% calcium gluconate solution. You can divide these 16 ml into 4 parts of 4 ml and add to IT portions containing 5% glucose.
Needs forMg+ are 0.2-0.4 mmol/kg per day. A 25% solution of magnesium sulfate is used, 1 ml of which contains 1 mmol Mg+.
Example calculating the introduction of Mg+. If a child weighs 8 kg, his daily requirement is Mg+ is 0.2 mmol/kg x 8 kg = 1.6 mmol, which is 1.6 ml of a 25% magnesium sulfate solution. You can divide 1.6 ml into 2 parts according to
8 ml and add to 2 and 6 servings of IT containing 5% glucose.
Correction of sodium and chlorine is not carried out additionally, because all intravenous solutions contain these electrolytes.
Distribution of administered solutions during the day
The following treatment periods are distinguished:
emergency rehydration phase - the first 1-2 hours;
final elimination of the existing deficiency of water and electrolytes - 3-24 hours;
maintenance detoxification therapy with correction of ongoing pathological losses.
In case of compensated exicosis, infusion solutions are administered over approximately 2-6 hours, in case of decompensated exicosis - over 6-8 hours.
Fluid injection rate determined by the severity of dehydration and the age of the patient.
In severe cases, forced fluid administration is used in the first 2-4 hours of IT, then slow, with an even distribution of the entire volume of fluid throughout the day. In case of hypovolemic shock, the first 100-150 ml of solution is administered slowly in a stream.
Injection rate = V / 3t,
where V is the volume of IT, expressed in ml,
t - time in hours, but not more than 20 hours per day.
The rate of fluid administration calculated in this way is expressed in drops/min, in the absence of a correction factor of 3 in the formula - in ml/hour.
Table 5
Approximate rate of fluid administration during infusion therapy, drops/min.
|
Introduction liquids | ||||
|
newborn | ||||
|
Forced | ||||
|
Slow | ||||
It is safe to administer up to 80-100 ml/hour for children under 3 months. - up to 50 ml/hour (10 drops/min).
IT in newborns requires special care and careful monitoring. The rate of intravenous fluid administration in case of exicosis of the first degree is usually 6-7 drops/min (30-40 ml/hour), in case of exicosis of the second degree
8-10 drops/min (40-50 ml/hour), III degree - 9-10 drops/min (50-60 ml/hour).
1 ml of aqueous solutions contains 20 drops, which means that an injection rate of 10 drops/min will correspond to 0.5 ml/min or 30 ml/hour; 20 drops/min - 60 ml/hour. Colloidal solutions are introduced at a rate approximately 1.5 times slower than aqueous ones.
IT Adequacy Assessment should be based on the dynamics of symptoms of dehydration, the condition of the skin and mucous membranes (moisture, color), the function of the cardiovascular system and other clinical manifestations of exicosis. Monitoring is also carried out by control weighings (every 6-8 hours), measuring pulse, blood pressure, central venous pressure (normally 2-8 cm water column or
196 - 0.784 kPa), average hourly diuresis, relative density of urine (the norm here is 1010-1015), hematocrit.
The adequacy of the qualitative composition of solutions for IT is monitored by indicators of acid-base status, concentration of electrolytes in blood plasma and urine.
Calculation of the amount of liquid for parenteral administration should be based on the following indicators for each individual child:
Physiological needs (Table 3.1).
Table 3.1. Daily requirement children in liquid (norm)
|
Correction of fluid deficiency in the body - calculation of the deficiency is based on clinical and laboratory indicators.
Compensation for additional pathological losses, which are divided into 3 categories:
1) insensible fluid loss through the skin and lungs; increase with fever: for every 1 °C - by 12%, which in recalculation means an increase in the total volume of fluid by an average of 10 ml/kg of weight for every 1 °C of increased temperature (Table 3.2). Note that it is better to correct increased perspiration during shortness of breath with the help of adequate humidification and warming of the respiratory mixture (microclimate);
2) losses from the gastrointestinal tract (GIT); if it is impossible to measure the volume of fluid that a child loses through vomiting, it is assumed that these losses per day are 20 ml/kg;
3) pathological sequestration of fluid into distended intestinal loops.
Let's reverse Special attention that during infusion therapy one should always strive to administer to the child as much fluid as possible per os; parenteral administration is resorted to only when
Notes: 1. During infusion, the difference between normal and pathological conditions is filled. 2. When body temperature rises above 37 °C, add 10 ml/kg for each degree to the calculated volume.
lack of such a possibility. This is especially true for young children, when it is necessary to decide on the prescription of infusion therapy for exicosis of various etiologies (Table
3.3). We should also not forget that there are a number of conditions when it is necessary to limit the physiological needs of the body for fluid. They will be discussed in special sections, but here we will only mention such as renal failure in the oliguria stage, heart failure, and severe pneumonia.
| Table 3.3. Fluid distribution depending on the degree of exicosis |
In general, it should be noted that when determining the volume of infusion therapy, it is necessary to draw up a program for its use. It should be carried out according to the “step by step” principle, with each stage not exceeding 6-8 hours and ending with monitoring of the most important indicators. First, this should be an emergency correction of disorders, for example, restoring the deficit of blood volume, restoring the deficit in fluid volume, the content of the most important electrolytes, protein, etc. Following this, infusion therapy, if necessary, is carried out in a maintenance mode with the correction of persistent disturbances of homeostasis. Specific schemes depend on the variants of the leading pathological syndrome.
Methods of infusion therapy
Currently, the only way to carry out infusion therapy can be considered the intravenous route of administration of various solutions. Subcutaneous injections of fluids are not currently used; intra-arterial injection is used only when special indications, and intraosseous administration of various medications and solutions today can only be used in emergency situations (in particular, during resuscitation measures and the impossibility of intravenous administration of drugs).
Most often in pediatrics, puncture and catheterization of peripheral veins are used. For this, the veins of the elbow and the dorsum of the hand are usually used. In newborns and children under 1 year of age, the saphenous veins of the head can be used. Venous puncture is carried out using a regular needle (in this case there are problems with its fixation) or a special “butterfly” needle, which is easily fixed to the child’s skin.
More often they resort not to puncture, but to puncture catheterization of peripheral veins. Its implementation has been significantly simplified with the advent of special catheters placed on a needle (Venflon, Brownyulya, etc.). These catheters are made of special thermoplastic materials that practically do not cause a reaction on the part of the vessel wall, and the existing sizes allow them to be administered to children from the neonatal period.
