Pediatric Liver Transplantation – Fluid Management.pptx

Title: Pediatric Liver Transplant Fluid Management: Strategies and Considerations

Pediatric liver transplant surgery presents unique challenges in fluid management, necessitating careful attention to resuscitation strategies, fluid boluses, choice of fluids, and assessment of fluid responsiveness. This comprehensive review delves into the why, how, what, and when of fluid management in pediatric liver transplant surgeries, highlighting key considerations for healthcare providers.

Introduction
Pediatric liver transplantation is a complex surgical procedure aimed at replacing a diseased liver with a healthy one. While advancements in surgical techniques have improved outcomes, fluid management remains a critical aspect of perioperative care. The liver's central role in regulating fluid balance and the potential for significant blood loss during surgery underscore the importance of meticulous fluid management in pediatric liver transplant patients.

Why Fluids in Resuscitation
Fluid resuscitation serves multiple purposes in pediatric liver transplant surgery. Firstly, it aims to maintain adequate tissue perfusion and oxygen delivery, particularly to vital organs, during the surgical procedure. Secondly, fluid resuscitation helps offset fluid losses resulting from surgical bleeding and third-space losses, thereby preventing hypovolemia and its associated complications. Lastly, optimal fluid management supports hemodynamic stability, reducing the risk of perioperative morbidity and mortality.

How: The Fluid Bolus
Fluid boluses are a cornerstone of resuscitative efforts in pediatric liver transplant patients. These boluses are administered rapidly to restore intravascular volume and cardiac output, particularly during periods of acute hemodynamic instability. Careful attention must be paid to the volume and rate of fluid administration to avoid complications such as fluid overload, which can exacerbate perioperative edema and compromise organ function.

What: Crystalloids and Colloids
The choice between crystalloids and colloids is a key consideration in pediatric liver transplant fluid management. Crystalloids, such as normal saline and lactated Ringer's solution, are widely used due to their availability, low cost, and ability to restore intravascular volume. However, colloids, including albumin and synthetic colloids, offer advantages such as higher oncotic pressure and may be preferred in cases of significant fluid loss or when crystalloids alone are insufficient to maintain adequate intravascular volume.

When: Fluid Responsiveness
Assessing fluid responsiveness is crucial for guiding fluid management decisions in pediatric liver transplant patients. Various clinical parameters, including heart rate, blood pressure, urine output, central venous pressure, and dynamic indices (e.g., pulse pressure variation, stroke volume variation), can be utilized to assess a patient's response to fluid therapy.

1. Pediatric Liver Transplantation – Fluid Management Karthik Ponnappan T

2. Why- Fluids in resuscitation How- The Fluid Bolus What- C rystalloids and colloids When- Fluid Responsiveness

3. Endothelial Glycocalyx Myburgh NEJM 2013

4. When?

5. Children have higher chest wall and lung compliance  The variation in intrathoracic pressure with normal tidal volume ventilation may not cause significant circulatory changes in children Children have a more compliant arterial tree than adults  PPV doesn’t work well

6. EDM The most convincing predictor was ΔVPEAK , a direct ultrasound measurement of variations in aortic blood flow induced by small reversible changes in preload due to ventilator induced changes in venous return.

7. PLR ΔCI PLR appeared to be an excellent predictor of fluid responsiveness in children

8. What? I don’t care what you use, as long as you use it carefully!”

9. The Maintenance Fluid

10. Total water needs 50mL from insensible + 66.7mL from urine = 116.7mL water needs/100kcal/day Assume water of oxidation provides 16.7mL 116.7-16.7 = 100mL/100kcal/day

11. Electrolyte Needs

12. Why ½ DNS recommended 2 mEq/100 kcal/day of both potassium and chloride and 3 mEq/100 kcal/day of sodium. These electrolyte requirements are theoretically met by the hypotonic maintenance fluid commonly used in hospitalised children by 5% dextrose (D5) with 0.45% normal saline (NS). For many decades , the fluid given to children by paediatricians was based on this concept Arya VK IJA 2012

13. preoperative deficits multiplying the hourly rate, as per 4 / 2/1 rule method, by the hours of fasting Replace half of this volume during the first hour of surgery, followed by the other half over the next 2 h.

14. Isotonic fluids and Desalination

15. Plasmalyte vs ½ NS

16. Time to Hyponatremia

17. Perioperative Glucose only in those children at greatest risk for hypoglycaemia Use fluids with lower dextrose concentrations ( 1% or 2.5%) Leelanukrom Paediatric Anaesthesia 2000

18. Perioperative Glucose The highest risk of hypoglycaemia is in neonates, children receiving hyperalimentation , and endocrinopathies , Glucose infusion at a rate of 120–300 mg/kg/h Regular Monitoring

19. Tailoring the Fluid use Frequent Monitoring  both hemodynamics AND electrolytes closely!!

20. Dissection Phase Preload crucial Watch Sodium!! Preop hyponatremia NS/Albumin/FFP can cause sudden spike of Sodium  Central Pontine Myelinolysis !!

21. Anhepatic Phase Vascular Clamping Children tolerate vena caval clamping better than adults, and less hemodynamic changes are seen

22. Reperfusion Phase Reperfusion is also less likely to result in hemodynamic changes or rhythm disturbances

23. Choice of Fluid Isotonic, buffered salt solutions  initial resuscitation fluids Consider saline  hypovolaemia and alkalosis Consider albumin  sepsis Hydroxyethyl starch should not be used in any patient population

24. Choice of Fluid Identify the fluid that is most likely to be lost and replace the fluid lost Consider serum osmolality and the acid-base status Consider cumulative fluid balance and actual body weight Consider the early use of catecholamines

25. Paediatric solution infusions ( Isolyte P, D5%+ NS 0.45 % Dangerous as boluses– Avoid Intraoperatively

26. Maintenance – Holliday Segar- 50% in critically ill kids!!

27. Maintenance – Still NS!!

28. Replacing Deficit

29. Massive Transfusions MABL = [(starting haematocrit – target haematocrit) ÷ starting haematocrit] × EBV If Target is 30% Hct , and PRBC has 70% Hct , we can simplify!! 0.5 ml PRBCs for each millilitre of blood loss beyond the MABL Barcelona SL, Thompson AA, Cote CJ. Intraoperative pediatric blood transfusion therapy: A review of common issues. Paediatr Anaesth . 2005