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REQUIREMENTS FOR SPECIFIC LOSSES

1. Nasogastric output is best replaced with D5 0.9NS + 20mEqKCl/L. It does not adversely affect the infant to provide more dextrose and simplifies nursing care.
2. Intestinal losses beyond the pylorus (even diarrhea) are replaced with LR
3. Third space losses are generally repleted by using saline or LR boluses, i.e. preop hydration for appendicitis.

Postop fluids are chosen and calculated to anticipate ongoing losses and can be dealt with in a number of ways. One of the easiest is to use D5LR at rates to provide between 100-150% maintenance volume for the first 8-12 postop hours(overnight) and then to switch to D50.45 NS with 20mEqKCL at maintenance. Another option is provide the maintenance solution and a supplemental solution (LR) concurrently at 150% maintenance rate with each providing 50% of the volume. In a more critically ill child the bolus solution is then already hanging and can be used promptly.

Example: 14 month old, 12-kg child s/p operative reduction of intussusception after multiple hydrostatic trials at reduction.

Maintenance volume/day = 1000 + (2 x 50) = 1100ml/d

150% maintenance = 1650 ml/d = 68ml/hr

Alternative 1: D₅LR @ 68ml/hr

Alternative 2: D₅ 0.45NS + 20mEqKCl/L @ 34ml/hr plus LR @ 34ml/hr

Alternative 3: D₅ 0.45NS + 20mEqKCl/L @ 68ml/hr

for the first 24 hours, then adjust back to the maintenance fluid and rate.

Note: when LR is used as a potential bolusing fluid there is no glucose, but when it provides the only source of electrolytes it must also provide a baseline glucose source.

Remember: Normal saline is not normal or physiologic – it provides an excessively high load of chloride to the child that may affect the acid/base status. In the acute resuscitation, it can certainly be used safely, but postoperatively we prefer LR.

Tip for success (safety): Rewrite the exact fluid orders desired every morning on rounds along with a notation alongside as to how many ml/kg/day are provided in total. The caloric provision if enteral feedings or TPN are being used, can be written next to it. Examples to follow.

Blood Product replacement:

Transfusion usually is provided as component therapy rather than whole blood.

In the critical care setting Packed Red Blood Cells(PRBC) and Fresh Frozen Plasma (FFP) is usually

administered in increments of 10cc/kg

Platelets are usually ordered as 10-30cc/kg and can be concentrated if there are volume restrictions (decreases function of platelets)

25% Albumin is used for severe hypoalbuminemia (serum value <2mg/L)

volume/bolus = 4ml/kg (1 gram/kg)

When transfusing PRBCs for correction of severe anemia it is usually safe to start with 15ml/kg over 3-4 hours and to ask the blood bank to save volume from the same unit for an eventual repeat transfusion if goals are not met, thus minimizing donor exposure.

Consents for transfusion must be obtained from the parent or guardian.

Specific requests for infants, immunosuppressed heme/onc patients, potential transplant candidates.

CMV negative/safe

Radiated

donor directed blood.

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