Maintenance fluid calculator peds1/13/2024 ![]() ![]() Restricted Therapy Data Favoring “Restrictive” Perioperative Fluids There is essentially no role for “maintenance” IV fluids in modern fluid management – rather, fluids are given as targeted boluses when they are expected to lead to a hemodynamic improvement. A promising alternative to EDM is optimization of respiratory variation, although it is not as well validated – three recent prospective, randomized, controlled trials have suggested that optimization of respiratory variation may have the potential to improve outcomes, although it will take time to accumulate the quantity and quality of data that currently support of EDM. In fact, esophageal Doppler monitoring (EDM) was recently endorsed by the National Health Service as a rational alternative to central venous pressure monitoring in patients undergoing major surgery. Management of fluids such that stroke volume is optimized is an extremely well-validated approach that has been shown repeatedly to reduce morbidity. The reality is that fluids can be harmful, and should only be given when they are expected to produce some benefit. The modern approach to fluid management is based on the concept of goal-directed therapy (GDT), in which it is believed that interventions should be performed specifically to affect a meaningful clinical variable. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion” (Level of Evidence 1D) Modern Fluid Management For comparison, in adults, the Surviving Sepsis Guidelines (2008 version) recommend “Give fluid challenges of 1000 mL of crystalloids or 300–500 mL of colloids over 30 mins. However, the 20-40 mL/kg bolus was thought to be relatively conservative in the presence of what appeared to be septic shock and by any account these results are surprising. Criticisms of this study include a protocol change (which increased the amount of the fluid boluses) midway through the study, lack of control or documentation of fluid management after the first hour, unavailability of monitoring data, and lack of advanced hemodynamic monitoring. Mortality at 4 weeks was 12.2%, 12.0%, and 8.7%, respectively ]. The primary outcome, death at 48 hours mortality was 10.6%, 10.5%, and 7.3% in the albumin-bolus, saline-bolus, and control groups, respectively. The perils of giving critically-ill patients arbitrary amounts of fluid without advanced monitoring (see section on modern fluid management below) was recently highlighted by the FEAST Trial, which included 3141 febrile pediatric patients with impaired perfusion (defined as capillary refill > 3 seconds, a lower-limb temperature gradient, “weak” radial-pulse volume, or severe tachycardia ) and randomized them to 20-40 mL/kg of normal saline, albumin, or no bolus on hospital admission. Danger Associated with Arbitrary Fluid Administration Remember to add up lap pads (100-150 cc each) and 4x4s (10 cc each). Step 4: Adjust for Unanticipated Fluid LossesĪ common recommendation is to give 3 cc of crystalloid for every 1 cc of blood loss. Step 3: Calculate Anticipated Surgical Fluid Lossesīased on patient’s weight and anticipated tissue trauma. Step 2: Calculate Ongoing Maintenance Requirementsīased on patient’s weight, using the same 4/2/1 rule as used to calculate preoperative maintenance requirements. Estimated maintenance requirements follow the 4/2/1 rule: 4 cc/kg/hr for the first 10 kg, 2 cc/kg/hr for the second 10 kg, and 1 cc/kg/hr for every kg above 20. Simply multiply the maintenance fluid requirements (cc/hr) times the amount of time since the patient took PO intake. Step 1: Calculate Preoperative Fluid Losses Furthermore, consider titrating fluid requirements to physiologic measures (ex. Calculating Fluid Requirementsįluids must be given based on an estimation of the following – fluid losses prior to start of anesthesia, maintenance requirements, normal fluid losses that occur during surgery, and response to unanticipated fluid (blood) loss. ![]() IT IS PRESENTED HERE FOR HISTORICAL INTEREST ONLY AND IS NOT RECOMMENDED. The “Classic” (read: outdated) approach to management of fluids in the perioperative setting involved trying to predict the amount of fluids needed based on a the duration and severity of a particular operation and empirically replacing fluids based on these estimates. Approaches to Fluid Management The “Classic” Approach to Fluid Management NOTE: This content is currently being rewritten by our editors, but we have included the original article from OpenAnesthesia’s encyclopedia section before our March 2023 site update. ![]()
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