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Pediatric IV Fluid Therapy: Historical Perspective and Controversies, Lecture notes of Pediatrics

The history of intravenous therapy in children, focusing on the origins of IV fluid therapy and the debate surrounding the existence of a third space. It also discusses the risks of postoperative hyponatremia associated with IV fluid therapy. insights into historical milestones in intravenous therapy, the concept of third space losses, and the implications of perioperative fluid shift.

What you will learn

  • What were the historical milestones in the development of intravenous therapy in children?
  • What are the risks of postoperative hyponatremia associated with IV fluid therapy in children?
  • How does surgical trauma and aggressive perioperative fluid therapy impact patient outcomes?
  • Does the third space exist, or is it a myth?
  • What is the concept of third space losses in pediatric perioperative fluid therapy?

Typology: Lecture notes

2021/2022

Uploaded on 09/12/2022

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PEGGY P. MCNAULL, MD
ASSISTANT PROFESSOR, ANESTHESIOLOGY AND PEDIATRICS
UNIVERSITY OF NORTH CAROLINA
The Myth of the Third Space
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Download Pediatric IV Fluid Therapy: Historical Perspective and Controversies and more Lecture notes Pediatrics in PDF only on Docsity!

P E G G Y P. M C N A U L L , M D A S S I S T A N T P R O F E S S O R , A N E S T H E S I O L O G Y A N D P E D I A T R I C S U N I V E R S I T Y O F N O R T H C A R O L I N A

The Myth of the Third Space

Objectives

 Discuss the origins of IV fluid therapy in children

 Debate the existence of a third space

 Discuss IV fluid therapy and the risks of

postoperative hyponatremia

Intravenous therapy – a historical perspective

 1818 Blundell performed first human to human blood transfusion

 1831 O’Shaughnessy published landmark article in Lancet about fluid and solute deficits in cholera victims

 1832 Latta reported that he had successfully resuscitated numerous moribund cholera patients with intravenous water and salts

Intravenous therapy – a historical perspective

 1918 Blackfan and Maxcy instilled 0.8% saline intraperitoneally to dehydrated infants

 1931 Karelitz and Schick administered D5NS or D5LR intravenously via continuous infusion to dehydrated infants

 1957 Holliday and Segar described the first practical method for the prescription of IV fluids

The third space – fact or fiction

The third space - defined

 Refers to sequestration of fluid in a non-functional extracellular space that is beyond osmotic equilibrium with the vascular space Non-functional extracellular fluid volume (nfECV)

Functional extracellular fluid volume (fECV)

The third space – fact or fiction

Acute change in extracellular fluids associated with major surgical procedures Annals of Surgery, 1961

 13 adults, elective major surgical procedures

 Plasma volume, red blood cell mass, and extracellular

fluid volume (ECV) measured preoperatively and after

two hours of operative time

 Loss of ECV (up to 28%), presumed from internal

redistribution to the third space

 Extracellular fluid volume loss correlated with amount of

observed surgical trauma

The third space – fact or fiction

 Extracellular volume determination via tracer

technique

 Requires suitable tracer  Requires appropriate equilibration time  Requires multiple samples  Requires steady state conditions

The third space – fact or fiction

 Numerous trials report an unchanged or increased

fECV after surgery

 Utilized different tracers (i.e. Bromide)  Calculated fECV from multiple blood samples  Calculated fECV after longer equilibration times

The third space - FICTION

 The classic “third space”

has never been localized

 The classic “third space”

does not exist

 Fluid is shifted within

the functional

extracellular fluid

compartment, from the

intravascular space to the

interstitial space

Functional extracellular fluid volume (fECV)

Perioperative fluid shift - implications

Extracellular fluid volume expansion and third space sequestration at the site of small bowel anastomoses British Journal of Surgery, 1983

 Water content of enteral anastomosis measured in rabbits

 Group 1

 Received no IV fluid therapy  Interstitial water load increased by 5-10%

 Group 2

 Received 5 mL/kg/hr intraoperatively of crystalloid infusion  Interstitial water load double that of Group 1

Perioperative fluid shift - implications

 Surgical trauma increases

the protein permeability of the vascular endothelium  Mechanical stress  Endotoxin exposure  Ischemia-reperfusion injury  Inflammation

 Acute hypervolemia from

liberal fluid therapy alters the endothelial glycocalyx

Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens Annals of Surgery, 2003

  • Restricted group: significant reduction in postoperative
complications such as anastomotic leakage, pulmonary
edema, pneumonia, and wound infection

Perioperative fluid shift - implications

Postoperative hyponatremia

 Case

 10 yo male trauma patient  Intubated for respiratory distress  Peri-intubation aspiration noted  To OR for left foot ORIF  4 days mechanical ventilation for aspiration PNA  Surgical team prescribed D5 ½ NS post transfer to floor  Rapid response for acute mental status changes  Tonic-clonic seizure while in the CT scanner  Serum Na 116