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Hi Linda. Good afternoon. Bye. Uh Yes. Uh Linda, do you want to uh just share your screen and see that we can uh push your slides forward and backward? So um uh it's just asking uh it's just asking me to change my system preferences. Let me just see. I'm just gonna quickly um log out and log back in again. Ok. No problem. Right. Yeah, I can see. Uh yeah, to see if you can go forward and backward. That's all. Yeah, that's, that looks good. Yes. So if you can uh stop sharing screen, I have a couple of slides to control you um at the beginning and uh Linda, I'm on leave. So I'm a uh arranging the meeting from home. So that's why I'm just keeping my video off. No problem. Yeah, and we'll start uh just exactly after five. Ok. Ok. Thank you. Ok. Uh We have just about 78 minutes so we'll just wait for people to join Linda. Can you see my first light? Yes, I can. Ok. Thank you another couple of minutes. Then we start. Mhm. And Linda you're happy for us to record the beating and then share the recording on various learning platforms. Yes, that's perfect. Ok. Ok. Good afternoon. Good evening, maybe. Good morning if you are joining from somewhere else and welcome to the Zoom Academic meeting of the Department of pediatric Surgery. And uh today we are really um happy and, and grateful that Doctor Linda Rimer is going to speak to us about fluid management in critically ill pediatric, mainly focusing on surgical patients. So just to, to introduce Doctor Rimer, uh Doctor Rimmer grew up in a small mining town named Carlton on the highfield up country. She did metric at the National School of Arts in Johannesburg and specialized in music, playing flute and piano. That's very interesting uh career. And then she did BSC in Human genetics, MB CB from the University of Pretoria and uh trained as a pediatrician in Red Cross uh um in Cape Town. Um then subspecialized in pediatric critical care for two years each at Red Cross Children's Hospital in Cape Town and at the prestigious hospital for sick Children in Toronto, Canada. She has passion to use her knowledge and skills to empower resource constrained healthcare systems. And uh we are really glad that she is working in our seriously resource constrained pediatric intensive care at hospital in East London since uh October 2022. And she runs the pediatric intensive care and we really work together uh very well as a team and she's the boss in PICU and we appreciate it Linda and Personal Life Loves a good murder mystery, a true crime series. She likes to travel to bake and good meals. I think most of us would uh share some similar hobbies and likings. She taught herself how to crochet on youtube and when she's at home, she spends time with her rescue cats, we and flower and tries to keep plants alive. I think all, all things will resonate with most of us. So, Linda, uh we stop sharing and thank you for sharing your knowledge uh and expertise with us. So you start sharing and then start your talk. OK. Can, can you all see my slides? Yeah. Uh We can see so we can hear you. Well, you can go ahead. Thank you. OK. OK. All right. So, um I entitled this lecture, Fluid Management in Critically Ill Children, um concepts and uh consideration. Uh I think there's someone that needs to be muted. Um concepts and considerations when prescribing IV fluids and I will focus on some specific surgical conditions. But um the majority of the talk is um some of it will be stuff that you've known, you know, already and some of the concepts might be relatively new. Um But it's really just about updating you on the latest evidence of fluids um giving you uh the, the knowledge and the tools for when you prescribe fluids um knowing the pitfalls involved. Oh OK. So in the last few years, there has been a, a lot of tension been focused on how we manage fluid in patients in the hospital. Um And as you can see in this editorial by Stuart Goldstein, uh pediatric nephrologist, um we need to start thinking of fluid as a drug and drugs have side effects and complications. And um to quote William Osler, the person who takes medication must recover twice, once from the disease and once from the medicine. Um and in fluid management, there really is no one size fits all recipe. Uh There are concepts and uh it's an evolving picture and it requires frequent reviewing. Um And as I said, every patient is slightly different. Uh and this has been the case since all the way back in 1832 almost 200 years ago in an editorial that was published in the lancet um regarding management of cholera cases and the different fluid regimens that were used and they spoke of the mass of the profession is unable to decide and thus, instead of any uniform mode of treatment, every town and village has its different system or systems. So, like I said, in the beginning, the aim is not to give you a recipe but rather to go through the physiology of fluids. So um that you have the tools to prescribe more efficiently. Um I'm gonna talk about some prescribing principles, complications of fluids, um Pathological considerations in sick Children, which fluid to give, how much to give duration and de escalation. And then I've also um added in a little bit about albumin infusions and also fluid management in burns patients. So, uh starting with prescription, we're thinking of fluid as a drug. We think of the four days of drug prescription. Um What is the drug? What is the dose? What is the duration? And when do we deescalate? And the four indications for prescribing fluids are resuscitation, maintenance, replacement and nutrition. So, complications of fluid therapy, uh you have your local complications which relates to drip side cannulas, um Thrombo phlebitis, extravasation, injuries and septicemia. And then your more systemic complications like electrolyte arrangements, acid base disturbances, hyperglycemia and fluid overload. And I'm gonna spend a little bit of time talking about these um three of these concepts. So the first one is electrolyte derangements and I've used um a case a CO2 case studies to illustrate this. So this was uh three case studies that were published out of the United States in 1994. Um uh in, in all three patients, there was iatrogenic hypernatremia caused following a pretty standard pediatric tonsillectomy. So in the first case, a ten-year-old girl who weighed 37 kg came in for a tonsillectomy postoperatively. She complained of headache and vomiting at 16 hours POSTOP. She started having seizures at 20 hours POSTOP. She had a respiratory arrest and was intubated and at the time her sodium was 100 and 15 millimoles per liter. Subsequently, she was declared brain dead. Going back through her notes, they found that she had been given uh maintenance fluid of 5% dextrose, 0.2% sodium chloride, which is very similar to pediatric maintenance solution. Uh if you still have that in your wards um and basically gives you a sodium concentration of 34 millimoles per liter. And she was prescribed this at 100 mils per hour, which works out to 100 and 50% of her maintenance. The second case is a six-year-old girl, 20 kg Ts and A's and grommets postoperatively had a seizure, fixed and dilated pupils at the time. The sodium was 100 and 22 millimoles per liter and she was declared brain dead as well. Her fluid management, the volumes were not clear from the records, but she also received the same hypotonic maintenance fluid in the ward. So what are the chances that you can cause iatrogenic hyponatremia? Um Looking at four uh studies. Uh First of all, Hannah et al out of Michigan published in 2010, they looked specifically at a gastroenteritis cohort managed with hypertonic solution and found that 20%. Um so one out of every five Children developed mild hyponatremia. Um Radnet et al in India in 2022 did a randomized controlled trial um in Children between the ages of three months and 12 years and they randomized them to either receive maintenance, fluids of either uh 0.45% sodium or 0.9%. And they demonstrate a statistically significant higher incidence of hyponatremia at 12 hours and 24 hours in the hypotonic group. Velasco in Spain between 2010 and 2013, looked specifically at pediatric ICU patients who were under 15 years. It was a retrospective study and looked at hypertonic versus isotonic fluids. Um and again, in patients, 41% incidence of hypernatremia with hypertonic fluids and 19% with isotonic fluids. And then lastly, uh Torres, uh it's all in Argentina, uh looked at patients between 29 days and 15 years old. In both pediatric ICU and general wards, it was a randomized controlled trial, double blinded and compared 0.45% versus 0.9% saline and found that there was almost four times risk of developing hyponatremia if the patients were managed with hypotonic fluid. The second complication is a little bit more complex. So I'm gonna use a couple of illustrations um but fluids can cause acid base changes. Um And to understand why there are essentially two theories on how acid base status works in the body. Uh The one that we are the most familiar with is Henderson Hasselbach and the PH HP K A um equation. But then there is a second one known as Stuart's Strong Iron theory. And basically Stuart says that the anions and the cas need to balance in solution in the body. So what does this mean. So electron neutrality must be maintained. So the cations and the anions need to balance out ie the columns must be the same height. Um The predominant cations in uh the blood are potassium and sodium and the predominant anions are bicarbonate and chloride with albumin and other acids like lactate making up a small um amount of them. So this based so to illustrate this, if I bolus myself with a liter of normal saline, now what's basically going to be happening is because I'm only giving sodium and chloride, the sodium in my blood is going to increase concentration and to buffer that um the potassium is going to be shifted intracellularly. Um On the anion side, sodium chloride, the chloride uh concentration is going to increase. And in order to buffer that um the bicarb is going to be reduced. And this reduction in bicarb is what drives something that we call a hyperchloremic metabolic acidosis. The third complication to mention is fluid overload. So, fluid overload is associated with prolonged ventilation, increased length of stay and increased mortality. Um And in a study by Diaz, et all published in the journal of critical care in 2017, they showed that in Children, a fluid overload of 10 to 20% by weight is independently associated with death. And if you think of a child, 10% of 5 kg is just being fluid overloaded by 500 mils. And then of course, there are pathological processes in sick Children that influence fluid therapy. And the first one I think is the most relevant to you as pediatric surgeons. And that is the predisposition to develop SS I A DH. So si A DH we know um can also be stimulated by non osmotic um factors, um pneumonia and C NS infections. So, meningitis, but also things like pain, nausea and being in the postoperative phase can um trigger it like inappropriate uh ADH secretion which obviously causes you to retain water. Um an acute kidney injury, which we often are dealing with when we have critically ill Children of all kinds, uh obviously predisposes to fluid overload and then capillary leak um means that our fluid is sitting in the wrong place. So let's go back to the four Ds and we'll start with which drug and fluid. So the decisions you have to make here is am I gonna give a crystalloid or a colloid? Am I gonna give isotonic versus hypotonic? Am I gonna give a balanced versus an unbalanced? And why am I giving it? Am I resuscitating? Am I doing maintenance therapy or am I replacing? So, let's quickly walk through some of the fluids, the main fluids that we use um in this table, I've got a comparison of 0.9% saline ringers, lactate and plasmalyte. And then I've also got the normal serum blood values um in the second column. So looking at 0.9% saline. So it's relatively cheap nine rand a liter. It's not really um isotonic, it's actually a little bit hypertonic. So the sodium is 100 and 54 and the chloride is 100 and 54. And what I want you to note here is that the sodium is relatively close to normal, but the chloride is very high um compared to normal se chloride. The next to are ringers and plasma lights, we'll talk a little bit about these uh in more detail just now. But um ringers also relatively cheap nine rand a liter. Whereas plasmalyte is um more than 20 rand a liter. Um plasmalyte is what we have at the hospital at the moment. Um And then you can see they're both much more physiological in terms of their sodium and chloride. Um And they've got a little bit of extra in them. So ringers has got some potassium and some calcium um and plasmalyte um has got some magnesium and then they have the buffer, which I'll talk a bit about later. Uh In ringers, it's lactate and in plasmalyte, it can be various compounds, hypertonic fluids that we use commonly. So, neonatal neonatal 0.45% saline and half DD. Um So you can see compared to normal serum values. Um uh neonatal has got virtually no sodium in it. Um potassium free neonatal is just sodium chloride and dextrose. Um But uh normal neonatal has got a whole bunch of other stuff. Uh potassium, calcium, magnesium phosphate and lactate. 0.45% saline is exactly half of 0.9. So 77 and 77 and then half DD uh really um sort of uh biochemically looks a bit like 0.45% saline with um 5% dextrose added some lactate and potassium and some potassium. So which one am I gonna use for resuscitation? You're only gonna use isotonic solutions and that you should remember from your medical school days. So you can use 0.9% normal um sodium chloride or you can use Rayna or plasmalyte um for maintenance and rehydration. Um So previously, uh people were, people would use um hypertonic solutions for maintenance and rehydration. But as illustrated in the case studies earlier, there's now actually a push towards avoiding erogenic hyponatremia and using an isotonic fluid um with some potassium if you need it and a bit of glucose. Um oh sorry, something just popped up here. Can you see that? There we go, see it sorted. I sorted it out. OK. So what do I mean when I talk about balanced versus unbalanced solutions? So this basically refers to there being an an an and buffer in the solution. So in an unbalanced solution, the sodium and the chloride balance each other out, right? Um But in a balanced solution because you're now using less chloride, you need a second, an iron to buffer the positive um cations in the solution. And these are um things like lactates, um acetate gluconate uh and balanced solutions are biochemically much more physiological um predominantly because of the chloride concentration in them. So, in the ICU world, we refer to 0.9% sodium chloride as abnormal saline because it's really not normal saline. Um there's too much chloride which predisposes you to developing a hyperchloremic metabolic acidosis. And we know that high chloride concentrations cause renal vasoconstriction, decrease renal blood flow and decrease the G fr which predisposes us to fluid overload. But what is the evidence? Uh in this editorial um uh sums up pretty much uh exactly what the situation is. So based solely on the latest evidence, it is hard, um it is hard to strongly argue for uh a practice change from normal saline to balanced fluids. But when you combine the interpretation of the evidence with the physiological advantages of balanced fluids, we advocate for the expanded use and consideration of balanced fluids in patients. All right. What about the dose? Uh So, in resuscitation. So, hypovolemic shock is pretty much give until you can get the hemorrhage under control and you can restore circulating volume. It's not difficult. Uh but then sepsis, it gets a little bit more complicated. So, in 2002, we had the surviving sepsis guidelines published. And at that stage, they were advocating um 20 mil per kg up to 60 mil per kg of fluid boluses for septic shock. And then in 2011 along came the pies trial. Now, for those of you who are not aware of the PT trial, um this was a randomized controlled trial that uh took place in Tanzania, Kenya and Uganda. It was um uh it's uh enrolled febrile Children who were admitted with impaired perfusion and it divided them up into three groups. The first two received a bolus of 20 to 40 mils per kg of either 5% albumin or 0.9% saline. And the second group received no fluid bolus. And just uh I think probably about six months before the end of the trial, the ethics committee actually told them to stop because they um found that mortality was higher in Children who received any fluid boilers regardless of whether it was albumin or um uh 0.9% saline compared with those Children who received no boluses and were just um started on maintenance. And so in 2020 the surviving sepsis, fluid resuscitation guidelines were changed. Um And now it depends on whether you live in a high resource or a low resource environment. Um essentially with access to PQ and ventilation or with no access in a high resource environment. They still recommend bolusing 40 to 60 mils per kg in the first hour. But in a low resource environment, if the patient is normotensive, they recommend no bolus. And if they are hypertensive to give 10 to 20 mil per kg, boluses up to 40 mil per kg and then to stop, um, moving on to maintenance. So, calculating maintenance, fluid requirements, I think a lot of you will be familiar with the holidays a rule which we still use. Um, uh, after it was um, founded, well, probably about 75 years ago. Um, so these were using, using healthy Children, um, holiday and sa uh worked out estimates of insensible losses and urine output for Children. Um At that stage, it was only used in Children over 28 days, but some people um use it from two weeks and it's essentially the 421 rule. So 4 mg per kg per hour for the 1st 10 kg, two per kg for the next 10, 1 per kg for anything after that. And what a lot of people don't actually know is we cap it at 80 mils per hour. So in adults, they won't receive more than 80 mils per hour of fluid unless they're on some kind of rehydration regimen. So for example, if you have a 6 kg, six months old, you're gonna give six times four mils. So 24 mils an hour, a 12 kg, 18 months old for the 1st 10 kg, uh you're gonna give four mils per kg. So that's 40 mils. And then for the second uh two K Gs, you're gonna give 22 mils per kg, which works out to four mils per hour. So in total 44 mils per hour and for a 50 kg twelve-year-old, um you're gonna give so 40 for the 1st 1020 for the 2nd 10 and then 30 times one for the remaining kilos, which gives you 90 mils per hour. But because we cap it at 80 that's where we would stop. The big question really is, is 100% maintenance appropriate. Um So there are patients where we actively fluid restrict and then there are patients where we are actively giving liberal fluid. So we are fluid restrict um patients who are predisposed to fluid overload and that includes your pneumonia sepsis and any of your postoperative patients. Um where we want to actively avoid fluid overload is in burns, patients with neurological injury and um cerebral edema and patients with hypernatremia where we don't want to dilute the sodium out too quickly. When do we give liberal fluid? So when there's intravascular depletion such as in gastro bowel obstruction, polyuria and burns in the 1st 24 hours and sometimes we actively overhydrate our patients such as when we anticipate tumor lysis syndrome or in patients with um uh a crush injury with rhabdomyolysis. The caveat to overhydration is that it must be accompanied by adequate um excretion. So if your child is not, is not passing as much urine as you are, would like them to, then you need to actively um diara them to get that fluid off them because obviously, if you don't, you're gonna sit with a fluid overload problem and then the last two duration and deescalation. So, fluid management is a frequent reevaluation and that can be clinical and it can also be biochemical, but it is a fluid process and it's changing during the day, every day um and then deescalating. So um the best maintenance fluid is food, uh enteral feeding, we know is better than parenteral feeding. You are far less likely to overload a patient by using um the enteral route. And actually um the uh European Society for Pediatric gastroenterology um and nutrition even recommends ng rehydration over IV for gastroenteritis. And that was in their last guidelines in 2014. Ok. On to a little bit more surgical specifics. So what about albumin? So we use albumin as a nutritional marker, but you can actually die of starvation and still have a normal albumin. And uh we know this because of anorexia and nervosa patients who very often have a normal albumin. And then we u it is a negative inflammatory marker and that is basically because of a combination of decreased synthesis, increased losses from transcapillary leak and dilution by crystalloids that are given as boluses. So two situations where you might consider using albumin is in resuscitation for decreased intravascular volume. And there we would use a four or a 5% solution. Um And when we are replacing severely low albumin, we would use a more concentrated solution. So what are the current recommendations? Um These were published in the chest journal in March 2024 and I've pulled out the pediatric one specifically. Um So this was from the International Collaboration for transfusion guidelines, uh the Albumin Group. So their recommendations were in pediatric patients with infection and hyperperfusion. Essentially shock septic shock, intravenous women is not recommended. Um in preterm infants with low serum albumin levels and respiratory distress, intravenous albumin is again not suggested. And in preterm infants uh with or without hyperperfusion intravenous, um albumin is not suggested for volume replacement in the pediatric 2020 surviving sepsis guidelines. They also have a statement um saying we suggest using crystalloids rather than albumin in the initial resuscitation of Children with septic shock. Um uh that is a moderate quality of evidence. But what about hyper hyperalbuminemia? So causes of a low albumin. Um It can be redistribution such as in inflammation and capillary leak. It can be from dilution, um from fluid overload. Um It can be nutrition or metabolic. Uh you can have decreased synthesis such as in liver failure or increased losses such as in protein losing enteropathy or nephrotic um or renal conditions. Um Alison, it's all um in a very nice review on the topic basically, uh summarizes it nicely. Um We reiterate there is no treatment for hypoalbuminemia per se therapeutic options must be directed towards the cause. Um And so that's pretty much uh my approach to a low albumin. However, there is one situation where I use it and it's recom well, I mean, there's evidence that it works and that is when I have a patient who has a very low albumin, all their fluid is sitting outside of their intravascular volume and I need to get fluid off. Um then I use a combination of 25% albumin and a Lasix infusion um to di to try and promote better diuresis. And in a systematic review and meta analysis published in 2021 they concluded that the coadministration of albumin Lasix did increase the urine output by 34 mil per hour. Um And that was statistically significant and then lastly burns fluid management, I'm sure um there are people who can give much more specialized talks about this. But um the two concepts. So the problem with burns is that if you under resuscitate them, they have hypervolemia, they have tissue ischemia, they land up with multiorgan dysfunction. But if they're over resuscitated, they land up with this concept of fluid creep, um which predisposes them to prolong respiratory support or ventilation. Um It can cause abdominal compartment syndrome. It has been shown to increase intraocular pressures and some patients have suffered blindness as a result and also it can cause significant tissue edema which can increase the depth of the initial injury. Now, what is fluid creep? Um it occurs when patients require more fluids than are predicted by the standard formulas and I know there are many formulas out there at the moment. It's been reported in between 30 90% of patients and the incidence increases with size. And the at risk patients are those who have received high fluid resuscitation volumes for the 1st 8 to 12 hours. Um The pathophysiology of this is that in the 1st 8 to 12 hours, which is the blue circles, uh you have after a burn injury, you have virtual total capillary permeability. And so not only have you got fluid leaking into the extravascular space, but you've also got large protein molecule that cross over. And once those large protein molecules cross over, they sit there and they generate an osmotic pool extravascularly. And so after about 12 hours, when your capillary permeability starts to improve, you have this tissue oncotic pool which still continues to um pull fluid into the extravascular face. This gives you a relative intravascular hypovolemia and you have patients that got higher than normal fluid requirements uh to maintain perfusion. And those are the patients that land up getting um significantly fluid overloaded with all the complications. Uh how do we manage or prevent it? Uh So we have to be do to do dis with our fluid regimens. Um This is also an area where they advocate uh using a colloid as either a rescue or a routine in the early part of the resuscitation to try and um prevent uh too many sort of uh oncotic, um too much oncotic pull uh from the extra extravascular compartments and then uh things like hypertonic saline resuscitation and Vitamin C infusions. I didn't go into great depth because they're not really something that we are doing at Fria. Um I just wanna give uh one comment and that is to not confuse hydration and nutrition. So uh maintenance, fluid requirements to keep up with sort of insensible losses and urine output do not necessarily equate um with the amount of fluid that you need to give to get the correct calorie input for a patient. Um So for example, a neonate probably doesn't need more than 100 and 100 and 20 mils per kg of fluid a day for hydration. Um but in when it comes to nutrition, they need about 100 and 80 mils per kg if it's a preterm and 150 if it's a term. So you can see there's a bit of a discrepancy and you can see how if you're prescribing your fluid at nutritional rates, you are putting your patient at risk of fluid overload. Mm. My last slide is just a little summary of. So what do I do? Um I believe less is more. I generally er on the fluid restricted side in all of my patients. I do very cautious rehydration and I start inotropes sooner in septic shock in my heart. I love a balanced fluid but 0.9% saline 5%. Dex saline is readily available, compatible with me, drugs and inexpensive. And at the end of the day, hyponatremia is more dangerous than hyperchloremia. Um I like half DD because it's got everything you need and it's premixed. So you don't need to be writing up complicated formulas for the nurses and working things out at four in the morning. Um The only patients getting neonatal should be neonates, uh neuro patients um status of L TBI. Uh I always give a 0.9% saline based fluid and I always fluid, restrict them to 50% maintenance. And lastly, I'm always looking to change IV anything to food. Um Thank you very much. Yes. Uh Th thank you Linda. That was really excellent. And uh it was uh it was probably necessary for all of us because most of my senior colleagues will agree that we as surgeons and quite often our anesthetist, we tend to over infuse patients who present with shock or who undergo major routine or emergency operations. And uh they probably come to you in PICU in a fluid creep state. So we have been picking up these things from you and we are learning, but I think it's this reminder uh in a scientific way is very welcome and very timely. So there's only one question which is from doctor you mentioned deficit. How do you calculate that? Uh It's difficult um to always calculate a deficit and I always teach my juniors that, um, when you have a patient who you need to rehydrate for whatever reason. And if they've, um, if they've had high nasogastric outputs and it's caused them to be dehydrated or for example, a pyloric stenosis who's um very badly dehydrated or just a kid with gastro, who's very badly dehydrated. Um, so we have that little, we have, we, we all know um, how to look for signs of dehydration and whether it's, it's moderate in which case we would rehydrate them at 50 mils per kg per day. Um And if it's 10% or severe, we would uh rehydrate at 100. Um uh but it's always just a starting point for me. So uh ii start um uh I'm quite restricted so I tend to always rehydrate uh on the moderate side, even if the child is severe. Um If the child is shocked, then I do give them a bolus to try and catch up faster. Um There's no formula for working out how much of a deficit you're in. You, you need to decide that clinically, your biochemical markers can help you in that. Um But the, the at the end of the day, it's about um uh coming back to that patient in 4 to 6 hours and assessing the situation are things worse. Are things getting better? Do I need to add more fluids? Do I need to cut back more fluids? Uh I hope that answers your question. Yes, I think uh that does uh that what you are emphasizing Linda is, it's a dynamic process. We just can't have fluids in the morning at eight o'clock and then come and review either eight o'clock at night or eight o'clock next morning. So it's especially if it's a critically ill patient. So, you know, if it's a patient who's recovering in the ward and they're day four or five postoperatively, then their fluid status is much more stable than a POSTOP baby that's just come back from theater. Um It's a very different situation. Uh And so that's what I tried to emphasize in the beginning is that there's no recipe for fluids. You need to be cognizant of the, the principles and um and the risk benefit ratio in each patient. I think another very important concept. Linda, you have taught us today is that consider fluid as a drug. So a as much as there are advantages, there can be serious disadvantages of giving a fluid to any patient. Uh There are a couple of uh interesting questions do is that Rous lactate is considered to be balanced fluid. May you kindly share how is the lactate not contributing to acidosis and lactic acidosis, especially in those patients who are acidotic already. Um So it's a, it's, first of all, it's a very small concentration of lactate and it's, it's gets, it's a specific type of lactate that gets metabolized by the liver directly back to pyruvate and fed into the Krebs cycle. So there is this common misconception that I can't give my patient lactate, bring his lactate because the lactate is high. Uh the lactate in the solution has no effect on the lactate in the blood. It's not going to push your lactate up. Um the fluid. Remember when, when you look at the volume like the amount of, of um of uh solvent in a liter of fluid, there's actually very little um compared to that big bag of fluid, the bag of fluid is essentially the, it's the water that you're giving. It's just the electrolyte concentrations that differ um in order to uh accommodate specific patient factors. OK. I think the last question is from Doctor Bealli James for gastroschisis babies with low albumin and generalized edema. Is it a good idea to administer fursemide alone? Uh You can try, you can definitely try. But I in a, in those babies, I find it's more if, if the albumin is less than 10, uh in fact, even less than 15 in those babies, you're not gonna get as effective diuresis as you are. Um with extra albumin, you will be able to diurese them, but um you are diuresing them far less efficiently and you will just be emptying out there, intravascular space. You won't necessarily be decreasing the extravascular edema, which is the big problem. OK. The next question is from Doctor Rajan Ras who is a senior pediatric surgeon from nak in India and has done a lot of work on I Ira's principles and uh postesophagectomy. Uh So he's asking importance of third space in postsurgery patients. Um Yeah, I think it's uh you have to be aware. Uh your, your patient postoperatively is in an inflammatory state. They've undergone anesthesia, their, their body's been under a significant amount of stress and there's definitely gonna be an element of um papillary or like tissue capillary leak. Uh And so you have to be cognizant that uh any, any unnecessary fluid that you are giving in the first sort of 12 to 24 hours, postoperatively because of that inflammatory response is going to move into the third space and become a problem in the next 48 hours. Um I don't know if that answers your question. Yes, I would think so. Um Doctor DEA Yasin, I think from Tanzania, if I'm correct. Uh What is the vascular access you prefer? Um If I can get away with peripheral, uh ivs, I will, but in critically ill patients, uh especially if they're coming back from a big surgery, um, it's very helpful to have uh central venous access. Um This, there's a couple of reasons it means that if the patient is hypotensive and we know it's from a s and not dehydration, um, we can start inotropes safer and sooner, um, as opposed to giving them lots of fluid boluses. Um, and then starting peripheral inotropes with all the complications that are associated with that. Um Obviously, it allows you to give nutrition if you can't uh easily, if you can't um if you can't uh feed them. Um And yeah, II it depends on the patients but in a critically unwell child, um central venous access is what I prefer. Yes. Uh Thank you Linda. So I'm just going to ask uh some of the colleagues who are present for any comments or any questions. So the first one I would like to ask is doctor A Oba I who is a younger dynamic uh pediatric minimally invasive surgeon in Nigeria. So, Arua, any comments, any experience to share from Nigeria, please? A call? Yeah. Thank you so much. Yeah. Can you hear me, sir? Yes. Yes. Yes. Yeah. Thank you so much Linda for the uh exquisite presentation. Uh um We have uh in my country here. We have a lot of um uh innuendos when it comes to fluid management for Children. Um During my residency training days, we were, you know, so used to using hypotonic fluids, 4.3% dextrose and 150 line was more of the common um um fluids that were being used for these patients. Um W what I noticed that most of my patients have um edema and uh peripheral edema. And we didn't really like to investigate, to find out how much degree of um fluid imbalance, the, the the like imbalance that that these patients, you know, have to go through before they recover from their um surgical trauma. So, but with the uh transition to more isotonic fluid and the advent of uh parenteral nutrition, most of the outcomes are improving. So, thank you so much for this um very educative. Um My only question would be um what's type of fluid? Um II, do you really prefer when uh you want to or um wwww when you want to place on maintenance? Do you, do you constitute because we want to balance between just hydrating the patient and also um supporting the glucose requirements of these patients, even if you are not given pa nutrition. What do you do you constitute like um the saline and then add some glucose and then, or do you just give 5% Detrol saline or do you, what, what do you really do in your own setting? Um So again, it's patient specific. Um the smaller babies don't always handle um 0.9% sodium chloride very well. They um it's too, too much of a solid load for their kidneys and they can get quite a significant um hyperchloremic metabolic acidosis. Um And on, on that uh on that point, uh uh surgical patients or any patient that comes in with a metabolic acidosis. Um I also don't want to be giving them high chloride um volumes. So uh my first choice is always usually an isotonic fluid and I use 5% dextrose normal saline because it's premixed. And so the only thing that I might add to that is some potassium if my patient needs it. Um, if they're smaller, uh, and they have a high chloride, then I prefer to use, um, something called half dextrose drowse. I don't know if you have that in your country. I know. Um, it's not available all over the world but it's essentially a premixed 5% glucose solution. Um That's got uh about more or less 0.45% sodium chloride and then a few other little additives and that's also premixed. And so again, I advocate for using solutions that are premixed because as soon as you start writing down equations uh and uh recipes for the nurses, um they can like if you write up, they, they can make a mistake so easily and you can make a mistake so easily. And instead, and we have seen it a few times when people have tried to make modified solutions that they trying to give a hypotonic solution. But because they gave the wrong, the wrong concentration of sodium bicarb, they actually land up giving the kid a hypertonic solution for example. So uh to, to, to summarize, I prefer an isotonic solution um in uh older child. Um and one who does not have a severe acidosis and in smaller kids or in severely acidotic, I prefer um a hypertonic solution. But really, that's just because that's the easiest one to access for us. Yeah, I think this you have. Thank you so much. Ok, sorry. Uh uh thank you for your questions and comments. Uh Then the this I think you have already answered but you, you can touch again. What is the preferred fluid management in pediatric crush injuries? Um It's basi basically you wanna give. So these are the kids that you would give liberal fluid to um I would probably run, these are a group of kids that I would run at um 100% maintenance and not fluid restrict them even though they are in a um s sort of state. But uh if they're not passing urine, then I give them Lasix. So I want them to. So these are the kids that you do sort of fluid, ins and outs monitoring and you make sure that what you're putting in is coming out and if that is not the case, then you need to actively diaries otherwise that fluid is gonna go sit on the lungs in the abdomen, etcetera. So, um yes, that's basically, and then uh as to which type of fluid I would probably go with an isotonic fluid because I'm gonna be giving large volumes. So uh I'm at risk of, I'm at risk of um hypo uh iatrogenic hyponatremia if I don't. Ok. Thank you. Um Joseph Brard is an American qualified surgeon. Um He, I met him in Lusaka last year. He has been doing good work in one in northern Zambia. So Joe uh any questions, any comments is Joe still in the meeting Joseph? Uh probably he's not there. The next question I will ask is is Marion Arnold Marion Arnold is a consultant pediatric surgeon at Red Cross Children's Hospital in Cape Town, Marion. Any comments, anything from Red Cross pediatric surgical side? No, it looks like Marion is also left us. Uh The last two people I would like to ask is uh Doctor Sello Maa, our senior consultant, pediatric surgeon. Sell your comments. Anything from, from surgical side from you? Hi, thanks Bob. Um Thanks Linda. Good talk. Um Just two questions. Very, very easy questions for you sha um your your preference blu versus um increasing maintenance. Like you have a child who urine output has been 0.8 mil per kg for the past six hours. Then all of a sudden it drops to 0.3. Um the pulse has not really changed that drastically went up by about 10. This is maybe a neonate. Yeah, it went up by 10 or it be more dramatic and say 20. Would you consider bolusing or just increasing the maintenance fluid? And the other question as well? Um is when we're having kids with high gastric aspirates uh post theater for instance. And um we're considering replacing the losses. Do you also consider bonus or do we replace the loss the following day and replace like they lost 60 mils the previous day. So let's do a catch up. Thanks. So to answer the first question. Sell. Um I think there's a, that was supposed to be that if the urine output drops, it's because the patient is fluid behind. But um it's not in a, in a, in a post inflammatory um state. It might be that they are third spacing, so they're not actually fluid behind. It's just that the fluids in the wrong space. And the second is that the acute kidney injury is now kicking in and the urine output is decreasing because your renal function is deteriorating. And so in that situation, giving in giving a bolus um is not really going to help, uh is actually gonna make the situation worse in 24 to 48 hours. So I think you need to decide like is there a reason this child could be dehydrated? And in, in ICU specifically, we do monitor our ins and outs and very often I see um the urine outputs dropped. So give a fluid, a fluid bance has been given. But actually, what they haven't realized is that the creatinine was 100 um POSTOP. And so there's, there's an acute, there's a kidney injury going on and um they're not fluid behind, they're not peeing because their kidneys are not working. So, uh I always look at the fluid balance. What was, how much have they got in? How much have they got out and then I make a decision if it's neutral and I think there might be a little bit fluid behind because of high aspirates or whatever, then I think giving a slow bolus is appropriate, but most of the time it's asser the fluids in the wrong place or the kidneys are not working. Um The second question, the sort of the same concept with gastric aspirates, why are we replacing the gastric aspirates Because we don't want the patient to be dehydrated. But if our patient is holding on to fluid because of si A DH and you look at the ins and outs and you see that their fluid balance is positive, then you don't wanna be replacing because the patient has already got fluid on board. Um If you've got electrolyte arrangements, then you need to look at changing your, what fluid is going in to try and correct that. Does that make sense? So I'm not an intensivist, but it's slowly making sense. Thanks. We'll make you one, we'll make you one. Ok. Sell a any more comments. Hello. Uh That's all. Thank you. Uh The last person I would like to ask comment is Doctor Yashoda Mann, our senior consultant, pediatric surgeon, Yashoda. Any comments from you? Uh Yeah, thanks prof and thanks Linda. That was a really excellent talk. I feel like I understand your decision is a lot better now to have you in our ICU. So and fluid can be a creep at times, but uh supposed to be life saving. So I'll share with you two quotes that my, my training professor uh used to say. Uh so you can understand surgeons a bit better. And one of the things he used to say was how much fluid do you give this child with a surgical problem? And whatever we said to him was wrong because the answer was enough. So you can do it until, you know, he's clinically better. So that was one of the things he said. And then the other thing he said was also, uh, he said to ask the clever doctors meeting the pediatricians. So, yeah, so that's how we think. And that's probably, um, you know what we're doing wrong a lot because we don't think like an intensivist and just a comment like on that, on, on your slides, there was a page that said fluid liberal and fluid district and I feel like a lot of POSTOP patients fall in both. So it's, it's very tricky to touch the fluids at times. So that's why we make the wrong decisions. Yeah, I think it's just, um, it's, it's just, uh, it's a lot of, um, going back and reassessing because, uh, yeah, like fluid requirements are they change so much, especially in that rocky 48 hours of a big surgery. Um, so for me, whatever fluid plan I start out with, I come back in four hours and I reassess. Um, are we good? Are we not good? Do I need to get more? Do I need to give less? Um, but yeah, fluids, fluids are tricky. And the feast trial that I spoke about is what really changed our whole thought process around fluids because up until then we were of the opinion that we were doing a good thing, giving lots of fluids. And then all of a sudden here comes this really well designed randomized controlled trial with more than like almost 2000 Children recruited. And the evidence was clear that fluid was increasing the risk of mortality. And so the whole sort of pediatric community sat up and had to say, well, now what do we do? You know? Um and I think our understanding of the process has changed a lot in the last 20 years. And um I mean, when I was being trained as a medical student, it was still very much give fluid, give fluid, give fluid. Um And now it's very much a case of, do you really need to give fluid? Do you really need to get fluid? So, yeah, it's tricky. Um But yes, we are always here to assist. Ok, thank you so much. OK. Thank, thank you Linda and thank you Urda if somebody needs to be muted. Uh Sorry. Um So, so I just want to uh make sort of two announcements before I ask doctor Linda to give her concluding remarks is uh uh the virtual learning platform of the Colleges of Medicine of South Africa went live yesterday. So you can log in uh or register at uh C MSA learn.co dot Z A um uh on your mobile, you can download the Moogle app and register with the above login details. Then you can navigate to the courses by types webinars or courses by college. So, College of pediatric surgeons is well represented and recordings of all the previous zoo academic meetings from January 2022 till April 2024 are available for access, free access to any health care worker from anywhere in the world. So just remember this is not restricted to South Africa, anybody from anywhere in the world. Once you register, you can access these webinars. And obviously tonight's meeting will be uploaded in the next day or two on to that platform. In addition, I will also upload the recording on the youtube channel and made all channel um and share the link on various whatsapp groups and Facebook and Twitter and Instagram. So the next month in June, we will have another interesting talk about palliative care in pediatric surgery and it will be given by a palliative care expert from the Baragwanath uh Baragwanath Hospital in Johannesburg. So Linda, I thank you maybe just your concluding remark. Last take home message. Um Less is more and frequent review. That's pretty much uh You can't go wrong if you do that. Yeah, th Thank you, Linda. I think everything is a dynamic process. Patients recovery is also dynamic and mhm really need to and obviously don't go by any formula and don't think that this patient is fluid restricted or you need to restrict and you need to be liberal. These patients shift from restricted to liberal, backward and forward. So I think proper regular clinical examination and attention to detail. And obviously for surgeons ask for advice And for us, we are lucky that you are always there. Even when you are not on call, you do answer our queries. So thank you Linda and thank you all for participation. We had really record attendance for this year. At one stage, we had 78 attendees. So I'm I'm glad that we had this talk. So Linda, thank you again and a good evening to any anybody, everybody. Thanks prob.