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Fluid management for Fluid management for well and sick childrenwell and sick children

Dr Yasser NegmDr Yasser NegmSpR of PaediatricsSpR of Paediatrics

King’s College HospitalKing’s College Hospital

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Vascular volumeInterstitialIntracellular

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Body Water Lost And SymptomsBody Water Lost And Symptoms

2% : Beginning to feel thirsty; loss of endurance capacity and appetite.2% : Beginning to feel thirsty; loss of endurance capacity and appetite.

3% : Dry mouth; performance impaired.3% : Dry mouth; performance impaired.

4% : Increased effort for exercise, impatience, apathy, vague discomfort.4% : Increased effort for exercise, impatience, apathy, vague discomfort.

5% : Difficulty concentrating, increased pulse and breathing.5% : Difficulty concentrating, increased pulse and breathing.

7% : Impairment of temperature regulation, flushed skin, sleepiness, 7% : Impairment of temperature regulation, flushed skin, sleepiness, tingling, stumbling, headache.tingling, stumbling, headache.

9% : Dizziness, laboured breathing, mental confusion, further weakness.9% : Dizziness, laboured breathing, mental confusion, further weakness.

10% : Muscle spasms, loss of balance, swelling of tongue.10% : Muscle spasms, loss of balance, swelling of tongue.

11% : Heat Exhaustion, delirium, stroke, difficult swallowing; death.11% : Heat Exhaustion, delirium, stroke, difficult swallowing; death.

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Types of dehydrationTypes of dehydration

Isotonic volume depletion: (Na: 130-150) Isotonic volume depletion: (Na: 130-150) - 60% of cases- 60% of cases - Causes include: Diarrhea, vomiting, fasting.- Causes include: Diarrhea, vomiting, fasting.

Hypertonic volume depletion: (Na >150)Hypertonic volume depletion: (Na >150) - 25% of cases, don't look as sick: Circulating volume preserved - 25% of cases, don't look as sick: Circulating volume preserved

by diffusion from intracellular compartment. by diffusion from intracellular compartment. - Caused by isotonic loss with hypertonic replacement.- Caused by isotonic loss with hypertonic replacement.

Hypotonic volume depletion (Na < 130)Hypotonic volume depletion (Na < 130) - 15% of cases- 15% of cases - Caused by isotonic loss with hypotonic replacement. Also - Caused by isotonic loss with hypotonic replacement. Also

cystic fibrosis and adrenogenital syndrome.cystic fibrosis and adrenogenital syndrome.

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Steps of rehydrationSteps of rehydration

Calculation of fluid deficit:

% of dehydration X weight X 10 = Fluid deficit in mls.% of dehydration X weight X 10 = Fluid deficit in mls.

Calculation of maintenance fluid

What about ongoing losses ?

Replace ongoing stool losses and vomitus: 10 mL/kg for each diarrheal stool. 5 mL/kg for each episode of vomitus.

Which fluid ?

ORS: Sodium, sugar, potassium, and flavouring agentsORS: Sodium, sugar, potassium, and flavouring agents

For IV: 0.45% Sodium Chloride (75 mmol/l) + Dextrose 5% .For IV: 0.45% Sodium Chloride (75 mmol/l) + Dextrose 5% .

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Over how long ?

Oral: Over 6 hours

IV: Longer

(The higher the Sodium, the slower

is the correction)

For hypernatraemia: 48 hours or

longer; Not quicker than 5 mmol/l

drop/day).

U/E every 4 hours.

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Crystalloid or colloid

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Hyponatraemia and hypokalaemia

Normal requirements:

Sodium: 2 – 4 mmol/kg/day

Potassium: 2 mmol/kg/day

Normal levels:

Sodium: 135 – 145 mmol/l

Potassium: 3.5 – 5.5 mmol/l

Calculate deficit

0.6 x weight (kg) x (desired level – plasma level)

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Case 2:Case 2:

Adam is a 3 week old term baby, 3.2kg.Adam is a 3 week old term baby, 3.2kg.

Projectile vomiting for 3 days. Projectile vomiting for 3 days.

Lethargic, eyes are sunken. His skin feels cool, doughy, and Lethargic, eyes are sunken. His skin feels cool, doughy, and when it is pinched it takes several seconds to return to its when it is pinched it takes several seconds to return to its former position. former position.

The capillary refill time is more than 8 secs. The capillary refill time is more than 8 secs.

Mother tells you that he has worn the same nappy all day. Mother tells you that he has worn the same nappy all day.

During examination an olive sized mass can be felt 3cm below During examination an olive sized mass can be felt 3cm below the right costal margin and gastric peristalsis is observed. the right costal margin and gastric peristalsis is observed.

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Case 2:Case 2:

A diagnosis of pyloric stenosis is made following ultrasound.A diagnosis of pyloric stenosis is made following ultrasound.

Blood taken for electrolyte estimation and acid base status Blood taken for electrolyte estimation and acid base status reveals:reveals:

- Na 128mmol/L- Na 128mmol/L- K 2.8mmol/L- K 2.8mmol/L- Cl 86mmol/L- Cl 86mmol/L- HCO3 32mmol/L- HCO3 32mmol/L- PH 7.55 - PH 7.55 - BE +10- BE +10

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Case 2:Case 2:

Typical hypochloraemic alkalosis with hypokalaemia. The fluid Typical hypochloraemic alkalosis with hypokalaemia. The fluid lost is gastric acid (HCl). lost is gastric acid (HCl).

Initial resuscitation with a bolus of 20ml/kg of 0.9% Sodium Initial resuscitation with a bolus of 20ml/kg of 0.9% Sodium Chloride.Chloride.

Fluid replacement with 0.45% Sodium Chloride in 5% dextrose Fluid replacement with 0.45% Sodium Chloride in 5% dextrose at 1.5 times normal maintenance rate – 19ml/hr. Any nasogastric at 1.5 times normal maintenance rate – 19ml/hr. Any nasogastric loss replaced ml for ml with 0.9% Sodium Chloride.loss replaced ml for ml with 0.9% Sodium Chloride.

Potassium chloride, 20mmol/L, only added once urine output is Potassium chloride, 20mmol/L, only added once urine output is established.established.

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Case 2:Case 2:

Electrolytes to be checked / 6 -12 hours until normal, then / 24 Electrolytes to be checked / 6 -12 hours until normal, then / 24 hours.hours.

Surgery only when dehydration is corrected and plasma Na and Surgery only when dehydration is corrected and plasma Na and K are normal, Cl is >100mmol/L, HCO3 is <28mmol/L and BE is K are normal, Cl is >100mmol/L, HCO3 is <28mmol/L and BE is <+2.<+2.

Intra-opertive fluid management to continue with the Intra-opertive fluid management to continue with the maintenance fluid already running at normal maintenance rate – maintenance fluid already running at normal maintenance rate – 13ml/hr. 13ml/hr.

Surgery relatively short and should not require any extra fluid to Surgery relatively short and should not require any extra fluid to be given.be given.

Ref: APAGBI guidelinesRef: APAGBI guidelines

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Case 3:Case 3:

Amina is a 6 year old female. Amina is a 6 year old female.

Presents with polyuria, polydepsia, abdominal pain, vomiting, Presents with polyuria, polydepsia, abdominal pain, vomiting, and fruity (acetone) breath odour.and fruity (acetone) breath odour.

You suspect Diabetic Ketoacidosis.You suspect Diabetic Ketoacidosis.

Urine: ++++ glucose, ++++ Ketones.Urine: ++++ glucose, ++++ Ketones.

Blood: Glucose 36, Na 130, K 5.5, HCO3 15, Cl 90, WBC 20.Blood: Glucose 36, Na 130, K 5.5, HCO3 15, Cl 90, WBC 20.

By the time the results are back, Amina has become drowsy By the time the results are back, Amina has become drowsy with tachycardia and prolonged capillary refill time. with tachycardia and prolonged capillary refill time.

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Case 3:Case 3:

10 - 20 mls/kg of Sodium Chloride 0.9% over 30 – 60 minutes. 10 - 20 mls/kg of Sodium Chloride 0.9% over 30 – 60 minutes. Can be repeated until shock is resolved (Don’t repeat Can be repeated until shock is resolved (Don’t repeat unnecessarily).unnecessarily).

Replace deficit evenly over 24 - 48 hours with added Potassium Replace deficit evenly over 24 - 48 hours with added Potassium 40 mmol/I litre bag. 40 mmol/I litre bag.

Add maintenance fluids as usual.Add maintenance fluids as usual.

When serum glucose reaches 12 mmol/l, switch to 5% dextrose When serum glucose reaches 12 mmol/l, switch to 5% dextrose with 0.9% Sodium Chloride maintaining glucose between 9 – 15 with 0.9% Sodium Chloride maintaining glucose between 9 – 15 mmol/l (10% dextrose may be needed). mmol/l (10% dextrose may be needed).

Check glucose & U/E / 2 -4 hours. Accurate fluid balance.Check glucose & U/E / 2 -4 hours. Accurate fluid balance.

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Case 3:Case 3:

After initial improvement for few hours, Amina started to After initial improvement for few hours, Amina started to deteriorate again with headaches, slow heart rate followed by deteriorate again with headaches, slow heart rate followed by irritability and confusion. Her BM was 16.5 at the time. Cerebral irritability and confusion. Her BM was 16.5 at the time. Cerebral oedema is now suspected:oedema is now suspected:

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Mannitol 0.5 g/kg stat (= 2.5 ml/kg Mannitol 20% over 15 Mannitol 0.5 g/kg stat (= 2.5 ml/kg Mannitol 20% over 15 minutes). This needs to be given as soon as possible.minutes). This needs to be given as soon as possible.

Restrict IV fluids to 2/3 maintenance and replace deficit over 72 Restrict IV fluids to 2/3 maintenance and replace deficit over 72 rather than 24 hours.rather than 24 hours.

The child will need to be moved to ICU (if not there already).The child will need to be moved to ICU (if not there already).

Intracerebral pressure monitoring may be required.Intracerebral pressure monitoring may be required.

Repeated doses of Mannitol (above dose every 6 hours) should Repeated doses of Mannitol (above dose every 6 hours) should be used to control intracranial pressure.be used to control intracranial pressure.

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