Maintainance & replacement fluid therapy pediatrics AG
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This document discusses maintenance and replacement fluid therapy in children. It begins by outlining the objectives of understanding the differences in pediatric physiology and the goals of maintenance fluid therapy. It then covers topics like the vulnerability of infants, the distribution of body water, electrolyte concentrations, commonly used IV fluids, and calculating fluid requirements using the 4-2-1 rule. The document emphasizes the importance of monitoring weight, urine output, and serum electrolytes when administering fluids. It also provides guidance on choosing appropriate replacement fluids for issues like diarrhea, vomiting, and altered renal output.
![KEY LEARNING POINT*
Sodium is the Principle electrolyte in ECF
[140mEq/L (+/- 5)]
Potassium is the Principle electrolyte in ICF
[150mEq/L (+/- 5)]
*IAP text book of Pediatrics 5th edition](https://image.slidesharecdn.com/maintainancereplacementfluidtherapy-141226142052-conversion-gate02/85/Maintainance-replacement-fluid-therapy-pediatrics-AG-12-320.jpg)
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Maintainance & replacement fluid therapy pediatrics AG
- 1. MAINTENANCE & REPLACEMENT FLUID THERAPY Moderated By Dr.Madhuri Engade Presented By Dr.Akshay
- 2. OBJECTIVES To know the difference in physiology of children. To know the Goals of maintenance fluid therapy. Able to Calculate total fluid requirement & do monitoring of the patient. To know Variations in maintenance water & electrolytes. To order Replacement fluids in “common” situations.
- 3. WHY THE INFANTS ARE MORE VULNERABLE?* Physiological inability to concentrate urine. Higher metabolic rate & larger surface area. Cant express thirst for more fluids. Larger turnover. *IAP text book of Pediatrics 5th edition
- 4. WHOM TO GIVE MAINTENANCE FLUIDS? Infants who are sick & whose oral intake is uncertain. Babies who are kept NBM for the surgery, with respiratory distress etc. neonates kept under radiant warmer.
- 5. GOALS OF MAINTENANCE FLUIDS* Prevent dehydration Prevent electrolyte disturbance Prevent ketoacidosis Prevent protein degradation *Nelsons Text book of pediatrics 19th edition
- 6. AT BIRTH… 75 % of the total body weight Obligatory diuretic phase 65 % of the total body weight Next 2 – 3 Days At the end of Ist year 60 % of the total body weight
- 8. BACK TO PHYSIOLOGY… Total Body Water 60%* Intra cellular fluid (ICF) 40% Extra cellular fluid (ECF) 20% Interstitial 15% Intravasular 5% *IAP text book of Pediatrics 5th edition
- 9. What osmolarity means… What tonicity means…
- 10. DISTRIBUTION OF BODY WATER Intravascular (5%) Interstitial (15%) Intracellular (40%) ICF ECF Na+ K+ Cl-
- 11. ELECTROLYTE CONCENTRATIONS Component ECF ICF Na+ High Low K+ Low High Ca++ Low Low (higher than ECF) Proteins High High
- 12. KEY LEARNING POINT* Sodium is the Principle electrolyte in ECF [140mEq/L (+/- 5)] Potassium is the Principle electrolyte in ICF [150mEq/L (+/- 5)] *IAP text book of Pediatrics 5th edition
- 13. Maintenance fluids consists of- i. Water ii. Glucose iii. Sodium iv. Potassium Advantages – Simplicity, long shelf life, low cost, compatibility. Prototypical maintenance therapy fluid doesn’t provide calcium, phosphorus, magnesium or bicarbonate.* *Nelsons Text book of pediatrics 19th edition
- 14. FLUID LOSSES IN INFANTS LUNGS URINE, FECES SKIN
- 15. CONCEPT OF MAINTENANCE OF WATER Crucial component of maintenance fluid therapy. Maintenance water = Measurable loss of water 65% (Urine 60%, stools 5%) + Insensible of water 35% (skin & lungs)
- 16. FOR NEONATES Day 1 60 ml/kg/day Day 2 90 ml/kg/day Day 3 120 ml/kg/day Day 4 150 ml/kg/day (maximum for term infants) Day 5 to 3 months 150 ml/kg/day
- 17. MAINTENANCE REQUIREMENTS* Weight Requirement 0-10 kg 100cc/kg/24hr 11-20 kg 1000 + 50cc/kg/24hr >20 kg 1500 + 20cc/kg/24hr Upper limit 2400cc/24hrs *Nelsons Text book of pediatrics 19th edition
- 18. Maintenance Fluids Hourly Maintenance Fluid Requirement* “4 - 2 -1 rule” WEIGHT FLUID 0 - 10 kg 4 ml/kg/hr 10 - 20 kg 40ml/hr + 2 ml/kg/hr > 20 kg 60ml/hr + 1 ml/kg/hr Upper limit 100cc/hr *Nelsons Text book of pediatrics 19th edition
- 19. CONCEPT OF MAINTENANCE OF ELECTROLYTES Insensible water loss contains no electrolytes* So, sodium & potassium present in the urine, stools & sweat would be the amount to be replaced plus the sodium & potassium required for normal metabolism of the body. 3mEq of sodium in 100 cc of fluid & 2mEq of potassium in 100 cc of fluid *IAP text book of Pediatrics 5th edition
- 20. Maintenance fluids usually contains 5% dextrose (5 gm/100ml) providing 17 calories/ 100 ml of fluid. Which is approx. 20% of the daily caloric needs. Prevents ketone production. CONCEPT OF MAINTENANCE OF GLUCOSE* *Nelsons Text book of pediatrics 19th edition
- 21. COMMONLY USED FLUIDS FOR MAINTENANCE* I. 0.9% Normal Saline – Think of it as ‘Salt and water’ Principal fluid used for intravascular resuscitation and replacement of salt loss e.g diarrhoea and vomiting Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l; K+ - Absent, But K+ is often added IsoOsmolar compared to normal plasma Distribution: Stays almost entirely in the Extracellular space Does not provide free water or calories. Restores NaCl deficits. *The Harriet Lane Handbook 19th edition
- 22. CONTENTS OF IV FLUID PREPARATIONS* Na (mEq/L) K (mEq/L) Cl (mEq/L) HCO3 (mEq/L) Dextrose (gm/L) mOsm/L NS 154 154 308 DNS 154 154 50 564 ½ NS 77 77 143 5%D + 1/2NS 77 77 50 350 D5W 50 278 Ringers Lactate (RL) 130 4 109 28 50 273 Iso P 23 20 23 30 50 367 Iso M 37 35 37 30 50 415.5 *The Harriet Lane Handbook 19th edition
- 23. II. Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L. Contains 130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate, and 4 mEq/L K+, 3 mEq/L Ca++ Lactate is used instead of bicarb because it's more stable in IVF during storage. Lactate is converted readily to bicarb by the liver. Has minimal effects on normal body fluid composition and pH. More closely resembles the electrolyte composition of normal blood serum. Does not provide calories. COMMONLY USED FLUIDS FOR MAINTENANCE
- 24. HOW TO CHOOSE?* 0.9% sodium chloride Suitable for initial volume resuscitation in hypovolaemia and for ongoing fluid therapy in older children with normal serum glucose. Fluid of choice in patients with head injury 5% dextrose + 0.9% sodium chloride Suitable for ongoing fluid therapy in infants and children, including post-operative cardiac patients. Use in head injured patients with hypoglycaemia. 5% dextrose + 0.45% sodium chloride Suitable for ongoing fluid therapy in infants and children, including post-operative cardiac patients 10%dextrose + 0.45% sodium chloride Suitable for ongoing fluid therapy in neonates or older infants who are hypoglycaemic, including post-operative cardiac patients *Leeds Teaching Hospitals NHS Trust Paediatric Intensive Care Units
- 25. MONITORING WHILE ADMINISTERING FLUIDS* Child should be weighed prior to the commencement of therapy, and daily afterwards. Children with ongoing dehydration/ongoing losses may need 6 hourly weights to assess hydration status All children on IV fluids should have serum electrolytes and glucose checked before commencing the infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue. *Royale Children’s Hospital Melbourne Guidelines
- 26. MONITORING WHILE ADMINISTERING FLUIDS* For more unwell children, check the electrolytes and glucose 4-6 hours after commencing, and then according to results and the clinical situation but at least daily. Pay particular attention to the serum sodium on measures of electrolytes. If <135mmol/L (or falling significantly on repeat measures) If >145mmol/L (or rising significantly on repeat measures) Children on iv fluids should have a fluid balance chart documenting input, ongoing losses and urine output. *Royale Children’s Hospital Melbourne Guidelines
- 27. MAINTENANCE FLUIDS & HYPONATREMIA* Production of ADH leading to water retention leading to water intoxication. Patients producing ADH due to subtle volume depletion can be safely treated with fluids containing higher sodium concentration, decrease in fluid rate or the combination of both. Persistent ADH production due to underlying disease requires less than total maintenance fluids Individualization & careful monitoring is must. *Nelsons Text book of pediatrics 19th edition
- 28. VARIATIONS IN MAINTENANCE WATER & ELECTROLYTES Source Causes of increased water needs Causes of decreased water needs Skin Radiant warmer Incubator Phototherapy Fever Sweat Burns lungs Tachypnea Humidified ventilator Tracheastomy GI tract Diarrhea Vomiting Nasogastric secretion renal Polyuria Oligo/anuria Misc. Surgical drain hypothyroidism Third spacing
- 29. REPLACEMENT FLUIDS* In addition to normal maintenance fluid requirements, unwell children may need: Fluid resuscitation for shock Replacement of pre-existing fluid losses Replacement of ongoing fluid losses *Royale Children’s Hospital Melbourne Guidelines
- 30. REPLACEMENT FLUIDS* GI losses are accompanied with loss of potassium, bicarbonate leading to metabolic acidosis. Impossible to predict the loses for next 24 hrs, so measure & replace excess GI losses as they occur. So each ml of the diarrheal stool or the vomitus should be replaced by the same amount every 1 to 6 hourly. *Nelsons Text book of pediatrics 19th edition
- 31. REPLACEMENT FLUIDS Replacement fluid for Diarrhea* Average composition of Diarrheal stools (except cholera) Na 55 mEq/l K 25 mEq/l Bicarbonate 15 mEq/l Approach to Replacement of Ongoing Losses D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl Replace stools ml/ml every 1 to 6 hrs *Nelsons Text book of pediatrics 19th edition
- 32. REPLACEMENT FLUIDS Replacement fluid for Emesis or Nasogastric losses* Average composition of Gastric Fluid Na 60 mEq/l K 10 mEq/l Chloride 90 mEq/l Approach to Replacement of Ongoing Losses NS + 10 mEq/l KCl Replace Output ml/ml every 1 to 6 hrs *Nelsons Text book of pediatrics 19th edition
- 33. REPLACEMENT FLUIDS Replacement fluid for Altered Renal Output* Oligouria / Anuria Place patient on insensible fluids (25 to 40% of maintenance) Replace Urine output ml/ml by half NS Polyuria Place patient on insensible fluids (25 to 40% of maintenance) Measure urine electrolytes Replace Urine output ml/ml by solution based on measured urine electrolytes *Nelsons Text book of pediatrics 19th edition
- 34. CASE I 5 day old baby boy weighing 3 kg having total billirubin 18.0 is to be kept under phototherapy. Baby having no other risk factors & accepts DBM well. What fluid at what rate should we prescribe?
- 35. Rate Day 5 (150 ml/kg/day) Weight 3 kg So, 150 * 3 = 750 ml is the total maintainence. For the babies under phototherapy we should give half of the maintainence. So 375 ml/24 hrs i.e 125 ml / 8hrly Fluid of choice is 5% dextrose + 0.45% NS or iso P will also be suitable.
- 36. CASE II 7 year old girl (weight 20 kg) admitted for bronchopneumonia with respiratory rate of 44/min & fever of 102 F. later developed 4 episodes of vomiting (each of 25 ml quantity) & loose stools 3 episodes (each of 80 ml quantity)
- 37. Weight 20 kg. So, Total maintenance fluid will be (100*10) + (50*10) = 1500 ml/ day i.e 500 ml / 8 hrly Choice of fluid will be 0.45% DNS + 20mEq/L KCl Replacement fluid for vomiting (each of 25 ml quantity) = 25 * 4 =100 ml of NS + 10 mEq/l KCl Replacement fluid for loose stools (each of 80 ml quantity) = 80 * 3 =240 ml of 0.2% DNS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl.
- 38. TACHYPNEA Respiratory Alkalosis Increase in rate and depth of breathing Loss of CO2 Causes of hyperventilation (tachypnea): Fear, pain, fever, CHF, anemia
- 39. FEVER Each degree of fever increases basal metabolic rate (BMR) 10%, with a corresponding fluid requirement
- 40. VOMITING Metabolic Alkalosis Loss of acid from stomach pH HCO3 H+ Treatment: Prevent further losses and replace lost electrolytes
- 41. DIARRHEA Metabolic Acidosis loss of HCO3 from G.I. Tract pH HCO3 Treatment: Correct base deficit, replace losses of with NaHCO3
- 42. TAKE HOME MESSAGE Fluid is like “prescription” so give it with caution. Children are more vulnerable for rapid fluid loss. Maintenance calculation by “4-2-1” rule or Holliday Segar’s formula. Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM SODIUM CONCENTRATION while giving fluid is must. As far as possible try to give maintenance fluid requirement orally. 0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children requiring maintenance therapy. Replacement of fluids should be prompt & appropriate.
- 43. !! THANK YOU !!