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FLUIDS &ELCTROLYTES
Prof. Hamida Esahli
• Objective:
• Normal fluid and electrolyte requirements in
childhood
• Assessment and management of the
dehydrated child
• Dehydration does not cause death, shock does.
• Shock occurs as result of rapid loss of 20ml/kg from the intravascular
s...
•
•
•
•

The critical clinical questions are therefore:
Is the patient shocked?
Is the patient dehydrated?
Does the patien...
• Cardiovascular signs Tachycardia usually associated with :
• poor volume peripheral pulses
• Poor peripheral perfusion w...
Clinical Signs of Dehydration
Signs/sympto
ms

Mild<5%

Moderate
5-10%

Severe >10%

Decrease urine
output

+

+

+

Dry m...
NORMAL Fluid Requirements
Body weight

Fluid requirement/day

Fluid requirement /hour

First 10kg

100ml/kg

4ml/kg

Secon...
Body Weight

Sodium
mmol/kg/day

Potassium
mmol/kg/day

Energy
(Kcal/day)

FIRST 10KG

2-4

1.5-2.5

110

3.00

Second 10k...
•
•
•
•
•

Example A 6-kg child is clinically shocked and 10%
dehydrated as a result of gastroenteritis.

Initial therapy
...
• INITIAL INFORMATION
• An 18 month old boy has had 2 days of vomiting and diarrhoea. He has a
respiratory rate of 24 and ...
• INITIAL INFORMATION
• An 18 month old boy has a history of 5 days of diarrhoea and
vomiting. He has a respiratory rate o...
• The principles in the treatment of hyponatraemia are:
• 1) Treat seizures with 3% NaCl
• 2) Calculate maintenance fluid ...
• INITIAL INFORMATION
• A 3 month old baby who has had diarrhoea and
vomiting for 4 days is brought into hospital. His
res...
• The principles in the treatment of hypernatraemia
are:
• 1) Treat shock first
• 2) Calculate the maintenance fluid and e...
• A 4 year old boy who is recovering from chicken pox, is brought into the
Emergency Department having a convulsion. This ...
Shock

N

Y

Assess%

Crystalloid
20mml/kg

dehydration

Y

Oral rehydration
possible

Maintenance fluids appropriate
to c...
Fluids&electrolytes
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Fluids&electrolytes

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normal requirement of fluids and electrolytes in a dehydrated child

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  • Diagnosis:&lt; 5% dehydrated. Isonatraemic.Guide weight 10kg.Deficit 500ml
  • Diagnosis:10% dehydrated. HyponatraemicGuide weight 10kg. Deficit 1000ml
  • Transcript of "Fluids&electrolytes"

    1. 1. FLUIDS &ELCTROLYTES Prof. Hamida Esahli
    2. 2. • Objective: • Normal fluid and electrolyte requirements in childhood • Assessment and management of the dehydrated child
    3. 3. • Dehydration does not cause death, shock does. • Shock occurs as result of rapid loss of 20ml/kg from the intravascular space. If the intravascular volume is maintained, clinical dehydration is only evident after losses of >25ml/kg of total body water. • It is possible to be shocked and not dehydrated, dehydrated and not shocked, or dehydrated and shocked • The treatment of shock requires rapid administration of a bolus of intravascular fluid, with electrolyte content that approximates to plasma. • The treatment of dehydration requires gradual replacement of fluids, with electrolyte content that relates to the electrolyte losses, or to the total body electrolyte content. • Damage from electrolyte abnormalities is related to either extreme levels, or rapid rates of change. •
    4. 4. • • • • The critical clinical questions are therefore: Is the patient shocked? Is the patient dehydrated? Does the patient have a significant acid–base abnormality? • Are there significant electrolyte problems
    5. 5. • Cardiovascular signs Tachycardia usually associated with : • poor volume peripheral pulses • Poor peripheral perfusion with prolonged capillary refill time and • cool peripheries • Low blood pressure as a pre-terminal sign • Consequences of poor perfusion: • Alteration of mental status • Development of metabolic acidosis with • compensatory tachypnoea • Poor urine out
    6. 6. Clinical Signs of Dehydration Signs/sympto ms Mild<5% Moderate 5-10% Severe >10% Decrease urine output + + + Dry mouth +/- + Notes + Decreased skin turgor - +/- + Unreliable in fat children and in hypertonic dehydration Sunken anterior fontanelle - + + Only useful if fontanell well patent and in absence of meningitis Sunken eyes - + + All these clinical signs are individually unreliable. Weight is the only objective measure of acute fluid losses from the body
    7. 7. NORMAL Fluid Requirements Body weight Fluid requirement/day Fluid requirement /hour First 10kg 100ml/kg 4ml/kg Second 10kg 50ml/kg 2ml/kg Subsequent kg 20ml/kg 1ml/kg Actual volume of insensible fluid loss is related to: caloric content of feeds, ambient temperature, humidity of inspired air, presence of pyrexia and the quality of the skin. Usually between 0 and 10ml/kg per day are lost in stool (may exceed 300ml/kg/day in diarrhoea). Urinary losses are usually between 1-2ml/kg per day (i.e. approximately 30ml/kg/day).
    8. 8. Body Weight Sodium mmol/kg/day Potassium mmol/kg/day Energy (Kcal/day) FIRST 10KG 2-4 1.5-2.5 110 3.00 Second 10kg 1-2 0.5-1.5 75 1.5 0.5-1 0.2-0.7 30 0.75 Subsequent kg Protein (g/kg) PERCENTAGE DEHYDRATION X WEIGHT X 10 Percentage dehydration means: the number of grams of fluid lost per 100gm of body weight. Percentage X 10 converts this volume into ml / kg
    9. 9. • • • • • Example A 6-kg child is clinically shocked and 10% dehydrated as a result of gastroenteritis. Initial therapy 20 ml/kg for shock = 6 × 20 = 120 ml of 0.9% saline given as a rapid intravenous • bolus • • Estimated fluid therapy over next 24 hours: • 100ml/kg for 10% dehydration = 100 × 6 = 600 ml • 100ml/kg for daily maintenance fluid = 100 × 6 = 600 ml • Rehydration + maintenance = 1200 ml • ∴ Start with infusion of 1200/24 = 50 ml/h
    10. 10. • INITIAL INFORMATION • An 18 month old boy has had 2 days of vomiting and diarrhoea. He has a respiratory rate of 24 and a pulse of 120. Capillary filling time is about 2 seconds, and he is alert and responsive • FURTHER INFORMATION • His mother says he has only had 2 wet nappies in the previous 24 hours. FURTHER INFORMATION • Urea, electrolyte, and glucose estimations show: • Na 135 mmol/l K • Urea 18 mg/dl • Glu 75mg/ dl • 3.5 mmol/l Cl 95 mmol/l
    11. 11. • INITIAL INFORMATION • An 18 month old boy has a history of 5 days of diarrhoea and vomiting. He has a respiratory rate of 30, a pulse of 150, and an initial blood pressure of 80 systolic. Capillary refill time is about 4 seconds. He has a dry mouth and sunken eyes. His mother says he is thirsty but can’t keep anything down. • FURTHER INFORMATION • Urea, electrolyte, and glucose estimations show: Na 130 mmol/l • K 3.2 mmol/ l Cl 90 mmol/l Urea 238 mgl/dl Glu 57 mg/dl •
    12. 12. • The principles in the treatment of hyponatraemia are: • 1) Treat seizures with 3% NaCl • 2) Calculate maintenance fluid and estimate fluid deficit carefully • 3) Aim to raise serum sodium no more than 8 mmol per day • 4) Check potassium, chloride, creatinine and glucose levels also • 5) Monitor electrolytes frequently • 6) Clinically assess hydration and weigh frequently
    13. 13. • INITIAL INFORMATION • A 3 month old baby who has had diarrhoea and vomiting for 4 days is brought into hospital. His respiratory rate is 40, pulse150, and capillary refill time 3 seconds. He is pale. • • • • • FURTHER INFORMATION Urea, electrolyte, and glucose estimations show: Na 164 mmol/l K 4.3 mmol/l Cl 115 mmol/l Urea 38.9 mg/dl Gluc 75 mg/dl
    14. 14. • The principles in the treatment of hypernatraemia are: • 1) Treat shock first • 2) Calculate the maintenance fluid and estimate fluid deficit carefully • 3) Aim to lower serum sodium at a rate of no more than 0.5 mmol per hour • 4) Check calcium and glucose levels also • 5) Monitor electrolytes frequently • 6) Clinically assess hydration and weigh frequently
    15. 15. • A 4 year old boy who is recovering from chicken pox, is brought into the Emergency Department having a convulsion. This started 10 minutes before. He is not febrile. • • FURTHER INFORMATION • His respiratory rate is 16, pulse 120, and capillary refill time • 1 second. Glucose stick test is in the normal range. His mother says he has not been going to the toilet as often as usual. • FURTHER INFORMATION • Urea, electrolyte, and glucose estimations show: Na 120 mmol/l • K 3.8 mmol/l Cl 85 mmol/l Urea 3.2 mmol/l Glucose 126 mgl/dl •
    16. 16. Shock N Y Assess% Crystalloid 20mml/kg dehydration Y Oral rehydration possible Maintenance fluids appropriate to clinical condition Y Oral rehydrate STRAT 0,45%. Maintenance +replacement over24h. Na> 150mmol/L plan to rehydrate over 48 h. Consider ongoing fluid losses Re-evaluate weight, clinical condition and electrolytes every 4-6 hours and adjust the rate of fluid and electrolytes Na<150 mmol/l plan to rehydrate over 24 hours
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