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Fluid management for well and sick children
 

Fluid management for well and sick children

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    Fluid management for well and sick children Fluid management for well and sick children Presentation Transcript

    • Fluid management for well and sick children Dr Yasser Negm SpR of Paediatrics King’s College Hospital
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    • Body Water Lost And Symptoms
      • 2% : Beginning to feel thirsty; loss of endurance capacity and appetite.
      • 3% : Dry mouth; performance impaired.
      • 4% : Increased effort for exercise, impatience, apathy, vague discomfort.
      • 5% : Difficulty concentrating, increased pulse and breathing.
      • 7% : Impairment of temperature regulation, flushed skin, sleepiness, tingling, stumbling, headache.
      • 9% : Dizziness, laboured breathing, mental confusion, further weakness.
      • 10% : Muscle spasms, loss of balance, swelling of tongue.
      • 11% : Heat Exhaustion, delirium, stroke, difficult swallowing; death.
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    • Types of dehydration
      • Isotonic volume depletion: (Na: 130-150)
      • - 60% of cases
      • - Causes include: Diarrhea, vomiting, fasting.
      • Hypertonic volume depletion: (Na >150)
      • - 25% of cases, don't look as sick: Circulating volume preserved by diffusion from intracellular compartment.
      • - Caused by isotonic loss with hypertonic replacement.
      • Hypotonic volume depletion (Na < 130)
      • - 15% of cases
      • - Caused by isotonic loss with hypotonic replacement. Also cystic fibrosis and adrenogenital syndrome.
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    • Steps of rehydration
      • Calculation of fluid deficit:
      • % 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 agents
      • For IV: 0.45% Sodium Chloride (75 mmol/l) + Dextrose 5% .
      • 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.
    • Crystalloid or colloid
    • 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)
    • Case 2:
      • Adam is a 3 week old term baby, 3.2kg.
      • Projectile vomiting for 3 days.
      • Lethargic, eyes are sunken. His skin feels cool, doughy, and when it is pinched it takes several seconds to return to its former position.
      • The capillary refill time is more than 8 secs.
      • Mother tells you that he has worn the same nappy all day.
      • During examination an olive sized mass can be felt 3cm below the right costal margin and gastric peristalsis is observed.
    • Case 2:
      • A diagnosis of pyloric stenosis is made following ultrasound.
      • Blood taken for electrolyte estimation and acid base status reveals:
      • - Na 128mmol/L
      • - K 2.8mmol/L
      • - Cl 86mmol/L
      • - HCO3 32mmol/L
      • - PH 7.55
      • - BE +10
    • Case 2:
      • Typical hypochloraemic alkalosis with hypokalaemia. The fluid lost is gastric acid (HCl).
      • Initial resuscitation with a bolus of 20ml/kg of 0.9% Sodium Chloride.
      • Fluid replacement with 0.45% Sodium Chloride in 5% dextrose at 1.5 times normal maintenance rate – 19ml/hr. Any nasogastric loss replaced ml for ml with 0.9% Sodium Chloride.
      • Potassium chloride, 20mmol/L, only added once urine output is established.
    • Case 2:
      • Electrolytes to be checked / 6 -12 hours until normal, then / 24 hours.
      • Surgery only when dehydration is corrected and plasma Na and K are normal, Cl is >100mmol/L, HCO3 is <28mmol/L and BE is <+2.
      • Intra-opertive fluid management to continue with the maintenance fluid already running at normal maintenance rate – 13ml/hr.
      • Surgery relatively short and should not require any extra fluid to be given.
      • Ref: APAGBI guidelines
    • Case 3:
      • Amina is a 6 year old female.
      • Presents with polyuria, polydepsia, abdominal pain, vomiting, and fruity (acetone) breath odour.
      • You suspect Diabetic Ketoacidosis.
      • Urine: ++++ glucose, ++++ Ketones.
      • 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 with tachycardia and prolonged capillary refill time.
    • Case 3:
      • 10 - 20 mls/kg of Sodium Chloride 0.9% over 30 – 60 minutes. Can be repeated until shock is resolved (Don’t repeat unnecessarily).
      • Replace deficit evenly over 24 - 48 hours with added Potassium 40 mmol/I litre bag.
      • Add maintenance fluids as usual.
      • When serum glucose reaches 12 mmol/l, switch to 5% dextrose with 0.9% Sodium Chloride maintaining glucose between 9 – 15 mmol/l (10% dextrose may be needed).
      • Check glucose & U/E / 2 -4 hours. Accurate fluid balance.
    • Case 3:
      • After initial improvement for few hours, Amina started to deteriorate again with headaches, slow heart rate followed by irritability and confusion. Her BM was 16.5 at the time. Cerebral oedema is now suspected:
      • Mannitol 0.5 g/kg stat (= 2.5 ml/kg Mannitol 20% over 15 minutes). This needs to be given as soon as possible.
      • Restrict IV fluids to 2/3 maintenance and replace deficit over 72 rather than 24 hours.
      • The child will need to be moved to ICU (if not there already).
      • Intracerebral pressure monitoring may be required.
      • Repeated doses of Mannitol (above dose every 6 hours) should be used to control intracranial pressure.
    • Thank you for your contribution