fluids

1. FLUID AND
ELECTROLYTES
&
ACUTE
GASTROENTERITIS
wan nusairi
imran
safiya

2. Well Children With Normal Hydration
● Well children rarely need Intravenous Fluid, if
possible, use enteral (oral) route

3. Fluids are given intravenously for the following
reasons:
• Circulatory support in resuscitating vascular collapse.
• Replacement of previous fluid and electrolyte deficit.
• Maintenance of daily fluid requirement.
• Replacement of ongoing losses.
• Severe dehydration with failed nasogastric tube fluid replacement
(e.g. on-going profuse losses, diarrhoea or abdominal pain).
• Certain co-morbidities, particularly GIT conditions (e.g. short gut or
previous gut surgery)

4. Intravenous Fluids
Resuscitation
Replacement
Maintenance

5. ● Bolus (over 1 hour)
● 0.9% NS
● 20ml/kg
● Use 10ml/kg in conditions:
a. Neonates
b. Diabetic ketoacidosis
c. Trauma
d. Failure/Fluid overload
Resuscitation

7. ● Fluid deficit sufficient enough to cause impaired tissue oxygenation
(clinical shock) should be corrected with a fluid bolus of 10-20mls/kg.
● Always reassess circulation - give repeat boluses as necessary.
● Look for the cause of circulatory collapse - blood loss, sepsis, etc.
This helps decide on the appropriate alternative resuscitation fluid
● Fluid boluses of 10mls/kg in selected situations -diabetic ketoacidosis,
intracranial pathology or trauma.
● If associated cardiac conditions, then use aliquots of 5- 10mls/kg
● Avoid low sodium-containing (hypotonic) solutions for resuscitation →
can cause hyponatremia.

9. ● Dehydration or ongoing losses
● 0.9% Sodium Chloride or Ringer’s/
Hartmann’s solution
● Formula:
○ %deficit x BW x 10
24
Replacement

10. ● D1: 60ml/kg/d
● D2: 80ml/kg/d
● D3: 100ml/kg/d
● D4: 120ml/kg/d
● D5 - 6 months : 150ml/kg/d
● 6months to 1year : 120ml/kg/d
● > 1year: Holliday-Segar calculator
○ First 10kg: 100ml/kg
○ Subsequent 10kg: 50ml/kg
○ All additional kg: 20ml/kg
● Fluids:
○ D1: D10%
○ D1 to 1month: ⅕ NSD10%
○ 1month to 1year: HSD5%
○ >1year: NSD5%
Maintenance

11. • Peri-or post-operative
• Require replacement of ongoing losses
• A plasma Na+ at lower range of normal (definitely if < 135mmol/L)
• Central nervous system (CNS) infection
• Head injury
• Bronchiolitis
• Sepsis
• Excessive gastric or diarrhoeal losses
• Salt-wasting syndromes
• Chronic conditions such as diabetes, cystic fibrosis and pituitary deficits
Children at high risk of hyponatremia should be given isotonic solutions
(0.9% saline ± glucose) with careful monitoring to avoid iatrogenic
hyponatremia. These include children with:

14. Electrolyte Imbalances
● Sodium Disorders
● Potassium Disorders
● Calcium Disorders
● Phosphate Disorders

15. Sodium Disorders
● Daily sodium requirement: 2-3mmol/kg/day
● Normal serum sodium: 135-145mmol/L
1. Hypernatremia
a. Serum Sodium >150mmol/L
b. Moderate Hypernatremia: 150-160mmol/L
c. Severe Hypernatremia: >160mmol/L

16. ● Causes: water loss in excess of sodium (e.g. diarrhoea), water
deficit (e.g. diabetes insipidus), sodium gain (e.g. large amount of
NaHCO3 infusion or salt poisoning)
● Signs: Irritability, Skin feels “doughy”, Ataxia, tremor,
hyperreflexia, Seizure, Reduced awareness, coma
○ Children may appear sicker than expected for degree of
dehydration.
○ Shock occurs late because intravascular volume is relatively
preserved.
○ Signs of hypernatremic dehydration tend to be predominantly
that of intracellular dehydration and neurological dysfunction
Hypernatremia

17. Management for Hypernatremia
● When correcting hypernatraemia, ensure that the rate of fall of
plasma sodium < 12 mmol/litre in a 24-hour period
(0.5mmol/l/hour).
● Measure plasma electrolytes every 4–6 hrs for the first 24 hrs, and
the frequency of further electrolyte measurements depends on
response.

18. • Patient with dehydration:
• If the patient is in shock, give volume resuscitation with 0.9% Normal saline as
required with bolus/es.
• Avoid rapid correction as may cause cerebral oedema, convulsion and death.
• Give 0.9% Sodium Chloride to ensure the drop in sodium is not too rapid.
• Remember to give maintenance fluids and replace ongoing losses
• Repeat blood urea and electrolytes every 6 hours until stable.
• If hypernatraemia worsens or is unchanged after replacing deficit, review fluid
type and consider changing to a hypotonic solution (e.g. 0.45% Sodium
Chloride with dextrose).

19. ● If no evidence of dehydration and an isotonic fluid is being used, consider
changing to a hypotonic fluid (e.g. 0.45% Sodium Chloride with dextrose).
● If the fluid status is uncertain, measure urine sodium and osmolality.
★ When correcting hypernatraemia, ensure that the rate of fall of plasma
sodium < 12 mmol/litre in a 24-hour period (0.5mmol/l/hour).
★ Aim to correct deficit over 48-72 hours

20. Hyponatremia
● Serum Na+ < 135mmol/L
● Symptoms associated with acute hyponatraemia during IV fluid
therapy:
○ Headache, nausea, vomiting, confusion, disorientation, irritability,
lethargy, reduced consciousness, convulsions, coma, apnoea.
● May occur in acute myeloid leukaemia (AML)
● Can occur as part of SIADH

22. Management for Hyponatremia
● In acute symptomatic hyponatraemia - Review the fluid status,
seek immediate expert advice (for example, from the paediatric
intensive care team) and consider taking action as follows:
○ A 2 ml/kg bolus (max 100 ml) of 3% Sodium Chloride over 10–15
mins.
○ A further 2 ml/kg bolus (max 100 ml) of 3% Sodium Chloride over
the next 10–15 mins if symptoms are still present after the initial
bolus.
○ If symptoms are still present after the 2nd bolus, check plasma
sodium level and consider a third 2ml/kg bolus (max 100 ml) of 3%
Sodium Chloride over 10–15 mins.
○ Measure the plasma sodium concentration at least hourly.

23. ● As symptoms resolve, decrease the frequency of plasma sodium measurements
based on the response to treatment.
● Do not manage acute hyponatraemic encephalopathy using fluid restriction alone.
● After hyponatraemia symptoms have resolved, ensure that the rate of increase of
plasma sodium does not exceed 12 mmol/l in a 24-hr period.
● Hyponatremic encephalopathy is a medical emergency that requires rapid
recognition and treatment to prevent poor outcome.

24. ● Children with asymptomatic hyponatremia do not require 3% sodium chloride
treatment and if dehydrated may be managed with oral fluids or intravenous
rehydration with 0.9% sodium chloride.
● Children who are hyponatremic and have a normal or raised volume status
should be managed with fluid restriction.
● For Hyponatremia secondary to diabetic ketoacidosis; refer DKA protocol
(Peads Protocol Pg 310-311)

25. Potassium Disorder
● The daily potassium requirement is 1-2mmol/kg/day.
● Normal values of potassium are:
○ Birth - 2 weeks: 3.7 - 6.0mmol/l
○ 2 weeks – 3 months: 3.7 - 5.7mmol/l
○ 3 months and above: 3.5 - 5.0mmol/l

26. Hypokalemia
● Serum K+ < 3.4 mmol/l (Treat if < 3.0mmol/l or Clinically
Symptomatic and < 3.4 mmol/l)
● Causes are: Sepsis, Gastrointestinal losses (diarrhoea, vomiting),
Iatrogenic (e.g. diuretic therapy, salbutamol, amphotericin B),
Diabetic ketoacidosis, Renal tubular acidosis, common in AML
● Hypokalaemia is often seen with chloride depletion and metabolic
alkalosis
● Refractory hypokalaemia may occur with hypomagnesaemia

27. Management for
Hypokalemia
● Identify and treat the underlying condition.
● Unless symptomatic, a potassium level of 3.0 and 3.4 mmol/l is
generally not supplemented but rather monitored.
● The treatment of hypokalaemia will need to be individualized for
each patient.
● Oral Supplementation
○ Oral Potassium Chloride (KCL), to a maximum of 2 mmol/kg/day in
divided doses is common but more may be required in practice.

28. ● Intravenous Supplementation (1gram KCL = 13.3 mmol KCL)
○ Potassium chloride is always given by IV infusion, NEVER by bolus
injection.
○ Maximum concentration via a peripheral vein is 40 mmol/l
(concentrations of up to 60 mmol/l can be used after discussion
with senior medical staff).
○ Maximum infusion rate is 0.2mmol/kg/hour (in non-intensive care
setting).
● Intravenous Correction (1gram KCL = 13.3 mmol KCL)
○ K+ < 2.5 mmol/L may be associated with significant cardiovascular
compromise. In the emergency situation, an IV infusion KCL may
be given
○ Dose: initially 0.4 mmol/kg/hr into a central vein, until K+ level is
restored.
○ Ideally this should occur in an intensive care setting.

29. Hyperkalemia
● Definition: serum K⁺ > 6.0 mmol/l (neonates) and > 5.5 mmol/l
(children).
● Cardiac toxicity generally develops when plasma potassium > 7 mmol/l
● Causes are:
○ Dehydration
○ Acute renal failure
○ Diabetic ketoacidosis
○ Adrenal insufficiency
○ Tumour lysis syndrome
○ Drugs e.g. oral potassium supplement, K+ sparing diuretics, ACE
inhibitors.

30. ● Drug doses:
○ IV Calcium 0.1 mmol/kg.
○ Nebulised Salbutamol:
Age ≤2.5 yrs: 2.5 mg; Age 2.5-7.5 yrs:
5 mg; >7.5 yrs: 10 mg
○ IV Insulin with Glucose:
- Start with IV Glucose 10% 5ml/kg/hr
(or 20% at 2.5 ml/kg/hr).
- Once Blood sugar level >10mmol/l
and the K+ level is not falling, add IV
Insulin 0.05 units/kg/hr and titrate
according to glucose level.
○ IV Sodium Bicarbonate: 1-2 mmol/kg.
PO or Rectal Resonium : 1Gm/kg

31. Hypercalcaemia
● Causes: Primary Hyperparathyroidism & malignancies e.g NHL
(Non Hodgkin Lymphoma), Hodgkin lymphoma, rhabdoid
tumours, alveolar rhabdomyosarcoma, etc. Less common causes
- Addison’s disease, renal failure
● Treatment:
○ Ensure adequate hydration
○ IV Frusemide (which increases calcium excretion)
● ECG changes
○ Shortened QT interval
○ Lengthened QRS
complex
○ Bradycardia

32. Hypocalcaemia
● Hypocalcaemia leads to altered sensorium, photophobia, neuromuscular irritability,
seizures, carpopedal spasm and GIT symptoms
● Treatment of hypocalcaemia depends on the phosphate level:
○ If phosphate is raised, correct the high phosphate.
○ If phosphate is normal /symptoms of hypokalaemia, give IV calcium correction.
● Treat if symptomatic (usually serum Ca²⁺ < 1.8 mmol/L), and if Sodium bicarbonate is
required for hyperkalaemia, treat with IV 10% Calcium gluconate 0.5 ml/kg, given
over 10 – 20 minutes, with ECG monitoring.
● If hypocalcaemia is refractory to treatment, exclude associated hypomagnesaemia
● ECG changes
○ Lengthened QT
interval
○ Shortened QRS
complex

33. Hyperphosphatemia
● Phosphate binders e.g. calcium carbonate or aluminium hydroxide
orally with main meals.
● Can be seen in Tumor Lysis Syndrome & commonly associated
with hypocalcemia or hyperkalemia

34. ACUTE GASTROENTERITIS

35. ● Acute gastroenteritis (AGE) is a leading cause of childhood morbidity
and mortality and an important cause of malnutrition
● Many diarrhoeal deaths are caused by dehydration and electrolytes
loss
● Dehydration can be safely and effectively treated with Oral Rehydration
Solution (ORS) but severe dehydration may require intravenous fluid
therapy.

36. History
Onset of diarrhea and vomiting
● Number of episodes of diarrhea and vomiting
● Bloody diarrhea / emesis
● Bilious emesis
Oral intake
● How much and what fluids are they taking orally
● Number of wet diapers and last void

37. ROS: fever, rash, abdominal pain, URTI symptoms, urinary symptoms,
joint swelling
● Sick contacts
● Daycare attendance
● Travel history
● Water source
● Pets
● Medications used
● Immunizations

38. Physical Exam
● First assess the state of perfusion of the child, is the child in
shock?
● Tachycardia
● Weak peripheral pulse
● Delayed capillary refil time > 2seconds
● Cold peripheries
● Depressed mental state with or without hypotension

40. Plan A
(Treat Diarrhoea at Home)
1) Give extra fliud
● Breastfeed frequently and for longer at each time
● Continue feeding on demand
● Give ORS after each loose stool (8sachets to use at
home)
2) Continue feeding
● Breastfeeding should continue throughout acute
gastroenteritis
● Formula fed infants should continue their usual formula
immediately on rehydration
● Foods high in simple sugar should be avoided as osmotic
load may worsen the diarrhea
3) When to return? (to clinic/hospital)
● Is not able to drink or breastfeed or drinking poorly
● Become sicker
● Develops fever
● Has blood in stool
Counsel mother on 3 rules of home
treatment:
Show mother how much to give ORS
Up to 2 years: 50-100ml after each loose stool
2 years or more: 100-200ml after each loose stool
(if weight is available, give 10ml/kg of ORS per purge)

41. Plan B:
Oral Rehydration
Therapy (ORT)
• Give frequent small sips from cup or spoon
• If child vomits, wait 10 minutes, then continue but
more slowly (1 spoon full every 2-3 minutes)
AFTER 4 HOURS
• Reasses the child and classify the child for
dehydration;
• Select appropriate plan to continue treatment: (Plan
A/B/C)
If mother have to leave before completing treatment;
-Show mother how to prepare ORS solution at home
-How much to ORS give to finish 4 hour treatment at home
-Give enough ORS packets to complete rehydration (8 sachets)
-Explain 3 Rules of Home Treatment (Plan A)

42. Plan C: Treat Severe Dehydration
Quickly
● Airway, breathing and circulation (ABCs)
● Start IV or IO fluids immediately
● Initial fluids for resuscitation of shock
○ 20ml/kg of 0.9% NS / HM as rapid IV bolus
○ Once circulation restored, commence rehydration, provide maintainence and
replace ongoing losses

43. Workup
• Usually no investigations needed
• May consider the following if severe dehydration:
-Electrolytes
-Blood glucose
-BUN, Cr
-Venous blood gas
• Stool studies
-School/child care or hospital outbreak
-Dysentery, recent travel, and immunocompromised patient

44. Cornerstone of management
● Reassess hydration status frequently and adjust infusion as
necessary
● CAUTION:
○ Children <6 months
○ Children with comorbidities
○ Children needing careful fluid balance (heart or kidney problems, severe
malnutrition)
○ Child with severe hypo/hypernatremia
● Start giving more of the maintainence fluid as oral feeds e.g. ORS
(5ml/kg/hr) as soon as child can tolerate orally

45. If unable to get IV/IO line:
● Send to the nearest center that can do so immediately
● Rehydrate the child with ORS orally by NG or OG tube
○ ORS (20ml/kg/hr) over 6 hours
○ Reassess child every 1-2 hours
● If repeated vomiting/abdominal distension, reduce rate of fluid

46. Indication for IV Therapy
● Unconscious child
● Failed ORS treatment due to
○ Continuous rapid stool loss (>15ml-20ml/kg/hr)
○ Frequent severe vomiting, drinking poorly
● Abdominal distension with paralytic ileus
● Glucose malabsorption

47. Indication for admission
● Shock or severe dehydration
● Failed ORS treatment and need for IV therapy
● Concern for other possible illness or uncertainty of diagnosis
● Patient factors (young age, unusually irritability worsening
symptoms)
● Caregivers not able to provide adequate care at home
● Social or logistical concerns that may prevent return

48. DOPS
● BLOOD C+S