Fluid Therapy in Illness

1. Fluid Requirements And Its
Imbalances
Presenter- Dr Rachit(JR-1)
Moderator-Dr Naveen(AP)

2. Scope of the Seminar
1)Physiology and fluid dynamics
2) Assessment of fluid deficits
3)Fluid therapy – 4Rs

3. 1)Fluid Distribution
2)Concept of osmolality/tonicity
3)Types of fluids and their composition
4)Normal fluid requirements in children
1. Physiology and Fluid Dynamics

4. Fluid Distribution..

5. Fluid Distribution.

6. K+
Na+ Cl
Body
Fluid
Compartments

7. Electrolyte Composition of
Compartments

8. OSMOLALITY..
• No. of osmoles/kg of solution.
• Osmoles
• They are the number of moles of particles present in
that solution
• Can be ions or molecules
• Measured by degree of freezing point
– the solute the freezing point

9. • Plasma osmolality
• 285-295 mOsm/kg
• Pressure and temp. independent
• Osmolality= 2x{Na}+{glucose}/18 + {BUN}/2.8
OSMOLALITY.

10. Effective Osmolality/Tonicity
• Measure of the water pressure inside of a cell as
compared to the water pressure outside of the
cell.
• Only influenced by substances that cannot cross
the membrane.
• Effective osmolality= 2x{Na}+{glucose}/18

11. Regulation of Na+ & Water Balance

12. • Preserve body water volume
• Preserve electrolyte composition
• To provide energy
Goal of Fluid Therapy

13. Conditions that alter maintenance
fluid needs
• Inc. fluid req.
– Fever (10-15% per °C above 38°C) Radiant warmer,
phototherapy ·
– Burns, sweating Physical activity; hyperventilation
– Diarrhea, vomiting polyuria,
– Very low birth weight babies
• Dec.fluid req.
• Oliguria or anuria
• Humidified ventilator
• hypothyroidism

14. Fluid needs in children

15. Normal Physiological Needs

16. Holliday Segar Method
NOT FOR OBESE( choose BSA)/ >65 Kg = 2400ml

17. BODY SURFACE METHOD

18. • Sodium = 2-3 mEq/100 ml water per day
• Potassium = 1-2 mEq/100 ml water per day
• Dextrose= Varies from condition to condition
Electrolyte and Dextrose Needs

19. Types and composition of fluid
Types of fluids
I/V fluids
Colloids Crystalloids
Oral
ORS

20. ORS

21. ReSoMal
• Rehydration Solution in severely malnourished
children with dehydration.
• High Na+ & low K+
• Contents:
• Potassium: 40 mEq/ L
• Sodium: 45 mEq/ L
• Magnesium, zinc, copper.
• Dose=5ml/ kg every 30 mins for first 2 hrs if
breastfed=continue breastfeeding

23. Crystalloids
Isotonic Hypotonic Hypertonic

25. Types of colloids
• 1-dextran
• complex polysaccharide
• are two types=HMW(70000) & LMW(40000)
• Dose: 10-20-ml/kg/ d IV infusions
• Easily stored for long time.
• may be associated with abnormal bleeding
• Contraindications
• Hypersensitivity, Marked hemostatic defects, Heart
Failure

26. • Gelatin (Haemaccel 30-35000)
• MW 5000 to 50000 (24000)
• Duration is about 2-5h
• Two types succinylated gelatin or polygeline
• Succinylated gelatin is less antigenic
• Haemaccel (Urea-linked gelatin)
• Conc. 3.5 % up to 2.5L/day.
• Stable for 3 years
• 60-80 % secreted by kidney

27. • Conc. 3.5 % up to 2.5L/day.
• Stable for 3 years
• 60-80 % secreted by kidney
• Less antigenic
• Not interfere with cross matching.
• No bleeding

28. • Hydroxy ethyl starch:
• nonionic starch derivative
• Given in Hypovolemic shock
• Adverse effects
• hypersensitivity,bleeding,Expensive=no advantage over gelatin &
dextran .

29. • Albumin(5%)
• Hypovolemia with or without shock
• Hypoalbuminemia
• Hemolytic disease of newborns
• Extensive Hemodialysis

30. Glucose concentrated fluids
• Indications
• Hypoglycemia
• To provide energy/cal
• Hyperinsulinemia
• Nutritional support
• TPN

31. GIR

32. ADH and Fluid Therapy
Unsuitable candidates for fluid replacement

33. Prescribing fluid in Children
Anticipation and Assessment
Choosing right fluid/ Route
Monitoring

34. Anticipate the problem
• On the basis of history

35. Assessment

36. Assessment
Resuscitation
Routine
maintenance
Redistribution
and Replacement

37. Assessment and monitoring

38. Fluid resuscitation

39. Septic Shock algorithm- 2020
UPDATE

40. Fluid resuscitation in SAM

41. Routine maintenance

42. Ongoing Losses For Children

43. Replacement and redistribution

44. Deficit Replacement
Solute Water

45. Water Deficit Replacement
• Water deficit Volume
– Water Deficit (L) =
• Pre-illness weight (kg) – Illness weight (kg)
• % Dehydration =
– (Pre-illness weight – illnessweight)/ Pre-illness weight x
100
• Each 1% dehydration corresponds to 10ml/kg
fluid deficit

46. Ongoing Losses
• give additional 10ml/ kg of ORS for each
additional diarrheal stool.
• Types of ORS
• Zinc fortified ORS
• ORS fortified with amino acids.
• Home made ORS
– 4g salt + 40g sugar in 1 L of water

47. Solute Deficit Replacement
• Na+ deficit (mEq)
• fluid deficit (L) x proportion from ECF (0.6) x Na+ conc.
(mEq/L) in ECF (145)
• K+ deficit (mEq)
• fluid deficit (L) x proportion from ICF (0.4) x K+ conc.
(mEq/L) in ICF(150)

48. • Excess Electrolyte Deficits
• mEq required = [conc. desired (mEq/L) – conc.present
(mEq/L) x fluid deficit x weight
• Free water deficit(FWD)
• 4ml/kg x pre-illness wt. (kg) x [Conc. present (mEq/L) –
[Conc. desired (mEq/L)]
• Solute fluid Deficit= Total fluid deficit – FWD
• Solute Na+ deficit = SFD (L) x 0.6 x 145
• Solute K+ deficit = SFD (L) x 0.4 x 150

49. Amt. of ORS To Be Given(No &
Some Dehydration)
•Age
•<24 months = 50-100 ml/ loose stool
•2-10yr= 100-200ml/loose stool
•>10yr=Ad lib.

50. Oral rehydration therapy in SAM
• Low osmolarity ors in 2 lt H20 + 50g sugar +
40ml of mineral mix solution
• If mineral mix not available then add 45ml of
syp. KCL
• Dose= 5-10ml/kg/hr upto max of 12 hr.
• Refeeding with F-75 within 2-3 hrs of starting
rehydartion.

51. • Rehydration monitored every ½ hourly for 2
hours then hrly for next 4-10 hours.

53. Fluid Therapy in Neonates

54. Maintenance fluid req during 1st week

55. Complications of Fluid Therapy
• Thrombophlebitis
• Sepsis
• Periphral edema
• Hypertension
• Cardiac Failure
• Electrolyte Imbalances (Discuss hypo and
hypernatremia)
• Resp Failure

56. Hypernatremia During IV Therapy
• No evidence of dehydration
– Consider hypotonic fluid( 0.45% NS)
• If dehydration
– Replace the water deficit over 48 hrs with0.9% NS
– Rate of Na+ fall <12mmol/litre

57. Hyponatremia During IV Therapy
• Change to isotonic fluid if child is on hypotonic
fluid
• Restrict maintenance fluid to 50-80%

58. Referernces
1. Nelson textbook of Pediatrics
2. OP Ghai textbook of Pediatrics
3. Harriet Lane
4. NICE guidelines -2016, 2020
5. F IMNCI

59. THANK YOU