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IV FLUID THERAPY
IN CHILDREN
DR. HAFSA
DNB PAEDIATRICS
MAINTENANCE THERAPY
• Used in a child who cannot be fed enterally.
• Children may require concurrent replacement fluids if they have continued
excessive losses( drainage from NG tube, high urine output in nephrogenic
diabetis insipidus)
• If dehydration is present, deficit replacement will be required.
• Child awaiting surgery- only maintenance fluids
• Child with diarrheal dehydration- maintenance + deficit therapy
+replacement fluids( if significant diarrhea continues)
Goals of maintenance fluids
• Prevent dehydration
• Prevent electrolyte disorders
• Prevent ketoacidosis
• Prevent protein degradation
• Children need not be started on IV, unless there is a pathological process that
necessitates high fluid intake
• Maintenance fluid – preop and postop surgery patients
• Teenager – NPO overnight for morning procedure – IV not required
• 6 month old baby - awaiting surgery- start IV within 8 hours of last feeds.
• Infants become dehydrated more quickly than older patients.
• Children with obligatory high urine output from Nephrogenic diabetes insipidus
should begin receiving IV soon after keeping them NPO
• Maintenance fluid – solution of water, glucose, sodium, potassium : have
simplicity, long shelf life, low cost
• Patient loose water, sodium, potassium in urine and stools; water is lost from
skin and lungs. Maintenance fluid is required to replace the losses to avoid
dehydration and sodium and potassium deficiency.
• Glucose in the fluid – 20% of calorie needs – prevent starvation
ketoacidosis, protein degradation- added osmoles; avoid hypotonic fluid
administration; prevent hemolysis
• Total Parenteral Nutrition should be started in children who cant be fed
enterally for more than few days especially patients with underlying
malnutrition.
• Do not provide- Ca, P, Mg, Bicarbonates
• Child with proximal Renal Tubular Acidosis - loose HCO3 in urine, rapidly
become academic if bicarbonate is not added to maintenance fluids.
Maintenance water
• Obligatory water losses:
- measurable- urine, stools
- not measurable- insensible loss from skin and lungs
- Failure to replace losses- thirsty, uncomfortable and dehydrated child
• Designed to provide enough water; so that kidney need not significantly
dilute or concentrate
• In overweight child – overestimation of water needs can occur- so base the
calculation on lean body weight; estimated by using the 50th percentile of
body weight for child’s height.
Fluid calculation
• Body weight method for calculating daily maintenance fluid volume
• Max total fluid/ day – normally 2400 ml
BODY WEIGHT FLUID PER DAY
0 – 10 Kg 100 ml / Kg
11- 20 Kg 1000 ml + 50 ml /Kg for each Kg > 10 Kg
>20 Kg 1500 ml + 20 ml/ Kg for each Kg > 10 Kg
• Hourly maintenance water rate:
• Max fluid rate is normally 100 ml/hr
Body weight Fluid rate
0- 10 kg 4 ml/kg/hr
10-20 kg 40 ml/ hr + 2ml/kg/hr (wt – 10 kg)
>20 kg 60 ml/hr + 1ml/kg/hr (wt - 20 kg)
IV SOLUTIONS
SL NO COMPOSITION Na+ Cl- K+ Ca2+ LACTATE
1 Normal saline (0.9% Nacl) 154 154 - - -
2 Half normal saline (0.45% Nacl) 77 77 - - -
3 0.2 N.S (0.2 Nacl) 34 34 - - -
4 Ranger lactate 130 109 4 3 28
• These are available with 5% Dextrose, 10% Dextrose or without.
• R.L – k+ (10 or 20 mEq/L)
• Balanced iv fluid – base – lactate / acetate, physiologic Cl- conc > N.S ; K, Ca, Mg
• Eg – RL, PlasmaLyte.
• Normal plasma osmolarity : 285 -295 mosmol/kg.
• Fluid with lower plasma osmolarity - Hemolysis.
• Hypotonic fluid - hyponatremia : isotonic fluid with 5% D are recommended as the
standard maintenance fluid except in neonates.
• Hospitalized children - decrease in water excretion due to volume depletion or non
osmotic stimuli for ADH production such as respiratory ds, CNS ds, pain, nausea,
medication (eg; narcotics)
Selection of maintenance fluid
• Isotonic fluid (NS, RL, PlasmaLyte) with 5% dextrose and KCl (10-20mEq/L)
recommended for maintenance iv fluid.
• Surgery patient - isotonic (NS, RL) - Surgery, post op (2/3rd maintenance rate).
• Patient with persistent ADH (SIADH, Congestive Heart Failure, Nephrotic
Syndrome, Liver Ds) should receive less than maintenance fluids.
• Children with meningitis - fluid restricted unless intravascular volume depletion
occurs.
• In all children : critical to monitor weight, urine output and electrolytes carefully to
identify overhydration or underhydration, hyponatremia and other electrolyte
disturbances.
VARIATION IN MAINTANANACE
WATER AND ELECTROLYTES
Sources of water loss :
• Urine - 60%
• Stool - 5%
• Insensible loss- 35% (skin and lungs)
Children with Cystic Fibrosis , pseudo-hyopoaldosteronism : increase in Na
loss from skin
Adjustments in maintenance water
SL
NO
SOURCE CAUSE OF INREASE IN WATER
NEED
CAUSE OF DECREASE IN WATER
NEEDS
1 SKIN Radiant warmer
Phototherapy
Fever
Sweat
Burns
Incubator (premature infant)
2 LUNGS Tachypnea
Tracheostomy
Humidified ventilator
3 GI TRACT Diarrhea
Emesis
NG suction
4 RENAL Polyurea
5 MISCHELLANEOUS Surgical drain
Third spacing
Replacement fluids
• GI tract : common route of water loss - loss of K - hypokalemia.
• Increase in Hco3 loss in stool - children with diarrhea – lead to metabolic acidosis.
• Volume depletion – hypoperfusion, lactic acidosis.
• Emesis, loss from N.G – result in metabolic alkalosis.
• Losses are replaced every 1-6 hr - depending on rate of loss ; very rapid losses -
replaced frequently
• Diarrhea – M.C.C of fluid loss in children - dehydration, electrolyte disturbance –
replace excessive stools, volume of stool is measured and equal volume of
replacement solution should be given.
Replacement fluid for diarrhea
Average composition of diarrhea :
• Na – 55 mEq/L
• K – 25
• Bicarbonate – 15
Approach to replacement of ongoing loss :
• Solution – D5 ½ NS + 30 mEq/L NaHCO3 + 20 mEq/L KCl.
• Replace stool ml/ml every 1-6 hr.
REPLACEMENT FLUID FOR EMESIS OR
NG LOSSES
Average component of gastric fluid.
• Na : 60 mEq/L
• K : 10 mEq/L
• Cl : 90 mEq/L
Approach to replacement of ongoing loss :
• Solution : N.S + 10 mEq/L KCl
• Replace : output mL/mL every 1-6 hr.
Patient with gastric loss : hypokalemia
• Restore patients intra vascular volume by decrease in aldosterone synthesis, decrease in urinary K
losses.
URINE OUTPUT
• Largest cause of water loss.
• Ds – Renal Failure, SIADH - decrease in urine volume
• Patient with oligurea, anuria – there is decrease in need for water and electrolytes, so
continuation of maintenance fluid – lead to fluid overload.
• Post-obstructive diuresis - polyuric phase of ATN, DM, DI - increase in urine production.
• To prevent dehydration, use > standard maintenance fluids.
• Patient receives fluid at a rate to replace insensible losses - by rate of fluid administration
25- 40 % of normal maintenance rate, depending on patient weight.
• Children with renal insufficiency - receive little or no potassium - as the kidney is the
principle site of K+ excretion.
ADJUSTING FLUID THERAPY FOR
ALTERED RENAL OUTPUT
OLIGURIA / ANURIA :
• Replacement of insensible fluid losses ( 25- 40% of maintenance) with D5 ½ N.S
• Replace urine output mL/mL with D5 ½ N.S +/- KCl
POLYURIA:
• Replacement of insensible fluid losses (25- 40% of maintenance) with D5 1/2 N.S +/- KCl.
• Measure urine electrolytes.
• Replace urine output mL/mL with solution based on measured urine electrolytes.
Third space losses
• Manifest as edema and ascites, caused by shift of fluid from intravascular space into
the interstitial space.
• Cant be quantified easily.
• Can be large, may lead to intravascular volume depletion despite patients weight
gain.
• Third space losses, chest tube output are isotonic, so they require replacement with
an isotonic fluid such as N.S, R.L.
• Protein loss from chest tube drainage can be significant - may require 5% albumin
as a replacement solution.
DEFICIT THERAPY
• Dehydration - M.C by gastroenteritis - M.C problem in children.
• Even children with mild to moderate hyponatremic or hypernatremic
dehydration can be managed with oral rehydration.
CLINICAL EVALUATION OF
DEHYDRATION
• Mild dehydration (<5% in infant, <3% in older child/adult) : Normal or
increase in pulse, decrease in urine output, thirsty, normal physical findings.
• Moderate dehydration (5-10% in infant, 3-6 % in older child or adult) :
tachycardia, little or no urine output, irritable/ lethargic, sunken eyes and fontanel,
decrease in tears, dry mucous membrane, mild delay in elasticity (skin turgor), cool
and pale skin, delayed capillary refill (>1.5 sec).
• Severe dehydration (>10% in an infant; >6% in an older child or adult):
peripheral pulses either rapid and weak or absent, decreased blood pressure, no
urine output, very sunken eyes and fontanel, no tears, parched mucous membranes,
delayed elasticity (poor skin turgor), very delayed capillary refill (>3 sec); cold and
mottled, depressed consciousness
• Degree of dehydration is underestimated in hypernatremic dehydration
because of movement of water from intracellular space to extracellular space
helps preserve the intravascular volume
• Neonate with dehydration caused by poor intake of breast milk often has
hypernatremic dehydration; it can occur in any child with diarrhea, poor oral
intake, because of anorexia or emesis.
• Hyponatremic dehydration occurs in child with diarrhea who is taking large
quantities of low salt fluid such as water or formula.
• Decreased urine output is present in most children with dehydration
• Good urine output may be deceptively present if a child has underlying
renal defect, such as Diabetes Insipidus or a salt wasting nephropathy or in
infants with hypernatremic dehydration.
Lab findings
• Serum Na – type of dehydration
• Serum K –low in diarrheal losses, emesis
high in renal insufficiency
• Metabolic acidosis- diarrhea, secondary renal insufficiency, lactic acidosis
from shock
• Metabolic alkalosis- emesis, NG losses
• BUN, S.Creatinine – useful to assess dehydration
• Volume depletion without parenchymal injury- increased BUN, with normal
S.Creatinine
• Significant rise in S.Creatinine- renal insufficiency
• Acute Kidney Injury- can occur due to volume depletion- mcc of renal insufficiency
• Renal vein thrombosis- sequelae of severe dehydration in infants-
(thrombocytopenia, hematuria)
• Hemoconcentration from dehydration- increase in PCV, Hb, Serum proteins
Calculation of fluid deficit
• Percentage of dehydration x patients weight
• Eg- Child weighing 10 kg and 10 % dehydrated- fluid deficit of 1L
Approach to severe dehydration
• Rapid restoration of circulating intravascular volume and treatment of shock
with an isotonic solution (NS, RL, PlasmaLyte)
• Child is given a fluid bolus, 20 ml/kg of isotonic fluid over 20 minutes
• In a child with known metabolic alkalosis RL or Plasma lyte should not be
used as they contain lactate or acetate which can worsen alkalosis
• Blood – used in significant anemia, acute blood loss
• Plasma used in coagulopathy
• 5% Albumin used in hypoalbumimemia
• Initial resuscitation and rehydration phase is completed- when adequate
intravascular volume is attained – assessed by clinical improvement- normal
HR, BP, adequate perfusion, better urine output, more alert affect.
• A balanced solution can be substituted for NS for further correction of
dehydration (RL, PlasmaLyte)
• In isonatremic or hyponatremic dehydration entire fluid deficits is corrected
over 24 hour, a slower approach is used for hyper natremic dehydration
• Potassium is not usually included in IV fluids until the patient voids and
normal renal function is documented by measurement of BUN and
creatinine
Fluid management of dehydration
• Restore intravascular volume
• Isotonic fluids (NS or RL) 20 ml /kg over 20 minutes
• Repeat as needed
• Calculate 24 hour fluid needs : Maintenance + deficit volume
• Subtract isotoinic fluid already administered from 24 hour fluid needs
• Administer remaining volume over 24 hour using 5% dextrose NS + 20meq/litre
KCl
• Replace ongoing losses as they occur
Monitoring and adjusting therapy
• Child with reduced BP and increased PR will benefit from a fluid bolus
• Input output chart is important in dehydrated child
• Urine output – indicates success of therapy
• Overhydrated – Signs of fluid overload – Edema, Pulmonary congestion
• Dehydration can be associated with acute renal failure and hyperkalemia, K is
withheld from IV fluids until the patient has voided
• Patient with raised serum creatinine and K level of 5 meq /litre does not
receive any K until the serum K level decreases
• Patient with K level of 2.5 meq/litre may require additional K
Monitoring therapy
• Vital signs
Pulse
Blood pressure
• Intake and output
Fluid balance
Urine output
• Physical examination
Weight
Clinical signs of depletion or overload
• Electrolytes
Hyponatremic rehydration
• Pathologic increase in fluid loss containing Na
• Can occur in renal salt wasting, third space losses, cholera, replacing diarrhoeal
fluids with water- without Na
• Volume depletion- ADH synthesis – Reduced water excretion
• Treatment – Initial goal – Correction of intravascular volume depletion with
isotonic fluids
• Rapid / over correction of Na – >12meq/litre over 1st 24 hour/
S.Na>135meq/litre - increased risk of central pontine myelinolysis
• Patient with neurological symptoms (seizures) need to receive an acute
infusion of hypertonic 3% saline to increase S. Na rapidly
Hypernatremic dehydration
• Can cause neurologic damage – CNS hemorrhages and thrombosis
• Occur due to movement of water from brain cells to ECF- Shrinkage of
brain cells and tearing of blood vessels within brain
• Clinically child lethargic, irritable when touched, fever, hypertonicity,
hyper-reflexia
• Mild to moderate hypernatremic dehydration can be corrected with oral
rehydration
• Severe case- Oral fluids must be used cautiously as it may contribute to rapid
decrease in S. Na because of its low Na concentration and increased free
water content
• To minimize risk of cerebral edema during the correction of hypernatremic
dehydration, S. Na concentration should not be decreased by >10meq/litre
every 24 hour. The deficit in severe hypernatremic dehydration may need to
be corrected over 2 - 4 days
• Rate of reduction of S. Na is related to free water delivery (water without
Na) – Water – 100% free water, ½ NS has 50% free water
Treatment of hypernatremic dehydration
• Restore intra vascular volume
NS : 20ml/kg over 20 minutes (Repeat until intra vascular volume restored)
Determine time for correction on basis of initial Na concentration :
{Na} 145-157 meq / litre : 24 hour
{Na} 158-170 meq / litre : 48 hour
{Na} 171-183 meq / litre : 72 hour
{Na} 184-196 meq / litre : 84 hour
• Administer fluid at constant rate over time for correction :
Typical fluid : 5% dextrose + ½ NS (with 20 meq/litre KCl unless contra
indicated)
• Typical rate : 1.25-1.5 times maintenance
• Follow S. Na concentration
• Adjust fluid on basis of clinical status and S. Na concentration
Signs of volume depletion : Administer NS 20 ml/kg
• Na decreases too rapidly :
Increase Na concentration of IV fluids
Decease rate of IV fluids
• Na decrease too slowly :
Decrease Na concentration of IV fluids
Increase rate of IV fluids
• Replace ongoing losses as they occur
Thank you

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IV FLUID THERAPY IN CHILDREN.pptx

  • 1. IV FLUID THERAPY IN CHILDREN DR. HAFSA DNB PAEDIATRICS
  • 2. MAINTENANCE THERAPY • Used in a child who cannot be fed enterally. • Children may require concurrent replacement fluids if they have continued excessive losses( drainage from NG tube, high urine output in nephrogenic diabetis insipidus) • If dehydration is present, deficit replacement will be required. • Child awaiting surgery- only maintenance fluids • Child with diarrheal dehydration- maintenance + deficit therapy +replacement fluids( if significant diarrhea continues)
  • 3. Goals of maintenance fluids • Prevent dehydration • Prevent electrolyte disorders • Prevent ketoacidosis • Prevent protein degradation
  • 4. • Children need not be started on IV, unless there is a pathological process that necessitates high fluid intake • Maintenance fluid – preop and postop surgery patients • Teenager – NPO overnight for morning procedure – IV not required • 6 month old baby - awaiting surgery- start IV within 8 hours of last feeds. • Infants become dehydrated more quickly than older patients. • Children with obligatory high urine output from Nephrogenic diabetes insipidus should begin receiving IV soon after keeping them NPO
  • 5. • Maintenance fluid – solution of water, glucose, sodium, potassium : have simplicity, long shelf life, low cost • Patient loose water, sodium, potassium in urine and stools; water is lost from skin and lungs. Maintenance fluid is required to replace the losses to avoid dehydration and sodium and potassium deficiency. • Glucose in the fluid – 20% of calorie needs – prevent starvation ketoacidosis, protein degradation- added osmoles; avoid hypotonic fluid administration; prevent hemolysis
  • 6. • Total Parenteral Nutrition should be started in children who cant be fed enterally for more than few days especially patients with underlying malnutrition. • Do not provide- Ca, P, Mg, Bicarbonates • Child with proximal Renal Tubular Acidosis - loose HCO3 in urine, rapidly become academic if bicarbonate is not added to maintenance fluids.
  • 7. Maintenance water • Obligatory water losses: - measurable- urine, stools - not measurable- insensible loss from skin and lungs - Failure to replace losses- thirsty, uncomfortable and dehydrated child • Designed to provide enough water; so that kidney need not significantly dilute or concentrate
  • 8. • In overweight child – overestimation of water needs can occur- so base the calculation on lean body weight; estimated by using the 50th percentile of body weight for child’s height.
  • 9. Fluid calculation • Body weight method for calculating daily maintenance fluid volume • Max total fluid/ day – normally 2400 ml BODY WEIGHT FLUID PER DAY 0 – 10 Kg 100 ml / Kg 11- 20 Kg 1000 ml + 50 ml /Kg for each Kg > 10 Kg >20 Kg 1500 ml + 20 ml/ Kg for each Kg > 10 Kg
  • 10. • Hourly maintenance water rate: • Max fluid rate is normally 100 ml/hr Body weight Fluid rate 0- 10 kg 4 ml/kg/hr 10-20 kg 40 ml/ hr + 2ml/kg/hr (wt – 10 kg) >20 kg 60 ml/hr + 1ml/kg/hr (wt - 20 kg)
  • 11. IV SOLUTIONS SL NO COMPOSITION Na+ Cl- K+ Ca2+ LACTATE 1 Normal saline (0.9% Nacl) 154 154 - - - 2 Half normal saline (0.45% Nacl) 77 77 - - - 3 0.2 N.S (0.2 Nacl) 34 34 - - - 4 Ranger lactate 130 109 4 3 28
  • 12. • These are available with 5% Dextrose, 10% Dextrose or without. • R.L – k+ (10 or 20 mEq/L) • Balanced iv fluid – base – lactate / acetate, physiologic Cl- conc > N.S ; K, Ca, Mg • Eg – RL, PlasmaLyte. • Normal plasma osmolarity : 285 -295 mosmol/kg. • Fluid with lower plasma osmolarity - Hemolysis. • Hypotonic fluid - hyponatremia : isotonic fluid with 5% D are recommended as the standard maintenance fluid except in neonates. • Hospitalized children - decrease in water excretion due to volume depletion or non osmotic stimuli for ADH production such as respiratory ds, CNS ds, pain, nausea, medication (eg; narcotics)
  • 13. Selection of maintenance fluid • Isotonic fluid (NS, RL, PlasmaLyte) with 5% dextrose and KCl (10-20mEq/L) recommended for maintenance iv fluid. • Surgery patient - isotonic (NS, RL) - Surgery, post op (2/3rd maintenance rate). • Patient with persistent ADH (SIADH, Congestive Heart Failure, Nephrotic Syndrome, Liver Ds) should receive less than maintenance fluids. • Children with meningitis - fluid restricted unless intravascular volume depletion occurs. • In all children : critical to monitor weight, urine output and electrolytes carefully to identify overhydration or underhydration, hyponatremia and other electrolyte disturbances.
  • 14. VARIATION IN MAINTANANACE WATER AND ELECTROLYTES Sources of water loss : • Urine - 60% • Stool - 5% • Insensible loss- 35% (skin and lungs) Children with Cystic Fibrosis , pseudo-hyopoaldosteronism : increase in Na loss from skin
  • 15. Adjustments in maintenance water SL NO SOURCE CAUSE OF INREASE IN WATER NEED CAUSE OF DECREASE IN WATER NEEDS 1 SKIN Radiant warmer Phototherapy Fever Sweat Burns Incubator (premature infant) 2 LUNGS Tachypnea Tracheostomy Humidified ventilator 3 GI TRACT Diarrhea Emesis NG suction 4 RENAL Polyurea 5 MISCHELLANEOUS Surgical drain Third spacing
  • 16. Replacement fluids • GI tract : common route of water loss - loss of K - hypokalemia. • Increase in Hco3 loss in stool - children with diarrhea – lead to metabolic acidosis. • Volume depletion – hypoperfusion, lactic acidosis. • Emesis, loss from N.G – result in metabolic alkalosis. • Losses are replaced every 1-6 hr - depending on rate of loss ; very rapid losses - replaced frequently • Diarrhea – M.C.C of fluid loss in children - dehydration, electrolyte disturbance – replace excessive stools, volume of stool is measured and equal volume of replacement solution should be given.
  • 17. Replacement fluid for diarrhea Average composition of diarrhea : • Na – 55 mEq/L • K – 25 • Bicarbonate – 15 Approach to replacement of ongoing loss : • Solution – D5 ½ NS + 30 mEq/L NaHCO3 + 20 mEq/L KCl. • Replace stool ml/ml every 1-6 hr.
  • 18. REPLACEMENT FLUID FOR EMESIS OR NG LOSSES Average component of gastric fluid. • Na : 60 mEq/L • K : 10 mEq/L • Cl : 90 mEq/L Approach to replacement of ongoing loss : • Solution : N.S + 10 mEq/L KCl • Replace : output mL/mL every 1-6 hr. Patient with gastric loss : hypokalemia • Restore patients intra vascular volume by decrease in aldosterone synthesis, decrease in urinary K losses.
  • 19. URINE OUTPUT • Largest cause of water loss. • Ds – Renal Failure, SIADH - decrease in urine volume • Patient with oligurea, anuria – there is decrease in need for water and electrolytes, so continuation of maintenance fluid – lead to fluid overload. • Post-obstructive diuresis - polyuric phase of ATN, DM, DI - increase in urine production. • To prevent dehydration, use > standard maintenance fluids. • Patient receives fluid at a rate to replace insensible losses - by rate of fluid administration 25- 40 % of normal maintenance rate, depending on patient weight. • Children with renal insufficiency - receive little or no potassium - as the kidney is the principle site of K+ excretion.
  • 20. ADJUSTING FLUID THERAPY FOR ALTERED RENAL OUTPUT OLIGURIA / ANURIA : • Replacement of insensible fluid losses ( 25- 40% of maintenance) with D5 ½ N.S • Replace urine output mL/mL with D5 ½ N.S +/- KCl POLYURIA: • Replacement of insensible fluid losses (25- 40% of maintenance) with D5 1/2 N.S +/- KCl. • Measure urine electrolytes. • Replace urine output mL/mL with solution based on measured urine electrolytes.
  • 21. Third space losses • Manifest as edema and ascites, caused by shift of fluid from intravascular space into the interstitial space. • Cant be quantified easily. • Can be large, may lead to intravascular volume depletion despite patients weight gain. • Third space losses, chest tube output are isotonic, so they require replacement with an isotonic fluid such as N.S, R.L. • Protein loss from chest tube drainage can be significant - may require 5% albumin as a replacement solution.
  • 22. DEFICIT THERAPY • Dehydration - M.C by gastroenteritis - M.C problem in children. • Even children with mild to moderate hyponatremic or hypernatremic dehydration can be managed with oral rehydration.
  • 23. CLINICAL EVALUATION OF DEHYDRATION • Mild dehydration (<5% in infant, <3% in older child/adult) : Normal or increase in pulse, decrease in urine output, thirsty, normal physical findings. • Moderate dehydration (5-10% in infant, 3-6 % in older child or adult) : tachycardia, little or no urine output, irritable/ lethargic, sunken eyes and fontanel, decrease in tears, dry mucous membrane, mild delay in elasticity (skin turgor), cool and pale skin, delayed capillary refill (>1.5 sec). • Severe dehydration (>10% in an infant; >6% in an older child or adult): peripheral pulses either rapid and weak or absent, decreased blood pressure, no urine output, very sunken eyes and fontanel, no tears, parched mucous membranes, delayed elasticity (poor skin turgor), very delayed capillary refill (>3 sec); cold and mottled, depressed consciousness
  • 24. • Degree of dehydration is underestimated in hypernatremic dehydration because of movement of water from intracellular space to extracellular space helps preserve the intravascular volume • Neonate with dehydration caused by poor intake of breast milk often has hypernatremic dehydration; it can occur in any child with diarrhea, poor oral intake, because of anorexia or emesis. • Hyponatremic dehydration occurs in child with diarrhea who is taking large quantities of low salt fluid such as water or formula.
  • 25. • Decreased urine output is present in most children with dehydration • Good urine output may be deceptively present if a child has underlying renal defect, such as Diabetes Insipidus or a salt wasting nephropathy or in infants with hypernatremic dehydration.
  • 26. Lab findings • Serum Na – type of dehydration • Serum K –low in diarrheal losses, emesis high in renal insufficiency • Metabolic acidosis- diarrhea, secondary renal insufficiency, lactic acidosis from shock • Metabolic alkalosis- emesis, NG losses • BUN, S.Creatinine – useful to assess dehydration
  • 27. • Volume depletion without parenchymal injury- increased BUN, with normal S.Creatinine • Significant rise in S.Creatinine- renal insufficiency • Acute Kidney Injury- can occur due to volume depletion- mcc of renal insufficiency • Renal vein thrombosis- sequelae of severe dehydration in infants- (thrombocytopenia, hematuria) • Hemoconcentration from dehydration- increase in PCV, Hb, Serum proteins
  • 28. Calculation of fluid deficit • Percentage of dehydration x patients weight • Eg- Child weighing 10 kg and 10 % dehydrated- fluid deficit of 1L
  • 29. Approach to severe dehydration • Rapid restoration of circulating intravascular volume and treatment of shock with an isotonic solution (NS, RL, PlasmaLyte) • Child is given a fluid bolus, 20 ml/kg of isotonic fluid over 20 minutes • In a child with known metabolic alkalosis RL or Plasma lyte should not be used as they contain lactate or acetate which can worsen alkalosis • Blood – used in significant anemia, acute blood loss • Plasma used in coagulopathy
  • 30. • 5% Albumin used in hypoalbumimemia • Initial resuscitation and rehydration phase is completed- when adequate intravascular volume is attained – assessed by clinical improvement- normal HR, BP, adequate perfusion, better urine output, more alert affect. • A balanced solution can be substituted for NS for further correction of dehydration (RL, PlasmaLyte)
  • 31. • In isonatremic or hyponatremic dehydration entire fluid deficits is corrected over 24 hour, a slower approach is used for hyper natremic dehydration • Potassium is not usually included in IV fluids until the patient voids and normal renal function is documented by measurement of BUN and creatinine
  • 32. Fluid management of dehydration • Restore intravascular volume • Isotonic fluids (NS or RL) 20 ml /kg over 20 minutes • Repeat as needed • Calculate 24 hour fluid needs : Maintenance + deficit volume • Subtract isotoinic fluid already administered from 24 hour fluid needs • Administer remaining volume over 24 hour using 5% dextrose NS + 20meq/litre KCl • Replace ongoing losses as they occur
  • 33. Monitoring and adjusting therapy • Child with reduced BP and increased PR will benefit from a fluid bolus • Input output chart is important in dehydrated child • Urine output – indicates success of therapy • Overhydrated – Signs of fluid overload – Edema, Pulmonary congestion • Dehydration can be associated with acute renal failure and hyperkalemia, K is withheld from IV fluids until the patient has voided
  • 34. • Patient with raised serum creatinine and K level of 5 meq /litre does not receive any K until the serum K level decreases • Patient with K level of 2.5 meq/litre may require additional K
  • 35. Monitoring therapy • Vital signs Pulse Blood pressure • Intake and output Fluid balance Urine output • Physical examination Weight Clinical signs of depletion or overload • Electrolytes
  • 36. Hyponatremic rehydration • Pathologic increase in fluid loss containing Na • Can occur in renal salt wasting, third space losses, cholera, replacing diarrhoeal fluids with water- without Na • Volume depletion- ADH synthesis – Reduced water excretion • Treatment – Initial goal – Correction of intravascular volume depletion with isotonic fluids • Rapid / over correction of Na – >12meq/litre over 1st 24 hour/ S.Na>135meq/litre - increased risk of central pontine myelinolysis
  • 37. • Patient with neurological symptoms (seizures) need to receive an acute infusion of hypertonic 3% saline to increase S. Na rapidly
  • 38. Hypernatremic dehydration • Can cause neurologic damage – CNS hemorrhages and thrombosis • Occur due to movement of water from brain cells to ECF- Shrinkage of brain cells and tearing of blood vessels within brain • Clinically child lethargic, irritable when touched, fever, hypertonicity, hyper-reflexia • Mild to moderate hypernatremic dehydration can be corrected with oral rehydration
  • 39. • Severe case- Oral fluids must be used cautiously as it may contribute to rapid decrease in S. Na because of its low Na concentration and increased free water content • To minimize risk of cerebral edema during the correction of hypernatremic dehydration, S. Na concentration should not be decreased by >10meq/litre every 24 hour. The deficit in severe hypernatremic dehydration may need to be corrected over 2 - 4 days • Rate of reduction of S. Na is related to free water delivery (water without Na) – Water – 100% free water, ½ NS has 50% free water
  • 40. Treatment of hypernatremic dehydration • Restore intra vascular volume NS : 20ml/kg over 20 minutes (Repeat until intra vascular volume restored) Determine time for correction on basis of initial Na concentration : {Na} 145-157 meq / litre : 24 hour {Na} 158-170 meq / litre : 48 hour {Na} 171-183 meq / litre : 72 hour {Na} 184-196 meq / litre : 84 hour
  • 41. • Administer fluid at constant rate over time for correction : Typical fluid : 5% dextrose + ½ NS (with 20 meq/litre KCl unless contra indicated) • Typical rate : 1.25-1.5 times maintenance • Follow S. Na concentration • Adjust fluid on basis of clinical status and S. Na concentration Signs of volume depletion : Administer NS 20 ml/kg
  • 42. • Na decreases too rapidly : Increase Na concentration of IV fluids Decease rate of IV fluids • Na decrease too slowly : Decrease Na concentration of IV fluids Increase rate of IV fluids • Replace ongoing losses as they occur