This document discusses maintenance and replacement fluid therapy in children. It begins by outlining the objectives of understanding the differences in pediatric physiology and the goals of maintenance fluid therapy. It then covers topics like the vulnerability of infants, the distribution of body water, electrolyte concentrations, commonly used IV fluids, and calculating fluid requirements using the 4-2-1 rule. The document emphasizes the importance of monitoring weight, urine output, and serum electrolytes when administering fluids. It also provides guidance on choosing appropriate replacement fluids for issues like diarrhea, vomiting, and altered renal output.
Fluid therapy in pediatrics/ oral dehydration solution/Dehydration.Haneen Hassan
Introduction.
Oral rehydration solution.
How to prepare ORS.
How to administer ORS.
How to give ORS.
Limitation of ORS.
Definition of Dehydration.
Degree of dehydration.
The purpose of this presentation is to provide an overview of fluid and electrolyte maintenance related handicaps and physiological changes in early neonatal period and its management in brief.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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ASA GUIDELINE
NYSORA Guideline
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. OBJECTIVES
To know the difference in physiology of children.
To know the Goals of maintenance fluid therapy.
Able to Calculate total fluid requirement & do
monitoring of the patient.
To know Variations in maintenance water &
electrolytes.
To order Replacement fluids in “common”
situations.
3. WHY THE INFANTS ARE MORE VULNERABLE?*
Physiological inability to concentrate urine.
Higher metabolic rate & larger surface area.
Cant express thirst for more fluids.
Larger turnover.
*IAP text book of Pediatrics 5th edition
4. WHOM TO GIVE MAINTENANCE FLUIDS?
Infants who are sick & whose oral intake is
uncertain.
Babies who are kept NBM for the surgery, with
respiratory distress etc.
neonates kept under radiant warmer.
5. GOALS OF MAINTENANCE FLUIDS*
Prevent dehydration
Prevent electrolyte disturbance
Prevent ketoacidosis
Prevent protein degradation
*Nelsons Text book of pediatrics 19th edition
6. AT BIRTH…
75 % of the total body weight
Obligatory diuretic phase
65 % of the total body weight
Next 2 – 3 Days
At the end of Ist year
60 % of the total body weight
7.
8. BACK TO PHYSIOLOGY…
Total Body Water 60%*
Intra cellular fluid
(ICF)
40%
Extra cellular fluid
(ECF)
20%
Interstitial
15%
Intravasular
5%
*IAP text book of Pediatrics 5th edition
12. KEY LEARNING POINT*
Sodium is the Principle electrolyte in ECF
[140mEq/L (+/- 5)]
Potassium is the Principle electrolyte in ICF
[150mEq/L (+/- 5)]
*IAP text book of Pediatrics 5th edition
13. Maintenance fluids consists of-
i. Water
ii. Glucose
iii. Sodium
iv. Potassium
Advantages –
Simplicity, long shelf life, low cost, compatibility.
Prototypical maintenance therapy fluid doesn’t
provide calcium, phosphorus, magnesium or
bicarbonate.*
*Nelsons Text book of pediatrics 19th edition
15. CONCEPT OF MAINTENANCE OF WATER
Crucial component of maintenance fluid therapy.
Maintenance water = Measurable loss of water 65%
(Urine 60%, stools 5%) + Insensible of water 35% (skin
& lungs)
16. FOR NEONATES
Day 1 60 ml/kg/day
Day 2 90 ml/kg/day
Day 3 120 ml/kg/day
Day 4 150 ml/kg/day (maximum for term infants)
Day 5 to 3 months 150 ml/kg/day
18. Maintenance Fluids
Hourly Maintenance Fluid Requirement*
“4 - 2 -1 rule”
WEIGHT FLUID
0 - 10 kg 4 ml/kg/hr
10 - 20 kg 40ml/hr + 2 ml/kg/hr
> 20 kg 60ml/hr + 1 ml/kg/hr
Upper limit 100cc/hr
*Nelsons Text book of pediatrics 19th edition
19. CONCEPT OF MAINTENANCE OF
ELECTROLYTES
Insensible water loss contains no electrolytes*
So, sodium & potassium present in the urine, stools
& sweat would be the amount to be replaced plus
the sodium & potassium required for normal
metabolism of the body.
3mEq of sodium in 100 cc of fluid
&
2mEq of potassium in 100 cc of fluid
*IAP text book of Pediatrics 5th edition
20. Maintenance fluids usually contains 5% dextrose (5
gm/100ml) providing 17 calories/ 100 ml of fluid.
Which is approx. 20% of the daily caloric needs.
Prevents ketone production.
CONCEPT OF MAINTENANCE OF GLUCOSE*
*Nelsons Text book of pediatrics 19th edition
21. COMMONLY USED FLUIDS FOR
MAINTENANCE*
I. 0.9% Normal Saline – Think of it as ‘Salt and water’
Principal fluid used for intravascular resuscitation and replacement of
salt loss e.g diarrhoea and vomiting
Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l; K+ - Absent, But
K+ is often added
IsoOsmolar compared to normal plasma
Distribution: Stays almost entirely in the Extracellular space
Does not provide free water or calories. Restores NaCl deficits.
*The Harriet Lane Handbook 19th edition
22. CONTENTS OF IV FLUID PREPARATIONS*
Na
(mEq/L)
K
(mEq/L)
Cl
(mEq/L)
HCO3
(mEq/L)
Dextrose
(gm/L)
mOsm/L
NS 154 154 308
DNS 154 154 50 564
½ NS 77 77 143
5%D +
1/2NS
77 77 50 350
D5W 50 278
Ringers
Lactate
(RL)
130 4 109 28 50 273
Iso P 23 20 23 30 50 367
Iso M 37 35 37 30 50 415.5
*The Harriet Lane Handbook 19th edition
23. II. Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L.
Contains 130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate, and 4
mEq/L K+, 3 mEq/L Ca++
Lactate is used instead of bicarb because it's more stable in IVF
during storage.
Lactate is converted readily to bicarb by the liver.
Has minimal effects on normal body fluid composition and pH. More
closely resembles the electrolyte composition of normal blood serum.
Does not provide calories.
COMMONLY USED FLUIDS FOR MAINTENANCE
24. HOW TO CHOOSE?*
0.9% sodium chloride Suitable for initial volume resuscitation in hypovolaemia
and for ongoing fluid therapy in older children with
normal serum glucose. Fluid of choice in patients with
head injury
5% dextrose + 0.9%
sodium
chloride
Suitable for ongoing fluid therapy in infants and
children, including post-operative cardiac patients. Use
in head injured patients with hypoglycaemia.
5% dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in infants and
children, including post-operative cardiac patients
10%dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in neonates or older
infants who are hypoglycaemic, including post-operative
cardiac patients
*Leeds Teaching Hospitals NHS Trust Paediatric Intensive Care Units
25. MONITORING WHILE ADMINISTERING FLUIDS*
Child should be weighed prior to the commencement of
therapy, and daily afterwards.
Children with ongoing dehydration/ongoing losses may
need 6 hourly weights to assess hydration status
All children on IV fluids should have serum electrolytes
and glucose checked before commencing the infusion
(typically when the IV is placed) and again within 24 hours
if IV therapy is to continue.
*Royale Children’s Hospital Melbourne Guidelines
26. MONITORING WHILE ADMINISTERING FLUIDS*
For more unwell children, check the electrolytes and
glucose 4-6 hours after commencing, and then according
to results and the clinical situation but at least daily.
Pay particular attention to the serum sodium on measures
of electrolytes. If <135mmol/L (or falling significantly on
repeat measures) If >145mmol/L (or rising significantly on
repeat measures)
Children on iv fluids should have a fluid balance chart
documenting input, ongoing losses and urine output.
*Royale Children’s Hospital Melbourne Guidelines
27. MAINTENANCE FLUIDS & HYPONATREMIA*
Production of ADH leading to water retention
leading to water intoxication.
Patients producing ADH due to subtle volume
depletion can be safely treated with fluids
containing higher sodium concentration, decrease
in fluid rate or the combination of both.
Persistent ADH production due to underlying
disease requires less than total maintenance fluids
Individualization & careful monitoring is must.
*Nelsons Text book of pediatrics 19th edition
28. VARIATIONS IN MAINTENANCE WATER &
ELECTROLYTES
Source Causes of increased water
needs
Causes of decreased water
needs
Skin Radiant warmer Incubator
Phototherapy
Fever
Sweat
Burns
lungs Tachypnea Humidified ventilator
Tracheastomy
GI tract Diarrhea
Vomiting
Nasogastric secretion
renal Polyuria Oligo/anuria
Misc. Surgical drain hypothyroidism
Third spacing
29. REPLACEMENT FLUIDS*
In addition to normal maintenance fluid
requirements, unwell children may need:
Fluid resuscitation for shock
Replacement of pre-existing fluid losses
Replacement of ongoing fluid losses
*Royale Children’s Hospital Melbourne Guidelines
30. REPLACEMENT FLUIDS*
GI losses are accompanied with loss of potassium,
bicarbonate leading to metabolic acidosis.
Impossible to predict the loses for next 24 hrs, so
measure & replace excess GI losses as they occur.
So each ml of the diarrheal stool or the vomitus
should be replaced by the same amount every 1 to
6 hourly.
*Nelsons Text book of pediatrics 19th edition
31. REPLACEMENT FLUIDS
Replacement fluid for Diarrhea*
Average composition of Diarrheal stools (except cholera)
Na 55 mEq/l
K 25 mEq/l
Bicarbonate 15 mEq/l
Approach to Replacement of Ongoing Losses
D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl
Replace stools ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 19th edition
32. REPLACEMENT FLUIDS
Replacement fluid for Emesis or Nasogastric losses*
Average composition of Gastric Fluid
Na 60 mEq/l
K 10 mEq/l
Chloride 90 mEq/l
Approach to Replacement of Ongoing Losses
NS + 10 mEq/l KCl
Replace Output ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 19th edition
33. REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria / Anuria
Place patient on insensible fluids (25 to 40% of maintenance)
Replace Urine output ml/ml by half NS
Polyuria
Place patient on insensible fluids (25 to 40% of maintenance)
Measure urine electrolytes
Replace Urine output ml/ml by solution based on measured urine
electrolytes
*Nelsons Text book of pediatrics 19th edition
34. CASE I
5 day old baby boy weighing 3 kg having total
billirubin 18.0 is to be kept under phototherapy.
Baby having no other risk factors & accepts DBM
well.
What fluid at what rate should we prescribe?
35. Rate Day 5 (150 ml/kg/day)
Weight 3 kg
So,
150 * 3 = 750 ml is the total maintainence.
For the babies under phototherapy we should give
half of the maintainence.
So 375 ml/24 hrs i.e 125 ml / 8hrly
Fluid of choice is 5% dextrose + 0.45% NS or iso P
will also be suitable.
36. CASE II
7 year old girl (weight 20 kg) admitted for
bronchopneumonia with respiratory rate of 44/min &
fever of 102 F. later developed 4 episodes of
vomiting (each of 25 ml quantity) & loose stools 3
episodes (each of 80 ml quantity)
37. Weight 20 kg.
So, Total maintenance fluid will be
(100*10) + (50*10) = 1500 ml/ day i.e 500 ml / 8 hrly
Choice of fluid will be 0.45% DNS + 20mEq/L KCl
Replacement fluid for vomiting (each of 25 ml quantity) =
25 * 4 =100 ml of NS + 10 mEq/l KCl
Replacement fluid for loose stools (each of 80 ml
quantity) = 80 * 3 =240 ml of 0.2% DNS + 20 mEq/l
sodium bicarbonate + 20 mEq/l KCl.
38. TACHYPNEA
Respiratory Alkalosis
Increase in rate and
depth of breathing
Loss of CO2
Causes of hyperventilation (tachypnea): Fear, pain, fever, CHF,
anemia
39. FEVER
Each degree of fever increases basal
metabolic rate (BMR) 10%, with a
corresponding fluid requirement
40. VOMITING
Metabolic Alkalosis
Loss of acid from stomach
pH
HCO3
H+
Treatment: Prevent further losses and replace lost
electrolytes
41. DIARRHEA
Metabolic Acidosis
loss of HCO3 from G.I. Tract
pH
HCO3
Treatment: Correct base
deficit, replace losses of
with NaHCO3
42. TAKE HOME MESSAGE
Fluid is like “prescription” so give it with caution.
Children are more vulnerable for rapid fluid loss.
Maintenance calculation by “4-2-1” rule or Holliday Segar’s
formula.
Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM
SODIUM CONCENTRATION while giving fluid is must.
As far as possible try to give maintenance fluid requirement
orally.
0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children
requiring maintenance therapy.
Replacement of fluids should be prompt & appropriate.