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![Hypertonic Dehydration
Phase 2 – Replacement Phase
• Goal: Replace deficit of fluids and electrolytes
and daily maintenance
• Amount:
– Deficits + daily maintenance
• Fluid:
– D5 ¼NS + 20-30 mEq/L KCl
• Give over 24-48 hours
• IMPORTANT: Lower serum Na by no more than
10-12 mEq/L/day
Hypertonic Dehydration
Phase 3 – Replacement Phase
• Goal: Replace ongoing losses and
transition towards maintenance fluid
therapy
• Amount:
– Replacement + daily maintenance
• Fluid:
– D5 ¼NS + 20-30 mEq/L KCl
Acute Severe Hyponatremia
• Serum Na < 120, CNS symptoms
• Administer 3% saline
• Total volume =
– [(130 - serum Na)(0.6)(wt in kg)] x 2
• Give 1/2 total in < 1 hr and remainder over
the next 2 hours if symptoms persist
13](https://image.slidesharecdn.com/pediatricfluidsandelectrolytes-130315131832-phpapp01/85/Pediatric-fluids-and-electrolytes-13-320.jpg)
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Pediatric fluids and electrolytes
The document provides information on pediatric fluids and electrolytes. It discusses how a child's body composition changes with age, describing them as having higher percentages of total body water when younger. It also outlines the three main components of fluid therapy: maintenance fluids, deficit fluids, and replacement fluids. Methods for calculating fluid rates are presented, including the Holliday-Segar method. Types, degrees, and treatment approaches for dehydration are defined. Oral and intravenous rehydration protocols are described for various clinical scenarios.
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Pediatric fluids and electrolytes
- 1. Pediatric Fluids and Electrolytes Rachel Sykes, PharmD, BCPS Clinical Assistant Professor Ernest Mario School of Pharmacy Rutgers University Saint Barnabas Medical Center September 27, 2007 Objectives • Describe how pediatric body composition changes over time • Identify the three main components of fluid therapy • Calculate the maintenance fluid rate for a child using the Holliday -Segar Method • Determine appropriate fluid components for a hospitalized child Objectives • Calculate fluid rates for a child with dehydration • Determine a 3% saline volume and rate for a child with severe hyponatremia • Recommend an oral rehydration regimen for a child with mild dehydration 1
- 2. Body Fluids • Total Body Water = Extracellular Fluid (ECF) + Intracellular Fluid (ICF) • ECF = Plasma + Interstitial Fluid • Total Body Water expressed in terms of % body weight (adolescent or adult): ICF (30-40%) Interstitial Plasma (15%) (5%) Changes in Body Water Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 17 th Ed. Philadelphia, PA: Elsevier Science; 2004. Change in Body Composition Miller RD. Miller’s Anesthesia . 6 th Ed. Philadelphia, PA: Elsevier Science; 2005. 2
- 3. “Babies are likebags of water” Full-term: 75% water http://chfs.ky.gov/dph/ach/ecd/newbornscreening.htm http://www.inmagine.com/rubberball-single-image-set-photos/Rubberball-rbv005 Premature babies: 83% water http://www.sciencemuseum.org.uk/antenna/babybrainscans/ http://www.jupiterimages.com/popup2.aspx?navigationSubType=itemdetails&itemID =22684522 Regulating Water and Electrolytes • What makes someone thirsty? – Increase in serum osmolarity – Volume depletion • Dehydration causes increased serum osmolarity – Antidiuretic hormone (ADH) released – SIADH – ADH is released even when the serum osmolarity is low 3
- 4. Fluid Therapy • Threetypes of fluid therapy – Maintenance fluid Fluid to compensate for – Deficit ongoing normal losses – Replacement Fluid to compensate Fluid to for ongoing losses compensate for during medical fluid loss prior to treatment medical treatment Case #1 • A 5 year-old boy is admitted to the hospital after a bike accident where he lost a significant amount of blood. During his hospital stay he has a chest tube placed for a few days. The patient is treated in the hospital for one week and is then discharged home. • What types of fluid therapy does he need? Maintenance Fluid • Where does the body lose fluid? – Urine – Insensible losses • Respiratory, skin, feces – Intrinsic losses • By -product of metabolism • What makes kids different? – Higher metabolic rate and evaporative losses 4
- 5. Insensible Losses • Factors affecting insensible losses – Respiratory rate • Age • Pain • Ventilator – Environmental temperature • Phototherapy – Congenital skin defects Gastroschisis http://www.nlm.nih.gov/medlineplus/ency/imagepages/9028.htm Omphalocele http://www.nlm.nih.gov/medlineplus/ency/imagepages/9030.htm 5
- 6. Respiratory Rates Respiratory Rate Age Group (per minute) Infant 30-60 Toddler 24-40 Preschool Age 22-34 School Age 18-30 Adolescent 12-16 HazinskiMF. Anatomic and physiologic differences between children andadults. Deficit Fluids • Causes of dehydration – Inadequate intake – Blood loss – Fever – Catabolic state • Extra solutes, need extra fluid in order to excrete Replacement Fluids • Type of fluids replaced depends on what ’s being lost – Cerebrospinal fluid drains • Generally replaced with normal saline – Chest tube drains • Generally replaced with albumin, particularly after heart surgery 6
- 7. Calculating Maintenance Fluids • Holliday-Segar Method Fluid per day Rate per hour 1st 10 kg 100 mL/kg/day 4 mL/kg/hr Next 10 kg 50 mL/kg/day 2 mL/kg/hr Weight > 20 kg 20 mL/kg/day 1 mL/kg/hr This method assumes that 100 kcal expended requires 100mL water Maintenance Fluid Example Calculations Calculate the maintenance fluids in mL/day and mL/hr for the following patient weights: • 25kg • 4kg • 16kg Electrolyte Maintenance Requirements Sodium 2 - 3 mEq/kg/day Potassium 1 - 2 mEq/kg/day Chloride 3 - 5 mEq/kg/day • Chloride needs are generally met by meeting sodium and potassium requirements with NaCl and KCl 7
- 8. What is theusual maintenance fluid for a child? • 28 kg, well-hydrated child - What fluid would you recommend? • FIRST - calculate the amount of fluid you need • NEXT - calculate how much sodium and potassium you need • FINALLY - pick a fluid based upon what is commercially available if you can Increased Maintenance Requirements • Fever • Vomiting • Hyperventilation • Hypermetabolic states • High environmental temperature • Intestinal losses • Burns Decreased Maintenance Requirements • Increased environmental humidity • Hypothermia • Hypometabolic states 8
- 9. Dehydration Clinical Signs of Dehydration • Weight loss • Babies - sunken – Weigh children fontanelle frequently • Decreased urine • Thirst production • Decreased skin turgor • Increased urine • Dry mucous membranes specific gravity • Lack of tears • Increased heart rate • Decreased blood pressure What are the implications of dehydration for drug therapy? Anterior Fontanelle http://commons.wikimedia.org/wiki/Image:Human_anterior_fontanelle_1_month_dscn1449.jpg 9
- 10. Degree of Dehydration • Need to accurately monitor patient weights frequently • Fluid deficit (L) = PIW (kg) – IW (kg) – PIW = Pre-illness weight – IW = Illness weight • % Dehydration = PIW (kg) – IW (kg) x 100% PIW (kg) Degree of Dehydration Mild Moderate Severe Older 3% 6% 9% Child (30 mL/kg) (60 mL/kg) (90 mL/kg) 5% 10% 15% Infant (50 mL/kg) (100 mL/kg) (150 mL/kg) Degrees of Dehydration Clinical Signs Mild Moderate Severe Weight Loss (%) 5 10 15 Hyperirritable to Behavior Normal Irritable lethargic Thirst Slight Moderate Intense Mucous May be Dry Parched membranes normal Tears Present ± Absent Anterior Flat ± Sunken Fontanelle 10
- 11. Degrees of Dehydration ClinicalSigns Mild Moderate Severe Eyes Normal Deepset Sunken Skin Turgor Normal ± Increased Blood Normal Normal Decreased Pressure Skin color Normal Pale Gray / mottled Full, normal Pulse Rapid Rapid, weak rate Markedly Urine output Decreased Anuria decreased Types of Dehydration • Isotonic – Serum Na = 130-150 mEq/L – 80% of dehydrated patients • Hypertonic – Serum Na > 150 mEq/L – 15% of dehydrated patients • Hypotonic – Serum Na < 130 mEq/L – 5% of dehydrated patients Dehydration – Developing a Plan of Action 1. Estimate the degree of dehydration 2. Determine the type of dehydration • This will lead you to your Plan! • Plan will have 3 phases 11
- 12. Phase I –Rapid phase • Goal: Restore circulation, reperfuse brain, kidneys • Mild-Moderate – 10 – 20 mL/kg bolus given over 30 – 60 minutes • Severe – May repeat bolus as needed • Fluids – something isotonic such as NS or lactated ringers (LR) Hypotonic / Isotonic Dehydration Phase 2 – Replacement Phase • Goal: Replace deficit of fluids and electrolytes • Amount: – 1/3 daily maintenance + ½ deficit • Fluids: – D5 ½ NS + 20-30 mEq KCl • Add KCl only if patient has voided • Time: Over 8 hours Hypotonic / Isotonic Dehydration Phase 3 – Stabilization Phase • Goal: Transition to maintenance fluids • Amount: – 2/3 daily maintenance + ½ deficit • Fluids: – D5 ¼ NS + 20-30 mEq KCl • Time: Over 16 hours 12
- 13. Hypertonic Dehydration Phase 2 – Replacement Phase • Goal: Replace deficit of fluids and electrolytes and daily maintenance • Amount: – Deficits + daily maintenance • Fluid: – D5 ¼NS + 20-30 mEq/L KCl • Give over 24-48 hours • IMPORTANT: Lower serum Na by no more than 10-12 mEq/L/day Hypertonic Dehydration Phase 3 – Replacement Phase • Goal: Replace ongoing losses and transition towards maintenance fluid therapy • Amount: – Replacement + daily maintenance • Fluid: – D5 ¼NS + 20-30 mEq/L KCl Acute Severe Hyponatremia • Serum Na < 120, CNS symptoms • Administer 3% saline • Total volume = – [(130 - serum Na)(0.6)(wt in kg)] x 2 • Give 1/2 total in < 1 hr and remainder over the next 2 hours if symptoms persist 13
- 14. Oral Rehydration • Effective, safe, inexpensive • Indications – Replacement fluid for mild dehydration – Following Phase I volume resuscitation in moderate dehydration • Contraindications – Severe dehydration – Electrolyte abnormalities – Ileus or gastric obstruction www.rehydrate.org Rehydration Solutions Recommendation: Glucose 2 - 2.5 g/dL Sodium 50-75 mEq/L Glucose Sodium Potassium (g/dL) (mEq/L) (mEq/L) Pedialyte 2.5 45 20 Gatorade 5.9 21 2.5 Apple Juice 11.9 0.4 26 Milk 4.9 22 36 Water 3 0.5 http://almostgirl.coffeespoons.org/?p=1131 http://www.yummy.com/subcategorylist.aspx?cGw8n4AckUu5BAvSiFaUNV n9hS91DEsEXmQyGJauVHM= Oral Rehydration • Patient vomiting – 5-10mL Q 5-10 minutes and increase as tolerated • Mild Rehydration – Deficit replacement: 50 mL/kg over 4 hours • Moderate Rehydration – Deficit replacement: 100 mL/kg over 4 hours 14
- 15. Hyperkalemia • Can cause life-threatening arrhythmias – Bradycardia – Ventricular dysrhythmias • First determine why the serum level might be high – Heel stick? – KCl in fluids? Blood Collection in Newborns http://health.state. ga. us/programs/nsmscd/screening_form.asp http://www.nlm.nih.gov/medlineplus/ency/imagepages/2961.htm Hyperkalemia • Treatment – Calcium – Bicarbonate – Insulin (with glucose) – Albuterol 15
- 16. Case #3 • JW,a 16 month old boy (11kg), is brought into your pharmacy by his mother. JW’s mom says that he had a mild bout of diarrhea a few days ago, and she is still noticing fewer wet diapers. Otherwise, he has no symptoms. JW’s mother would like to know what she should do. What do you recommend? Case #4 • DR is a 4 year old girl (16kg) who presents to the emergency room with fatigue, headache, generalized malaise, and severe gastrointestinal distress. The ER team gets a chem-7 and discovers her sodium to be 118. They would like to give 3% NS and ask you for a recommendation on how much to give, and at what rate. Case #5 • LM is a 4 month old, 7kg (preillness) girl who presents to the ER with a sunken fontanelle, dusky skin, lethargy, and is not crying. She has not urinated in several hours. Current weight is 6kg. Her sodium is 137. What type and degree of dehydration does she have? How do you recommend treating her? 16
- 17. Case #5 • Howdo I double-check my answer? It’s easy! Just add up all the fluid you gave. It should equal the deficit + the daily maintenance requirement. 17