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Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

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Page 1: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Elspeth FergusonST4 PaediatricsSeptember 2011

Fluid & Electrolyte balance

Page 2: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Learning objectives

Maintenance fluid requirementsDeficit & Supplemental fluid requirementsGrades of dehydrationTypes of dehydrationFluid & Electrolyte management Scenarios

Page 3: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

How are children different?

15 % turnover of body fluids (adults 5%)

Limited access to fluidsEasier to give inappropriate fluids

Page 4: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Maintenance requirements

Based on calorie requirements and fluid losses from the body

Insensible losses 1/5th

Essential urine output 1/5th

Normal urine output 3/5th

Page 5: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Maintenance requirements (Child)

Body Body weight weight (kg)(kg)

FluidFluid

(ml/kg/d)(ml/kg/d)NaNa

(mmol/kg/(mmol/kg/d)d)

KK

(mmol/kg/(mmol/kg/d)d)

ProteinProtein

(g/kg/d)(g/kg/d)EnergyEnergy

(kcal/kg/d)(kcal/kg/d)

<10 <10 100100 33 22 2.52.5 100100

10-2010-20 +50+50 +1.5+1.5 +1+1 +1.5+1.5 +75+75

>20>20 +20+20 +0.75+0.75 +0.4+0.4 +1+1 +30+30

Page 6: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Maintenance requirements (Neonates)

Day of lifeDay of life Fluid(ml/kg)Fluid(ml/kg) TypeType

11 6060 10% 10% dextrosdextrosee

22 9090 Na 3 mmol/kgNa 3 mmol/kg

K 2 mmol/kgK 2 mmol/kg

10% dextrose10% dextrose

+ additives+ additives33 120120

44 150150

55 180180

Page 7: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Deficit

Deficit = abnormal lossesAbnormal losses

vomitingdiarrheafevertachypneahot weatherDKA3rd space losses

% dehydration x 10 = ml/kg deficit

Page 8: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Supplemental

Supplemental = ongoing abnormal lossesComposition of body fluids (mmol/l)

Na K Cl Bicarb

diarrhoea 50 40 40 40gastric 50 15 150 40small bowel 130 15 110 30

Page 9: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Dehydration

HistoryAgeIntakeOutputSystemic illness

Pre-illness weight comparisonRehydrated wt estimate

= admission wt (kg) x 100100 - % dehydration

Page 10: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Grades of dehydration

1(symptoms) 1(symptoms) 5%5%

2(signs) 7%2(signs) 7% 3(shock) 10%3(shock) 10%

Clinical Clinical conditioncondition

Thirsty alert Thirsty alert restlessrestless

Lethargic Lethargic irritable drowsyirritable drowsy

Floppy Floppy comatosecomatose

PulsePulse NormalNormal FastFast FeebleFeeble

RespirationRespiration NormalNormal DeepDeep Deep & RapidDeep & Rapid

FontanelleFontanelle NormalNormal SunkenSunken Very sunkenVery sunken

Systolic BPSystolic BP NormalNormal Postural dropPostural drop LowLow

CRTCRT NormalNormal >2 seconds>2 seconds > 3 seconds> 3 seconds

EyesEyes NormalNormal SunkenSunken Very sunkenVery sunken

Mucous membMucous memb MoistMoist Dry Dry Very dryVery dry

Urine outputUrine output NormalNormal ConcentratedConcentrated AnuriaAnuria

Deficit (ml/kg)Deficit (ml/kg) 5050 7070 100 100

Page 11: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Types of dehydration

Hyponatremic (< 135 mmol/l)greater loss of Na relative to waterdeficit exaggerated by hypotonicityseizures may occur

Isonatremic (135-150 mmol/l)equal losses of Na and water

Hypernatremic (>150 mmol/l)difficult to estimate the degree of dehydrationcorrect over 48 hoursNa fall should be < 10 mmol/day

Page 12: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Types of fluids

FluidFluid NaNa

(mmol/(mmol/l)l)

KK

(mmol/l)(mmol/l)ClCl

(mmol/l)(mmol/l)CaloriesCalories

(kcal/l)(kcal/l)

0.9% Saline0.9% Saline 150150 00 150150 00

0.45% Saline 0.45% Saline

+ 5% dextrose+ 5% dextrose7575 00 7575 200200

10% dextrose10% dextrose 00 00 00 400400

0.45% Saline 0.45% Saline

+ 5% dextrose+ 5% dextrose

+ KCl+ KCl

7575 4040 7575 200200

Page 13: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Principles of fluid therapy

Fluids are drugs : Check calculations !Add K when U&Es are back ( 40 mmol/l)Rehydration usually corrects metabolic

acidosisMonitor U&Es closely

Page 14: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

To admit or not?

> 5 % dehydrationPersistent vomitingNeed for IV therapyFailure of outpatient managementDiagnosis is not clear

Page 15: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Which route?

Oral when possibleDioralyteRehidrat

Nasogastric fluidsIV fluids

persistent vomitingsevere ongoing lossesShockOral therapy fails

Page 16: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Which fluid?

Use 0.9% saline as bolusUse 0.45% saline + 5 % dextrose for all types

of dehydration initiallyThen fluid composition is guided by U&Es

Page 17: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

How much fluid?

Hourly rate =

Maintenance + Deficit + Ongoing losses24

Page 18: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Monitoring

IntakeOutputWeightCRTPulseBPConscious levelU&Es

Page 19: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 1

A previously healthy 11 month old infant isreferred to CAU with a 3 day history of diarrhoeaand vomiting with a poor urine output

She has sunken eyes, sunken fontanelle and drymucous membranes. The pulse is rapid and easilyfelt. She vomits all her feeds

Calculate her fluid requirements over the next24 hours

Page 20: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 2

A 10 year old girl has been brought by ambulancein a semi-comatose state. She is found to have anon-blanching rash over her trunk, neck stiffnessand an axillary temperature of 39.5°C. Hercapillary return time is 7 seconds and her systolicBP is 90 mm/HG.

How will you manage her fluids in the emergencysetting and subsequently?

Page 21: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 3

A 6 year old boy has been referred by his GP for being unwell and wetting his bed lately. His mothers says that he has been losingweight since he came back from Pakistan 4 weeks ago. His urine shows 4+ glucose and “large” ketones and a lab blood sugar is 32.

On examination he is found to be lethargic with a capillary return time of 5 seconds. He is afebrile with a dry mouth and a pulse of 120/min.Blood pressure is 110/70.

What is your diagnosis?How will you write up the fluids for this child?

Page 22: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 4

A 6 month old infant of a drug addict is brought to the Children’s Ward with a history of vomiting and excessive drowsiness. The Health Visitor accompanying the infant fears that the mother may have made up the feeds wrongly over the past few days.

The infant is found to have a sunken fontanelle and has not passed urine for a few hours. The S. Na+ is 165, S. K+ is 3.5, Urea is 8, Creatinine is 70.

How will you manage this infant?

Page 23: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 5

A 6 week old male infant who was born at 38 weeks gestation is referred by his GP on a Saturday for non bilious vomiting after most feeds for the last two weeks. His birth weight centile was the 10th but now is is less than the 3rd.

On examination he is alert and hungry. He looks thin and has a capillary return time of 4-5 seconds. Abdomen palpation reveals no abnormality but you notice that his nappy is wet.

The lab results area as follows:Na+ 132K+ 3.2C1- 96HCO3 32pH 7.45

How will you manage the fluid and electrolyte needs of this infant?

Page 24: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Case 6

A 5 day old baby who was a planned home birth is seen by theCommunity Midwife who feels that the baby’s genitalia are odd. The

baby isseen in the clinic and has an underdeveloped phallus and scrotum. No

testesare palpable in the scrotum.

The baby has a poor perfusion and weak cry. It is admitted from clinic.Dextrostix is 2.

The lab results are back urgently:S. Na+ 125S. K+ 7.5 (non-haemolysed sample)Blood sugar 1.8

How will you manage this neonate’s fluids?

Page 25: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Summary

Maintenance fluid requirementsDeficit & Supplemental fluid requirementsGrades of dehydrationTypes of dehydrationFluid & Electrolyte management Scenarios

Page 26: Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

Questions