Fluid Tutorial

7/28/2019 Fluid Tutorial

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Paediatric Surgery Fluids

Tutorial


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Case 1 8 year old boy 3 day history of

nausea, vomiting,anorexia, pyrexia,acute abdomen

Marked peritonism inright iliac fossa

Lethargic with drymucosa and furred

tongue Capill.refill 1,5 sec.

PR 140, RR 30, BP

105/65 Temp 38.5 C


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What is the most likely diagnosis?

a) Appendicitis

b) Gastroenteritis

c) Perforated peptic ulcerd) Pyelonephritis

e) Acute Hepatitis A infection


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List ways in which this boy has lost

fluid

Vomiting

Inadequate oral intake due to anorexia

Evaporative losses due to pyrexiaIncreased metabolism due to pyrexia &

infection

Fluid sequestration into peritoneal cavity dueto infectious process


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Estimate the percentage dehydration

a) 0%b) 2.5%

c) 5%

d)7.5%e) 10%

Tips:

Are his vital signs within normal ranges forhis age? (Check on the table inside one of

the ward patients files if you are unsure)

Is he shocked or not?


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What type of fluid was lost?

Rough guide!! Na+ K+ Cl- HCO3- H+

Gastric juice 60 10 120 65

Bile 148 5 100 35Pancreatic

juice

140 5 75 80

Small boweldrainage

110 5 105 30

Diarrhoeal

stools

120 25 90 45


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Based on the type of fluid lost, which

of the following would you use as

resuscitation fluid, and why?Resuscitation

fluid:

Na K Cl Ca Mg Lact/

HCO3

Dex pH

0.9% NaCl 154 154 5.5

SHS 130 3.5 130 1.2 60 7.5

Plasmalyte B 130 4 109 1.5 28 7.4

Ringers Lactate 131 5.4 111 2 29 6.5

Haemacel 145 5.1 145 6.25 7.3


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How much fluid (ml) would you give

to resuscitate the child with?

Use both formulae and compare amount

calculated:

(Weight= 25kg)

[(%dehydration)x10 -(%dehydration)]/kg

10-20ml/kg bolus repeat every 20-30minutes as necessary


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When would you start maintenance

fluids in this child?

a) Straight away

b) After resuscitating with initial resuscitation

fluids

c) In theatre

d) After theatre

e) Not necessary- only needs resuscitationf) Encourage oral intake once pyrexia resolved


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Calculate maintenance fluid

requirements using both formulaeWEIGHT DAILY RATE HOURLY RATE

2-10kg 100ml/kg/d (4ml/kg/hr)

10-20kg 1000ml/d +50ml/kg/d (40ml/hr +2ml per kg over10kg/hr)

>20kg 1500ml/d +20ml/kg/d (60ml/hr +1ml per kg over20kg/hr)


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Which of the following is the best

maintenance fluid for this boy?Maintenance fluid//mmol

Na K Ca Mg Cl HCO3 Dextrose

Maintelyte 35 25 2.5 65 50-100

Paediatric

Maintenance Solution

(PMS)

35 12 47 50g/L

Neonatalyte 20 15 2.5 .5 21 20 100

5%DW &0.2% NaCl 34 34 50

Extra-cellular fluid 142 4 5 3 103 27


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Replacement of ongoing losses

The child continues to vomitand you put in a nasogastrictube. It drains small bowelcontents.

What electrolyte disturbanceswould you expect to develop ifyou do not replace these losses(see table on next slide )?


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What type of fluid was lost?

Rough guide!! Na+ K+ Cl- HCO3- H+

Gastric juice 60 10 120 65

Bile 148 5 100 35Pancreatic

juice

140 5 75 80

Small boweldrainage

110 5 105 30

Diarrhoeal

stools

120 25 90 45


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What fluid would you use to replace

these ongoing losses?

Fetch all the different vaculitres you can find

from the procedure room in the ward.

Compare the following with respect to content:

Ringers lactate/ Hartmanns solution; 0.9% NaCl;0.45% NaCl & 5% dextrose; Paediatric

Maintenance solution; Neonatalyte; Plasmalyte;

etc. Ask the nursing sister for an ampoule of

potassium and see how much KCl is in one amp.


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Paediatric vital signs

What is the normal urine output for a child?

(ml/kg)

What is the problem with using blood pressure as

an indicator of haemodynamic stability in a child?

a) Inaccurate as difficult to find right size cuff

b) Usually lower in children than adults, so need to know

age-appropriate levels

c) Drops late child as pulse rate usually increases to

maintain BP until decompensation occurs

d) Nurses dont routinely check blood pressure in kids


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Re-evaluation: which parameters

would you use to decide if the child is

adequately resuscitated for surgery?

PR

urine output

capillary refill

peripheral perfusion

BP

level of consciousness

skin turgor

pulse deficit

pH

Lactate

base deficit

serum Na, K, Cl, Urea,Creatinine

Haematocrit


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Case 2

6 week old infant

Presents with hypertrophic pyloric stenosis


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What is the usual age of presentation

of HPS?

a) Any time after birth until 3 years

b) As early as 1 week after birth in term babies

c) Rare after 3 months of aged) Usually between 4-8 weeks after birth

e) Congenital aetiology, thus child starts

vomiting from birth


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What biochemical picture is typical

of HPS? pH?

Na?

Cl?

K+?

Does this abnormality develop acutely,

subacutely or is it a chronic condition?


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What would your

initial

management(resuscitation)

be for this child

(with HPS)?

IV li


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IV line

Resuscitate with 0.9% NaCl

bolus (10-20ml/kg) till

passing urine

Then cont. resuscitation

with 0.45% NaCl & 5%

dextrose (adding KCl as

necessary) till pH


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a) It is cheaper than other fluids

b) It is actually a maintenance fluid and thus notideal for resuscitation

c) The electrolyte abnormalities in HPSdeveloped over several days (>48h) andshould thus be corrected slowly to avoid

rapid fluid shiftsd) Extra potassium may need to be added, so

rather use something like Ringers lactate

Why is 0.45% NaCl used for

resuscitation in HPS?


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Central pontine myelinolysis

Neurologic disease caused by severe damage of the myelinsheath ofnerve cells in thepons

Characterized by acute paralysis, dysphagia (difficultyswallowing), and dysarthria (diffuculty speaking), and otherneurological symptoms.

Complication of treatment of patients with profound, life-threatening hyponatremia (low sodium)

Consequence of a rapid rise in serum tonicity followingtreatment in individuals with chronic, severe

hyponatraemia who have made intracellular adaptations tothe prevailing hypotonicity

Individuals with hyponatremia should receive no more than8-10 mmol/L of sodium per day to prevent central pontinemyelinosis.

From Wikipedia, the free encyclopedia
http://en.wikipedia.org/wiki/Myelin_sheathhttp://en.wikipedia.org/wiki/Neuronhttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Myelin_sheathhttp://en.wikipedia.org/wiki/Myelin_sheathhttp://en.wikipedia.org/wiki/Neuronhttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Dysarthriahttp://en.wikipedia.org/wiki/Dysphagiahttp://en.wikipedia.org/wiki/Dysarthriahttp://en.wikipedia.org/wiki/Hyponatremiahttp://en.wikipedia.org/wiki/Hyponatremiahttp://en.wikipedia.org/wiki/Hyponatremiahttp://en.wikipedia.org/wiki/Dysarthriahttp://en.wikipedia.org/wiki/Dysphagiahttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Neuronhttp://en.wikipedia.org/wiki/Myelin_sheathhttp://en.wikipedia.org/wiki/Myelin_sheath


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On urine dipstick:

You find this baby with HPS has alow urine-pH

Is this expected?

Why do you think this hashappened?

What is the most importantextracellular ion? Andintracellular ion?

What are the implications formanagement of this urine pH?


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Mechanisms ofparadoxical aciduria:

1. Nasogastric suction or refractory vomiting results in lossof gastric acid.

2. Physiologic stress and hypovolemia promote renalretention of sodium and water

3. To retain sodium, the renin-angiotensin-aldosterone isactivated, the kidney must release other cations(potassium and hydrogen) for exchange with Na

4. The body tries to maintain adequate potassium level asthe priority, so instead of using Na/K pump in the distal

tubule which would result in further loss of K, the Na/Hpump is favored. Sodium is then reabsorbed as hydrogenions are excreted, making the urine acidic. Therefore thissituation aggravates the state of metabolic alkalosis.


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Surgery for HPS

Does this baby necessarily need an operation?

a) No , as it is a self-limiting condition and after a fewmonths of TPN or very thin feeds, it will resolve

b) Yes; medical therapy against nitric oxide receptors isexperimental only

If so, when?

a) Immediately (after a few saline boluses)

b) Once the serum pH95 and s-HCO3


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What is the name of this operation?


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Case 3

Newborn with gastroschisis

What extra fluid losses are

expected?

What is the emergency

management for this condition?


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