Fluids in Renal Disorders

7/23/2019 Fluids in Renal Disorders

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Fluids in Renal Disorders

Title of Guideline (must include the word “ Guideline” (not protocol, policy,procedure etc) Guideline for Management of Fluids in

Children and Young People with known RenalDisorders

Contact Name and Job Title (author)

Dr Farida Hussain, Consultant PaediatricNephrologist

Directorate & Speciality

Family Health; Renal

Date of submission

July 2011

Date on which guideline must be reviewed (this should be one to t hree years)

July 2014

Explicit definition of patient group to which it applies (e.g. inclusion andexclusion criteria, diagnosis) Patients with Renal Disorders

Abs trac t

This guideline describes Management of Fluidsin Children and Young People with known RenalDisorders

Key Words

Fluids; Renal

Statement of the evidence base of the guideline – has the guideline been peerreviewed by colleagues?

Evidence base: (1-5) 5: recommended best practise based on theclinical experience of the guideline developer

Consultation Process

Paediatric Renal Team

Target audience

Staff at Nottingham Children’s Hospital

This guideline has been registered with the Nottingham University Hospital Trust. However, clinical guidelines areguidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individualclinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the reviewdate.



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Contents

Page

Introduction 2

Summary of organization 3

Patients with chronic kidney disease: 4

Oligo-anuria

Polyuria

Tubulopathies 5

Nephrogenic diabetes insipidus 6

Acute renal impairment 7

Appendix 8

Composition of fluidsChronic kidney disease categories

Normal ‘maintenance’ fluid requirements

Introduction

The aim of this guideline is to provide guidance in management of intravenous fluids in

patients with known renal disease who are nil by mouth (for whatever reason). This includes

patients with chronic renal impairment, acute renal failure and tubulopathies . The commonest

situation where this arises is in the peri-operative time period, but is also applicable if the

patient is nil by mouth for other reasons e.g. unable to tolerate oral fluids due to severe

gastroenteritis .

For ALL patients undergoing surgery, good liaison with the surgeons and

anaesthetists is imperative.

• Discussion with the surgeons may limit the length of time that the patient requires to

be nil by mouth (for fluids +/- medicines) which will help with the overall management

of these patients.

• Co-ordinate to place the child first on the operating list if possible.

• Wherever possible (e.g. routine surgery) the problem should be anticipated and fluids

calculated before the patient is admitted for surgery. This is especially important in

certain groups of patients (e.g. patients with cystinosis) where preparation of the i.v.

fluids need to be checked by pharmacy and can cause delays .

The following is intended to be used as a guideline only. Al l cases shou ld be

discussed with the consultant paediatric nephrologist on-call.

For all patients, on-going assessment of their clinical state and regular review of weight, alongwith regular blood tests are imperative (the frequency of which should be discussed with the

consultant on-call) as this may alter the fluid regime that needs to be prescribed.



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Summary of OrganisationPlanning for elective procedures

Referral letter from Paediatric nephrology to surgical team (with a copy in the notes) . Thesurgical team should ensure the relevant anaesthetist is also sent a copy of the letter . The

letter should include:

• Current weight• Height

• BP

• Estimated 24 hour urine output

• Current recommended fluid intake (restriction / target)

• Current medication

• Current electrolyte results

For all procedures:

Pre-op assessment (by surgical team):

• 24 hour urine output estimation

• current fluid intake (restriction or target)

• current medications (inc. mineral supplements)• recent U&E results

• liaison w surgeons & anaesthetists (&PICU if necessary)

• prescribe fluids if requires pharmacy input

At time of operat ion:

• confirm above details

• examine patient paying particular attention to:

O State of hydration

O Weight – compare with previous weights

O Height

O Blood pressure

• Prescribe fluids if not already done

Post-op monitoring of patient: (frequency to be agreed)• Clinical status

• Strict fluid input / output charts

• Weight

• U&E’s - (should include full renal profile: includes HCO3-, Ca and PO4 frequency

decided by consultant

• An immediate post-op sample should be sent on all patients

• Liaise with surgeons re: when can restart oral / gastrostomy feeds +/- medications



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Patients with Chronic Kidney Disease

The management pre, peri, and post-operatively, of ALL of these patients should be

discussed with the paediatric nephrologists on-call, even if the patient is admitted under a

different team (e.g. surgical team).

Depending on the patient’s diagnosis, and current CKD staging (See appendix), their

management will be different, and an up-to-date knowledge of their current estimated 24 hour

urine output, current fluid requirements and current medications (as outlined in the planning

stage) allows a decision as to which of the following categories to place the patient .

a) Oligo-anuric

These patients usually have severe chronic renal insufficiency

(typically GFR < 15mls/min/1.73m2)

Pre-renal t ransplant

This is a very specific clinical situation, as the patients need to be well hydrated pre-op.

Please refer to separate renal transplant guidelines

Other situations

• If the patient has a set fluid restriction at home (provided that they are not eitherdehydrated or fluid overloaded), this can be set as a 24 hour fluid requirement .

• Fluid prescription – this will depend on recent blood results, but in general 5%dextrose 0.45% saline is used.

• For most oligo/anuric patients, potassium should NOT be added to i.v fluids

• Regular monitoring of both clinical and biochemical status is required and fluids

adjusted accordingly. (typically this involves blood test monitoring 12 hourly initially)

•

If no fluid limits have been set, the patient can be managed safely with a regime ofinsensible losses + urine output

Insensible losses are calculated as: 400mls/m2/day).

Body Surface Area calculated using the equation: √ (ht in cm x wt in kg / 3600).

b) Polyuric patients

These patients may produce large volumes of urine, and are also typically salt-losers, and are

therefore at high risk of dehydration without adequate fluid replacement.

Pre- renal transplantThis is a very specific clinical situation, as the patients need to be well hydrated pre-op

Please refer to separate renal transplant guidelines

Other situations

• Pre-operative calculate current daily fluid intake

• Review recent U&E’s blood results

• Calculate current sodium intake (if on supplements)

• Check urinary sodium



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Tubulopathies

Fanconi syndrome (e.g. cystinosis)

Cystinosis is an autosomal recessive disorder characterized by defective lysosomal cystine

transport, leading to excessive intracellular cystine accumulation. This affects predominantlythe proximal tubule, leading to a severe Fanconi’s syndrome (hypophosphataemia,

aminoaciduria, glycosuria and acidosis). They also have a high fluid requirement due to

polyuria.

Pre-op

• Calculate the current fluid intake that the patient requires

• Calculate daily sodium, potassium and bicarbonate requirements from medications.

• Choose appropriate fluid, and calculate how much potassium chloride and sodium

bicarbonate need to be added to each bag.

O Please note that these patients often have very high potassiumrequirements.

Addition of potassium to i.v fluid bags is restricted to certain wards

and therefore it may be necessary for the fluids to be made up in

pharmacy – these should be written up in advance to avoid anydelays

all calculations should be checked with responsible nurse

Fluids should be commenced as soon as the patient is nil by mouth, and not wait until the

patient is in theatre – as there is a risk of dehydration in this time .

Post-op

Fluids continued with

regular clinical review (including repeating patient weight if necessary)

regular blood monitoring ((U&E should be a full renal profile - includes HCO3-, Ca

and PO4 and is typically 8 hourly)

with adjustment to fluids (rate +/- composition) if necessary .

Liaise with surgeons about re-starting medications and using NG tube or gastrostomy (ifpatient has one) as soon as possible, as this will aid management .

Nephrogenic Diabetes Insipidus (NDI)

NDI is the inability of the kidney to concentrate urine in response to arginine vasopressin,

leading to polyuria and polydipsia. In contrast to the conditions mentioned already, these

patients produce very dilute urine and ‘hold on’ to sodium. Patients are normally able to ‘self-

regulate’ their sodium concentration, provided they have access to free water and are able to

tolerate this.

If they are kept nil by mouth, their clinical status can change rapidly and this is reflected in the

level of monitoring suggested for them post-operatively.

Admission to PICU / HDU electively should be considered for al l NDI patients who

require to be kept NBM post-operatively Discussion with the surgeons as to when the earliest time water can be given orally or

via gastrostomy should occur, as this will ease management.

Pre-op

Knowledge of current total daily fluid intake – allows calculation of hourly fluid

requirement.

Fluids should be commenced as soon as the patient is nil by mouth

Calculate the ‘normal’ maintenance volume for 24 hours the patient would receive for

their weight. This volume should be given as 4% dextrose / 0.18% Saline

Then calculate what ‘extra’ fluid they normally take per day . This volume should begiven as 5% dextrose.



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The 2 fluids should be run simultaneously (i.e. 2 iVAC pumps will be required)

As these patients run the risk of hypernatraemic dehydration, close monitoring is required

including:

Hourly input/ output (weighing nappies is usually sufficient)

Regular weights (up to 6 hourly if NBM)

Regular biochemistry monitoring including BM’s (6 hourly initially – as long as initial

post-op bloods satisfactory)

Bloods samples should be requested as urgent, and results should be chased up and

entered onto a results flow sheet)

If there is any evidence of worsening hypernatraemia, weight loss or negative fluid

balance discuss w ith consu ltant. The ratio of fluids being given may need to change andthe rate of administration may need to be altered (if the rate requires changing, it will usually

involve increasing the rate of 5% dextrose alone)

If there is evidence of hypokalaemia, potassium should be added –to the ‘maintenance’ (4%

dex/0.18% Saline) fluids.

If there is evidence of hyperglycaemia, this should be controlled, as this may drive the urine

output further – discuss with consultant if rising BM or BM>15 or glycosuria .

As soon as the patient can tolerate enteral fluids (discuss with surgeon if post-op, to see if

clear fluids allowed as soon as possible) allow them to take water orally / via NG / via

gastrostomy, and reduce the iv fluid rate accordingly (as long as clinically stable)

A decision as to which fluid rate to reduce will depend on factors including: current sodium

and glucose levels.

Patients w ith Acute Renal Failure +/- Acute Glomerulonephriti s

These patients usually present with oliguria or anuric. ALL o f these pat ien ts shou ld be

referred to paediatric nephrology

Many patients will be given a set fluid restriction by the consultant paediatric

nephrologists on-call

Fluid prescription – this will depend on recent blood results, but in general 5%

dextrose 0.45% saline is used.

For most oligo/anuric patients, potassium should NOT be added to i.v fluids

Regular monitoring of both clinical and biochemical status is required and fluids

adjusted accordingly. (typically this involves blood test monitoring 8 –12 hourly)

If no fluid limits have been set, the patient can be managed safely with a regime of

insensible losses + urine output

Insensible losses are calculated as: 400mls/m2/day.

Body Surface Area calculated using the equation: √ (ht in cm x wt in kg / 3600).



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AppendixComposition of Commonly Used Intravenous Fluids:

Note: 0.45% solution alone is a hypotonic so lution and its use is severely restri cted.

Chronic Kidney Disease Categories

“ Normal’ Maintenance Fluid requirements per 24 hours

100mls/kg– for the 1st 10kg

50mls/kg– for the 2nd 10kg

20mls/kg thereafter

Insensible Losses

These are estimated on the basis of body surface area as 400mls/m2/day.

Body Surface Area is estimated using the equation: √ (height [cm] x wt [kg] / 3600)

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Fluids in Renal Disorders