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Intravenous Fluids in ChildrenIntravenous Fluids in Children

NPSA GuidelinesNPSA Guidelines

Dr Pam CupplesDr Pam CupplesSPAN Meeting Friday the 20SPAN Meeting Friday the 20thth of April 2007 of April 2007

DunkeldDunkeld

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AimsAims

Historical approach to fluid management Historical approach to fluid management based on Holliday & Segar’s ‘4/2/1’ formulabased on Holliday & Segar’s ‘4/2/1’ formula

Problems with hypotonic fluids in the Problems with hypotonic fluids in the Paediatric PopulationPaediatric Population

NPSA guidelinesNPSA guidelines

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Maintenance Fluid RequirementsMaintenance Fluid Requirements

Maintenance fluid requirements parallel energy Maintenance fluid requirements parallel energy metabolismmetabolism

Energy Expenditure - using tables and nomogramEnergy Expenditure - using tables and nomogram Darrow et Pratt, JAMA 1950Darrow et Pratt, JAMA 1950

Body surface Area – Body surface Area – Crawford et al, Pediatrics 1950Crawford et al, Pediatrics 1950 Age - Age - Wallace, Am. J. Clin. Path. 1953Wallace, Am. J. Clin. Path. 1953 WeightWeight – – Holliday & Segar, Pediatrics 1957Holliday & Segar, Pediatrics 1957

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Holliday & Segar’s FormulaHolliday & Segar’s Formula

‘ ‘healthy’ infants and healthy’ infants and childrenchildren

Energy expenditure at rest Energy expenditure at rest and during activityand during activity

Energy expenditure Energy expenditure equated to water equated to water requirementsrequirements

1ml of water required to 1ml of water required to burn 1 calorieburn 1 calorie

• 1.2mls water are consumed1.2mls water are consumed• 0.2mls water are produced0.2mls water are produced

3mmols/kg of Na3mmols/kg of Na 2mmol/kg of K2mmol/kg of K

Infants require ~ 100cal/kg/dayInfants require ~ 100cal/kg/day Older Children ~ 75cal/kg/dayOlder Children ~ 75cal/kg/day Adults ~ 35cal/kg/dayAdults ~ 35cal/kg/day

Calorie RequirementsCalorie Requirements100cal/kg/day100cal/kg/day <10kg<10kg50cal/kg/day50cal/kg/day 10-20kg10-20kg20cal/kg/day20cal/kg/day >20kg>20kg

Hypotonic fluid

0.18% NaCl with 4% Dextrose

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How we got the ‘4-2-1’ ruleHow we got the ‘4-2-1’ rule

Calorie Requirements Based on Weight

0-10kg: 100cal/kg/day

10-20kg: 1000cal + 50cal/kg/day for each kg over 10kg

> 20kg: 1500cal + 20cal/kg/day for each kg over 20kg

Water Requirements – ‘ 4-2-1 rule’Water Requirements – ‘ 4-2-1 rule’

0-10kg: 100 water/kg/day

( 4ml / kg/ hour)

10-20kg: 1000 water + 50 water/kg/day for each kg over 10kg

( 2ml/kg/hour)

> 20kg: 1500 water + 20 water/kg/day for each kg over 20kg (1ml/kg/hour)

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Holliday & Segar - the flawsHolliday & Segar - the flawsThe Maintenance Need for Water in Parenteral Fluid The Maintenance Need for Water in Parenteral Fluid

TherapyTherapy– – Pediatrics 1957Pediatrics 1957

WEIGHTWEIGHT

Illner et al 2000Illner et al 2000 - - resting energy expenditure is resting energy expenditure is based on fat free massbased on fat free mass

Accounts for 80% of the BMR but only 7% of the Accounts for 80% of the BMR but only 7% of the total body masstotal body mass

Calculating energy expenditure based on weight Calculating energy expenditure based on weight significantly over estimates the calorie significantly over estimates the calorie requirements and hence the water requirementsrequirements and hence the water requirements

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Energy ExpenditureEnergy Expenditure

No allowance for the different energy expenditure in No allowance for the different energy expenditure in acute disease / post surgeryacute disease / post surgery

Actual energy expenditure is 50% lower than Actual energy expenditure is 50% lower than values used by Holliday & Segarvalues used by Holliday & Segar– Briassoulis et al, 2000Briassoulis et al, 2000– Lindahl et al, 1988Lindahl et al, 1988

Lower energy requirements due to :Lower energy requirements due to :– 50% of calorie expenditure allowed for growth50% of calorie expenditure allowed for growth– Catabolic stateCatabolic state– InactivityInactivity– PICU setting – IPPV / sedated and paralysedPICU setting – IPPV / sedated and paralysed

Exceptions – fever,sepsis & burnsExceptions – fever,sepsis & burns

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Water LossesWater Losses

Insensible water losses 27ml/kg/day Insensible water losses 27ml/kg/day – Heeley & Talbot , 1955Heeley & Talbot , 1955

50% of this value –50% of this value – Lamke, 1977Lamke, 1977– Skin 7ml/kg/daySkin 7ml/kg/day– Lungs 5ml/kg/dayLungs 5ml/kg/day

Urinary lossesUrinary losses– 50-60ml/kg/day 50-60ml/kg/day Holliday & Segar, 1957Holliday & Segar, 1957

No allowance for non-osmotic stimuli for ADHNo allowance for non-osmotic stimuli for ADH– Stress, pain, surgery, feverStress, pain, surgery, fever– Drugs – opioids, NSAIDsDrugs – opioids, NSAIDs– Urinary volume reduced to 25ml/kg/dayUrinary volume reduced to 25ml/kg/day

Endogenous water production from tissue catabolism Endogenous water production from tissue catabolism

in acute illnessin acute illness

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Hazards of Hypotonic FluidsHazards of Hypotonic FluidsAcute Hospital Acquired HyponatraemiaAcute Hospital Acquired Hyponatraemia

Prescription of hypotonic fluidsPrescription of hypotonic fluids Provision of excess free water in conditions Provision of excess free water in conditions

where patient unable to excrete the excess where patient unable to excrete the excess water loadwater load

Non – osmotic stimuli for ADHNon – osmotic stimuli for ADH

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Non Osmotic Stimuli for ADH Non Osmotic Stimuli for ADH SecretionSecretion

– StressStress– PainPain– Post-operative periodPost-operative period– SepsisSepsis– PyrexiaPyrexia– Nausea & vomitingNausea & vomiting– Co-existing medical Co-existing medical

conditionsconditions• CNS infectionsCNS infections• Respiratory disordersRespiratory disorders• Metabolic & endocrine Metabolic & endocrine

disordersdisorders

DrugsDrugs MorphineMorphine NSAID’sNSAID’s SSRI’sSSRI’s BarbituratesBarbiturates CarbamazepineCarbamazepine ClofibrateClofibrate IsoprenalineIsoprenaline ChlorpropamideChlorpropamide VincrisitineVincrisitine

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Hazards of Hypotonic FluidsHazards of Hypotonic FluidsAcute Hospital Acquired HyponatraemiaAcute Hospital Acquired Hyponatraemia

Acute HyponatraemiaAcute Hyponatraemia– Na < 136mmols/L occurring within 48 hoursNa < 136mmols/L occurring within 48 hours– Severe hyponatraemia if Na < 130mmols/LSevere hyponatraemia if Na < 130mmols/L– Or any level of hyponatraemia associated with clinical signsOr any level of hyponatraemia associated with clinical signs– Risk groupRisk group

• ChildrenChildren• Premenopausal womenPremenopausal women• HypoxiaHypoxia

– Hyponatraemic encephalopathy Hyponatraemic encephalopathy • 50% of children with Na<125mmol/L50% of children with Na<125mmol/L• 8% mortality rate8% mortality rate

– Risk of developing hyponatraemia with hypotonic fluids is Risk of developing hyponatraemia with hypotonic fluids is 17.2 times than with isotonic fluids17.2 times than with isotonic fluids

• Choong et al, 2006Choong et al, 2006– Children have a poorer outcome than adults for a given level Children have a poorer outcome than adults for a given level

of hyponatraemiaof hyponatraemia

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Acute Hospital Acquired Acute Hospital Acquired Hyponatraemia – children at riskHyponatraemia – children at risk

Common symptomsCommon symptoms HeadacheHeadache Nausea & vomitingNausea & vomiting WeaknessWeakness

Advanced signsAdvanced signs SeizuresSeizures Respiratory arrestRespiratory arrest Dilated pupilsDilated pupils Decorticate posturingDecorticate posturing ComaComa Pulmonary oedemaPulmonary oedema

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Risks of Hypotonic FluidsRisks of Hypotonic Fluids

50 cited cases of child death or neurological 50 cited cases of child death or neurological injury in the international literatureinjury in the international literature

4 deaths and 1 ‘near miss’ in the UK since 4 deaths and 1 ‘near miss’ in the UK since 20002000

Post-op setting in previously healthy childrenPost-op setting in previously healthy children Minor surgical proceduresMinor surgical procedures

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ConclusionsConclusions

Hypotonic fluids are not benign but potentially Hypotonic fluids are not benign but potentially dangerousdangerous– 17.2 times more likely to develop hyponatraemia with 17.2 times more likely to develop hyponatraemia with

hypotonic fluids than with isotonichypotonic fluids than with isotonic Isotonic fluids offer a safe alternative to hypotonic Isotonic fluids offer a safe alternative to hypotonic

fluids with no risk of hypernatraemiafluids with no risk of hypernatraemia Fluid regimes should be tailored to the individualFluid regimes should be tailored to the individual Appropriate monitoringAppropriate monitoring

– Weight, baseline U&E’sWeight, baseline U&E’s

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Background to the NPSA Background to the NPSA

March 2003March 2003 – RCA asked by the RCPCh to issue – RCA asked by the RCPCh to issue warning re. The use of 0.18% Saline in 4% warning re. The use of 0.18% Saline in 4% DextroseDextrose

November 2004November 2004 – Inquiry set to investigate the – Inquiry set to investigate the deaths of 3 children from hyponatraemia following a deaths of 3 children from hyponatraemia following a documentarydocumentary

Audit in 2004/2005Audit in 2004/2005 – few anaesthetists had seen – few anaesthetists had seen the warningthe warning

NPSA – advice to healthcare professionals on how NPSA – advice to healthcare professionals on how to reduce risk develop solutions and introduce them to reduce risk develop solutions and introduce them into clinical practiceinto clinical practice

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NPSA Plan of ActionNPSA Plan of Action

July 2005July 2005 – form an internal working group to – form an internal working group to assess problemassess problem

August 2005August 2005 – External working group appointed – External working group appointed after after

October to November 2005October to November 2005 – meetings of the – meetings of the external group to discuss evidence collectedexternal group to discuss evidence collected

Dec 2005Dec 2005 – draft of the safe practice – draft of the safe practice recommendationsrecommendations

Jan-Feb 2006Jan-Feb 2006 – Wide stakeholder consultation on – Wide stakeholder consultation on draftdraft

April 2006April 2006 – publish NPSA guidance – publish NPSA guidance

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NPSA – Patient safety alert 22: Reducing the risk NPSA – Patient safety alert 22: Reducing the risk of hyponatraemia when administering intravenous of hyponatraemia when administering intravenous

infusions to children (Alert 5 of 5)infusions to children (Alert 5 of 5)Applies to all paediatric patients from 1 month to 16 yearsApplies to all paediatric patients from 1 month to 16 years

2828thth March 2007 March 2007

Remove 0.18% NaCl / 4%Dextrose from general Remove 0.18% NaCl / 4%Dextrose from general stockstock

Produce and disseminate clinical guidelines for the Produce and disseminate clinical guidelines for the fluid management of paediatric patientsfluid management of paediatric patients

Adequate training and supervision of staffAdequate training and supervision of staff Reinforce safe practiceReinforce safe practice Promote the recording and reporting of hospital Promote the recording and reporting of hospital

acquired hyponatraemiaacquired hyponatraemia Audit programme to ensure that the NPSA Audit programme to ensure that the NPSA

recommendations are being adhered torecommendations are being adhered to

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NPSA guidelinesNPSA guidelines

Template for developing local guidelines for Template for developing local guidelines for the prescription & monitoring infusions in the prescription & monitoring infusions in childrenchildren

Importance of rigorous clinical and laboratory Importance of rigorous clinical and laboratory monitoringmonitoring

Prescription of fluids same importance and Prescription of fluids same importance and consideration as other medicinesconsideration as other medicines

Fluids must be individualisedFluids must be individualised Calculate fluid balance and monitor plasma Calculate fluid balance and monitor plasma

NaNa

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Oral fluids preferable to ivOral fluids preferable to iv Resuscitation Fluids – Resuscitation Fluids –

bolus of bolus of 0.9% saline0.9% saline Deficit – calculated and Deficit – calculated and

replaced as replaced as 0.9% saline0.9% saline or or 0.9% saline with 5% 0.9% saline with 5% dextrosedextrose Replace over 24 hoursReplace over 24 hours

Maintenance – do not use Maintenance – do not use 0.18% saline with 4% 0.18% saline with 4% dextrosedextrose 0.45%saline with 5% 0.45%saline with 5%

dextrosedextrose

Children at high risk – only isotonic fluids

Peri and post operative Na levels lower end of normal or

<135mmol/L Volume depleted Hypotension CNS infection Head injury Bronchiolitis Sepsis Excessive gastric / GI losses Chronic conditions – CF,IDDM Salt wasting syndromes

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NPSA GuidelinesNPSA Guidelines

Ongoing lossesOngoing losses Assessed 4 hourly Assessed 4 hourly Replacement fluid should reflect the Replacement fluid should reflect the

type of electrolyte composition of the type of electrolyte composition of the fluid being lostfluid being lost

Isotonic safest choiceIsotonic safest choice

MonitoringMonitoring Robust regimeRobust regime Weight of childWeight of child Baseline and daily measurements of Baseline and daily measurements of

Na, K, urea & CrNa, K, urea & Cr More frequent if Na already low or More frequent if Na already low or

clinical picture changesclinical picture changes

TrainingTraining E-modules to assess current E-modules to assess current

level of competencies & level of competencies & knowledgeknowledge

Doctors in training (80-90%)Doctors in training (80-90%) Review their fluid Review their fluid

prescriptionsprescriptions

IV Prescription ChartsIV Prescription Charts Review & redesign – include Review & redesign – include

guidelines on fluid presciptionsguidelines on fluid presciptions Monitoring data requiredMonitoring data required How to calculate fluid How to calculate fluid

requirementsrequirements

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www.npsa.nhs.uk/health/alerts

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Arieff et al, BMJ 1992Arieff et al, BMJ 1992 Prospective clinical case Prospective clinical case

study study 16 children who died or 16 children who died or

developed permanent developed permanent neurological damageneurological damage

0.34% incidence of post-op 0.34% incidence of post-op hyponatraemiahyponatraemia(83 affected out of 24,412 (83 affected out of 24,412 patients)patients)

8.4% mortality rate8.4% mortality rate((7 deaths)7 deaths)

Halberthal et al, BMJ Halberthal et al, BMJ 20012001

23 patients23 patients– 13 hyponatraemic in post-op 13 hyponatraemic in post-op

periodperiod– 15 referred to critical care15 referred to critical care

• 11 from wards and 4 from 11 from wards and 4 from other institutesother institutes

– Seizures (18) and vomiting Seizures (18) and vomiting (17)(17)

– 5 had Rx withdrawn due to 5 had Rx withdrawn due to brainstem herniationbrainstem herniation

– 1 patient sustained 1 patient sustained permanent, severe permanent, severe neurological damageneurological damage

– 16 / 23 receiving 16 / 23 receiving maintenance fluids at 50% maintenance fluids at 50% more than recommended more than recommended valuesvalues

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Paut et al, Paut et al, Ann Fr Anesth Reanim 2000Ann Fr Anesth Reanim 2000 7 Children 3-6 years7 Children 3-6 years ASA 1-2ASA 1-2 Scheduled surgical Scheduled surgical

proceduresprocedures Vomiting, seizures, status Vomiting, seizures, status

or or GCS (5/7) GCS (5/7) 1 respiratory arrest with Na 1 respiratory arrest with Na

120mmol/L120mmol/L All had hypotonic fluidsAll had hypotonic fluids 3/7 IPPV3/7 IPPV Rx – fluid restriction, NaClRx – fluid restriction, NaCl 1 death1 death

McRae et al, Int J Pediatr McRae et al, Int J Pediatr Otorhinolaryngol 1994Otorhinolaryngol 1994

3 post-op tonsillectomy 3 post-op tonsillectomy patientspatients

2 deaths2 deaths

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Choong et al, 2006Choong et al, 2006

Systematic reviewSystematic review 6 studies satisified inclusion criteria6 studies satisified inclusion criteria

– 2 unmasked RCT2 unmasked RCT– 1 non randomised CT1 non randomised CT– 3 observational studies3 observational studies

Mean Na in hypotonic group –3.39mmol/LMean Na in hypotonic group –3.39mmol/L Small number of studies with small group sizeSmall number of studies with small group size

– Total of 404 patientsTotal of 404 patients

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Holliday & SegarHolliday & Segar

0-10kg: 100cal/kg/day

10-20kg: 1000cal + 50cal/kg/day for each kg over 10kg

> 20kg: 1500cal + 20cal/kg/day for each kg over 20kg