1. IV FLUIDS

2. Basic Principles

3. BASIC PRINCIPLES
Osmolality/Osmolarity
Tonicity
Sodium & Water balance

4. What is Osmolality?

6. OSMOLALITY Measurement of concentration of particles in a solution
(Total concentration of penetrating & nonpenetrating solutes)
i.e. Concentration of electrolytes, drugs, glucose in a solution such as serum or urine

7. OSMOLALITY Normal = 285-295 mOsm/kg
The ICF and ECF are in osmotic equilibrium

8. OSMOLALITY OSMOLALITY = mOsm/kg of solvent
OSMOLARITY = mOsm/liter of a solution

9. What is Tonicity?

10. TONICITY
measure of the ability of a solution to cause a change in the volume or tone of a cell by promoting osmotic flow of water
(Total concentration of penetrating solutes only)

11. TONICITY

12. Who regulates osmolality?

13. Water

14. WATER BALANCE Important in the regulation of osmolality
Modification of water intake and exretion

15. 60%
ICF
TOTAL BODY WATER
ECF
Interstitial Fluid
Plasma

16. FORCES THAT MOVE WATER
Osmolality Tonicity Na/K ATPase pump Hydrostatic pressure Oncotic pressure

17. SODIUM BALANCE
The main regulator of intravascular volume status

18. Electrolyte composition
EXTRACELLULAR FLUID
INTRACELLULAR FLUID

19. WHAT IS THE BODY’S GOAL? PHYSIOLOGIC HOMEOSTASIS EUVOLEMIA
ISOTONIC ENVIRONMENT

20. What mechanisms in the body makes sure that the balance of sodium and water is normal? What hormones play a big role in the maintenance of physiologic homeostasis?

21. There are upper & lower limits to the amount needed to achieve ideal physiologic homeostasis

22. WATER REPLACEMENT
1.5 to 2 liters / day

23. SODIUM REQUIREMENT DIET: RDA = < 2400mg/day (1 teaspoon/day)
or < 104 meq/day
PLASMA : Normal levels = meq/L
FOR Na CORRECTION:
Maintenance of 2-4 meq/kg/day

24. Intravenous Fluids

25. INTRAVENOUS FLUIDS chemically prepared solutions
Achieve and maintain a euvolemic and isotonic environment within the body
They are tailored to the body’s needs and used to replace lost fluid and/or aid in the delivery of IV medications

26. ISOTONIC IV FLUIDS
created to distribute evenly between the intravascular, interstitial, and cellular spaces.

28. HYPOTONIC IV FLUIDS
What IV fluids are specifically designed so the fluid leaves the intravascular space and enters the interstitial and intracellular spaces?

30. HYPERTONIC IV FLUIDS
What IV fluids are designed to stay in the intravascular space (intra, within; vascular, blood vessels) to increase the intravascular volume, or volume of circulating blood?

32. ISOTONIC SOLUTIONS = 285-295 mOsm/L
Na = meq/L
HYPERTONIC SOLUTIONS = > 300 mOsm/L
Na = > 150meq/L
HYPOTONIC SOLUTIONS = < 260 mOsm/L
Na < 130meq/L

33. CRYSTALLOIDS
contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids.
classified according to their “tonicity.”
describes the concentration of electrolytes (solutes) dissolved in the water, as compared with that of body plasma (fluid surrounding the cells).

34. COMPOSITION OF IV FLUIDS
OSMOLARITY
(mosm/L)
Na+ (mmol/L) K+
Cl-
Base
PNSS
308
154 ?
PLR
273
130
D5LR
525 4
109 28
D5NR
552
140 98 50
D50.3NaCl
355 51
D5IMB
350 25 20 22 23
D5NM
368 40 3 16
D5W
255

35. COLLOIDS
contain solutes in the form of large proteins or other similarly sized molecules.
Remain in the blood vessels for long periods of time and can significantly increase the intravascular volume (volume of blood).

36. COLLOIDS/PLASMA EXPANDERS
Albumin = 1-2 kg/dose infused in 2 hours
Haes-teryl = 20-40ml/kg
Voluven = 20-40ml/kg
Gelofuschin = 20-40ml/kg
Fresh frozen plasma = 10-15ml/kg x 4 hours
Dextran 40 or 60

37. BLOOD AND BLOOD PRODUCTS
are the most desirable fluids for replacement but are not the first choice for immediate volume expansion in children with shock
Not only is the intravascular volume increased, but the fluid administered can also transport oxygen to the cells.

38. BLOOD AND BLOOD PRODUCTS
COMPUTATION
pRBC
10 ml/kg to run for 4 hours
Fresh whole blood
10-20 ml/kg in 4-6 hours
Platelet Concentrate
15-20 ml/kg as fast drip
Cryoprecipitate
1 unit/6kg/dose

39. Computation

40. OVERALL GOALS 1)ESTIMATE LOSSES Fluid & Electrolyte deficit
Maintenance requirements
Ongoing losses
2)SELECT IV FLUID
Initial replacement – always with ISOTONIC FLUID
Maintenance requirement & ongoing losses

41. STEP ONE: Estimate Losses
SEVERITY OF DEHYDRATION
INFANT (ml/kg)
ADOLESCENT (ml/kg)
CLINICAL SIGNS
MILD
5% (50)
3% (30)
Dry mucous membranes
Oliguria
MODERATE
10% (100)
6% (60)
Poor skin turgor
Sunken fontanel
Marked oliguria
Tachycardia
Quiet tachypnea
SEVERE
15% (150)
9% (90)
Marked tachycardia
Weak to absent distal pulses
Narrow pulse pressure
Hypotension and altered mental status

42. STEP TWO: In shock?

43. MACRODRIP SETS = 10 – 15 drops (gtts)/ml
MICRODRIP SETS= 60 microdrops (ugtts)/ml)

44. (Volume in mL) x (drip set) gtts =
(Time in minutes)    min

45. CONVERSION FACTORS
1 ml = 15 drops (gtts) = 60 microdrops (ugtts) 1 drop (gtt) = 4 microdrops (ugtts) 1 microdrop (ugtts)/min = 1 ml/hour

46. FLUID DEFICITS Ludan’s Method
WEIGHT
MILD DEHYDRATION
ml/kg/8 hours
MODERATE DEHYDRATION
SEVERE DEHYDRATION
<15 kg 50
100
150
>15 kg 30 60 90
Give ¼ in 1 hr
Give ¾ in 7 hr
Give 1/3 in 1 hr
Give 2/3 in 7hr
PLAIN LR/PLAIN NSS
D5LR
PLAIN LR/ PLAIN NSS

47. FLUID DEFICITS – WHO *Use Ringer’s Lactate
SOME DEHYDRATION
75ml/kg in 4 hours
SEVERE DEHYDRATION
AGE
FIRST GIVE
30ml/kg in:
THEN GIVE
70ml/kg in:
Infants under 12 months
1 hour
5 hours
Older
30 minutes
2 ½ hours

48. SODIUM CORRECTION
DEFICIT CORRECTION: desired-actual x weight x * Desired Na+ is meq
MAINTENANCE COMPUTATION: maintenance x weight *Maintenance is 2-4meq/kg
COMPUTE FOR ACTUAL Na+ Needed to be incorporated in your IV FLUID = Maintence + Deficit
*Give the First ½ in 8 hours then ¼ in each succeeding 8 hour shifts to complete your 24 hour correction

49. POTASSIUM CORRECTION COMPUTE FOR THE K+ REQUIREMENT = 2-4meq/kg/day
DETERMINE how much KCL you will be incorporating in your IV fluid to complete a 24 hour correction
Check IV fluid rate
*Maximum 40meq/Liter of KCL incorporation in IV Fluid
CHECK POTASSIUM INFUSION RATE (KIR) =
meq of KCL x IV rate (ml/hour) x weight
(maximum of 0.2meq/kg/hour)

50. MAINTENANCE REQUIREMENTS Holliday-Segar Method
BODY WEIGHT
WATER (ml/kg/day)
First 10 kg
100 ml/kg
Second 10 kg (<20kg)
50ml/kg for each kg > 10kg ml
Each additional kg (>20kg)
20ml/kg for each kg > 20kg ml

51. MAINTENANCE REQUIREMENTS Ludan Method
BODY WEIGHT (kg)
TOTAL FLUID REQUIREMENT (TFR) at ml/kg/day
> 3-10 kg
100ml/kg/day
> kg
75ml/kg/day
> kg
50-60ml/kg/day
>30-60 kg
40-50ml/kg/day

52. IV FLUID SELECTION
INITIAL REPLACEMENT (GOAL: Restore Intravascular volume & Tissue Perfusion)– always with an ISOTONIC SOLUTION
PNSS , PLR, PNR
FOLLOW UP HYDRATION (For Ongoing Losses) – Isotonic/Hypertonic, can be Glucose containing
D5LR, D5NR
MAINTENANCE – Usually Hypotonic
D5IMB , D5NM

53. FLUIDS NOT WORKING? Review medications: Dopamine Dobutamine
Norepinephrine
Epinephrine
Milrinone
Vasopressin
Nitroprusside

54. STEP THREE: Frequent Reassessment
Pulse quality
Heart Rate
Capillary Refill Time
Urine Output
Temperature
Blood Pressure
Neurologic Function
Oxygen saturation
Breath sounds and respiratory rate

55. STEP FOUR: Ancillary studies & Pharmacologic interventions
TREATMENT
Shock etiology & severity
Organ dysfunction
Metabolic derangements
Response to therapeutic interventions
Medications
Correct metabolic derangements
Manage pain and anxiety
Subspecialty consult

56. ADDITIONAL READING CASES
HYPOVOLEMIC SHOCK
DISTRIBUTIVE SHOCK
OBSTRUCTIVE SHOCK
CARDIOGENIC SHOCK
NEUROGENIC SHOCK
OTHERS
Diarrhea
Sepsis
Pericardial tamponade
Brain tumor
Poisonings
DKA
Tension pneumothorax
Brain trauma
Nephrotic/Nephritic syndrome
Burns
Ductal dependent heart lesions
Fluids for newborns
Dengue
Massive pulmonary embolism
Anaphylactic shock
Trauma
Surgical cases

57. BURNS Parkland Formula
Crystalloid at 4ml/kg x % BSA burned + Maintenance requirement
Give ½ over the first 8 hours
Then ½ over the next 16 hours
*See Burn Assesment Chart for %BSA burned

58. DENGUE PPS 2010 Recommendations
NOT in Shock
With MILD Dehydration
D5LR/ D5NSS/ D50.9NaCl Maintenance rate using Holliday Segar/Ludan Correct in 24 hours
D5LR/ D5NSS/ D50.9NaCl Maintenance rate (Ludan) + Mild Dehydration (Ludan) Give ½ in the first 8 hours Give the rest in the remaining 16 hours

59. END NELSON’S TEXTBOOK OF PEDIATRICS HARRIET LANE
PPS DENGUE 2010 GUIDELINES

60. CASE
1 year old MALE was brought to the ER by his hysterical mother due to sudden generalized tonic clonic convulsions and upward rolling of the eyeballs which occurred five minutes prior to consult. This is reported to be his first attack. On further investigation, you noted a 3 day history of vomiting followed by diarrhea. The vomiting occurs 2x/day, postprandial, amounting to ½ cup per episode.

61. The frequency of the diarrhea was 6-8 stools/day amounting to 1 cup/episode, watery, blood streaked; This was accompanied by fever (tmax 39) and intermittent episodes of abdominal pain; No known unusual food intake but the child plays with the neighborhood kids a lot and comes home very dirty. (+) decrease in appetite; Noted progressive decrease in activity

62. Last urine output noted 9 hours prior to consult; (+) Family history of BFC – paternal relatives The rest of the history was unremarkable

63. PHYSICAL EXAMINATION
Temperature 39; Heart rate 140/ minute; Respiratory rate 42/min; Blood pressure 90/60 Asleep, arousable; Not in respiratory distress; Good skin turgor; Pink, dry lips, no tpc, dry oral mucosa, sunken eyeballs, no clad; Equal chest expansion, clear breath sounds, no retractions;

64. Heart with regular rhythm, no murmurs; Abdomen tympanitic, soft, hyperactive bowel sounds Full and equal pulses