4Daily Water Losses all losses must be replaced for homeostasis types of losses:sensibleinsensible
5Daily Water Losses Area ml/100 cal expended obligatory urine volume 50-55stool water0-5skin30lungs15
6Maintenance Fluid Requirements maintenance fluidsamount of fluid the body needs for replacement of usual daily lossesmethods of computationHolliday-Segar MethodBody Surface Area MethodLudan’s Method*
7Maintenance Fluid Requirements Holliday-Segar Methodtotal maintenance water requirement is directly related to caloric expenditureequal to 1 ml/cal expended per daynot suitable for:neonates < 14 days oldconditions associated with abnormal losses
8Maintenance Fluid Requirements Holliday-Segar MethodWeightDaily Requirements3-10 kg100 ml/kg11-20 kg1000 ml + 50 ml/kg for each kg > 10 kg> 20 kg1500 ml + 20 ml/kg for each kg > 20 kg
9Maintenance Fluid Requirements Body Surface Area Methodbased on the assumption that caloric expenditure is proportional to surface areanot suitable for < 1 year or < 10 kg
10Maintenance Fluid Requirements Body Surface Area MethodRequirementsWater1500 ml/m2/dayNa+30-50 meq/m2/dayK+20-40 meq/m2/day
11Maintenance Fluid Requirements Case 1Jessa is a 5/F weighing 18 kg who was placed on NPO. She is for elective surgery in the morning.Maintenance fluid requirement?TFI?
12Maintenance Fluid Requirements Case 2Aries is a 16/M with possible CNSLeukemia, placed on NPO for Cranial CT.He weighs 116 kg and has a height of179 cm.BSA?Maintenance fluid requirement?
13Factors Modifying Fluid Requirements Additional Fluids Neededfever12% for each ºC > 37.5ºCsustained hyperventilation or excessive muscular activity25-50%hypermetabolic states25-75%for burns: 2% increase per 1% BSA with burnsdiarrhea and vomitingvolume per volumesweating10-25%room temperature > 31ºC30% per ºC rise > 31ºCnewborn under radiant warmer or phototherapy25%
14Factors Modifying Fluid Requirements Less Fluids Neededhypothermia12% per ºC fall below 37.5ºCvery high humidity30%humidified inspired air25%oliguria or anuriaindividualizedsedated or paralyzed40%
15Factors Modifying Fluid Requirements Case 3Loida is a 2/F weighing 12 kg intubated forpneumonia, currently on continuous ambu-bagging with an RR of 50. She has a fever of 38.5ºC.Factors to consider in determining maintenance fluids?Maintenance fluid requirement?
16Daily Electrolyte Requirements urine is the major source of electrolyte losses in childrenNa+ and K+ are also lost through the skin and sweatno electrolyte loss occurs during ventilation
18Daily Electrolyte Requirements Case 4Rita is a 6 mos/F weighing 7 kg who came in forseizures. Currently under observation, she hasbeen placed on NPO. She has a fever of 39ºC.Maintenance fluid requirement?Maintenance Na+ and K+?Which IVF to use?
20Daily Electrolyte Requirements Case 5Jon is a 4/M admitted for status epilepticus.He later develops cerebral edema with signs ofincreased ICP. You decide to start Mannitol.Maintenance fluid requirement?Maintenance Na+ and K+?Which IVF to use?Write down your IVF orders.
22Dehydration most common cause in children is diarrhea types of dehydration:isotonichypotonic (hyponatremic)hypertonic (hypernatremic)
23Correction of Dehydration assess severity of dehydration(Clinical Assessment of Severity of Dehydration – AAP)determine the fluid deficitSeverity of DehydrationInfantChild(>10 kg)mild50 cc/kg30 cc/kgmoderate100 cc/kg60 cc/kgsevere150 cc/kg90 cc/kg
24Correction of Dehydration determine the maintenance fluid requirementgive the ½ of the fluid deficit over the 1st 8 hours then ½ over the next 16 hoursre-assess hydration status periodicallyfor moderate to severe dehydration, check serum electrolytes
25Correction of Dehydration Case 6Armi is a 5 mos/F weighing 6 kg noted to have episodes of vomiting. On admission she was irritable, with a sunken anterior fontanel and dry mucous membranes. Extremities are slightly cool but with full pulses and CRT of 2 secs.Severity of dehydration and fluid deficit?Maintenance fluid requirement?Write down your IVF orders for correction of dehydration.
26Correction of Dehydration Case 7Edison is a 6/M weighing 20 kg who has been having diarrhea for the past 3 days. On admission he was lethargic with BP 90/50 HR 140 RR 36. He had sunken eyeballs, dry oral mucosa, and a rapid, thready pulse.Diagnosis?What to do first, fluid-wise?Severity of dehydration and fluid deficit?Maintenance fluid requirement?Write down your IVF orders for correction ofdehydration.
28Fluids in the Neonate maintenance fluid requirements in the neonate BW 0-2 days3-14 days15-30 daysg110140150g100130g90120> 1500 g80
29Fluids in the Neonate initial IVF: D10W determine serum electrolytes on the 12th HOL (preterm) or 24th HOL (full term) and change IVF accordingly
30Glucose Infusion Rate determines adequacy of infused glucose (dextrosity)(drip rate in cc/hr)(0.167)body weight (kg)desired GIR = 5-8 mg/kg/min
31Glucose Infusion Rate Case 8A Baby Planta is a 2 day-old/M weighing 3 kgreferred for persistent hypoglycemia. He is onNPO with an IVF of D5IMB at 12.5 cc/hr.TFI?GIR?What to do?
32Dextrosity of Fluids D5W contains 5 g of glucose per 100 ml changing dextrosities of fluids –factor = desired dextrosity – lower dextrosityhigher dextrosity – lower dextrosityamount of D50 to be added to actual IVF = (factor)(actual IVF being given)
33Dextrosity of Fluids Case 8B You decide to change the dextrosity of Baby Planta’s IVF from D5IMB to D10IMB.Write down your new IVF orders.
34Infusions / Drips Dopamine Dobutamine Epinephrine amount (cc) = dose (mcg/kg/min) x BW (kg) x 48040,000Dobutamine12,500Epinephrineamount (cc) = 0.6(BW) + sterile water to make 100 cc0.1 mcg/kg/min = 1 cc/hr
35Infusions / Drips general formula drip rate = dose x BW x 60 x total volume___volume per amp