4 Daily Water Losses all losses must be replaced for homeostasis types of losses:sensibleinsensible
5 Daily Water Losses Area ml/100 cal expended obligatory urine volume 50-55stool water0-5skin30lungs15
6 Maintenance Fluid Requirements maintenance fluidsamount of fluid the body needs for replacement of usual daily lossesmethods of computationHolliday-Segar MethodBody Surface Area MethodLudan’s Method*
7 Maintenance 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
8 Maintenance 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
9 Maintenance Fluid Requirements Body Surface Area Methodbased on the assumption that caloric expenditure is proportional to surface areanot suitable for < 1 year or < 10 kg
10 Maintenance Fluid Requirements Body Surface Area MethodRequirementsWater1500 ml/m2/dayNa+30-50 meq/m2/dayK+20-40 meq/m2/day
11 Maintenance 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?
12 Maintenance 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?
13 Factors 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%
14 Factors Modifying Fluid Requirements Less Fluids Neededhypothermia12% per ºC fall below 37.5ºCvery high humidity30%humidified inspired air25%oliguria or anuriaindividualizedsedated or paralyzed40%
15 Factors 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?
16 Daily 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
18 Daily 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?
20 Daily 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.
22 Dehydration most common cause in children is diarrhea types of dehydration:isotonichypotonic (hyponatremic)hypertonic (hypernatremic)
23 Correction 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
24 Correction 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
25 Correction 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.
26 Correction 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.
28 Fluids in the Neonate maintenance fluid requirements in the neonate BW 0-2 days3-14 days15-30 daysg110140150g100130g90120> 1500 g80
29 Fluids in the Neonate initial IVF: D10W determine serum electrolytes on the 12th HOL (preterm) or 24th HOL (full term) and change IVF accordingly
30 Glucose 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
31 Glucose 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?
32 Dextrosity 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)
33 Dextrosity 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.
34 Infusions / 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
35 Infusions / Drips general formula drip rate = dose x BW x 60 x total volume___volume per amp