6OSMOLALITY 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
7OSMOLALITY Normal = 285-295 mOsm/kg The ICF and ECF are in osmotic equilibrium
8OSMOLALITY OSMOLALITY = mOsm/kg of solvent OSMOLARITY = mOsm/liter of a solution
25INTRAVENOUS FLUIDS chemically prepared solutions Achieve and maintain a euvolemic and isotonic environment within the bodyThey are tailored to the body’s needs and used to replace lost fluid and/or aid in the delivery of IV medications
26ISOTONIC IV FLUIDScreated to distribute evenly between the intravascular, interstitial, and cellular spaces.
33CRYSTALLOIDScontain 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).
34COMPOSITION OF IV FLUIDS OSMOLARITY(mosm/L)Na+ (mmol/L)K+Cl-BasePNSS308154?PLR273130D5LR525410928D5NR5521409850D50.3NaCl35551D5IMB35025202223D5NM36840316D5W255
35COLLOIDScontain 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).
36COLLOIDS/PLASMA EXPANDERS Albumin = 1-2 kg/dose infused in 2 hoursHaes-teryl = 20-40ml/kgVoluven = 20-40ml/kgGelofuschin = 20-40ml/kgFresh frozen plasma = 10-15ml/kg x 4 hoursDextran 40 or 60
37BLOOD AND BLOOD PRODUCTS are the most desirable fluids for replacement but are not the first choice for immediate volume expansion in children with shockNot only is the intravascular volume increased, but the fluid administered can also transport oxygen to the cells.
38BLOOD AND BLOOD PRODUCTS COMPUTATIONpRBC10 ml/kg to run for 4 hoursFresh whole blood10-20 ml/kg in 4-6 hoursPlatelet Concentrate15-20 ml/kg as fast dripCryoprecipitate1 unit/6kg/dose
46FLUID DEFICITS Ludan’s Method WEIGHTMILD DEHYDRATIONml/kg/8 hoursMODERATE DEHYDRATIONSEVERE DEHYDRATION<15 kg50100150>15 kg306090Give ¼ in 1 hrGive ¾ in 7 hrGive 1/3 in 1 hrGive 2/3 in 7hrPLAIN LR/PLAIN NSSD5LRPLAIN LR/ PLAIN NSS
47FLUID DEFICITS – WHO *Use Ringer’s Lactate SOME DEHYDRATION75ml/kg in 4 hoursSEVERE DEHYDRATIONAGEFIRST GIVE30ml/kg in:THEN GIVE70ml/kg in:Infants under 12 months1 hour5 hoursOlder30 minutes2 ½ hours
48SODIUM CORRECTIONDEFICIT CORRECTION: desired-actual x weight x * Desired Na+ is meqMAINTENANCE COMPUTATION: maintenance x weight *Maintenance is 2-4meq/kgCOMPUTE 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
49POTASSIUM 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 correctionCheck IV fluid rate*Maximum 40meq/Liter of KCL incorporation in IV FluidCHECK POTASSIUM INFUSION RATE (KIR) =meq of KCL x IV rate (ml/hour) x weight(maximum of 0.2meq/kg/hour)
50MAINTENANCE REQUIREMENTS Holliday-Segar Method BODY WEIGHTWATER (ml/kg/day)First 10 kg100 ml/kgSecond 10 kg (<20kg)50ml/kg for each kg > 10kg mlEach additional kg (>20kg)20ml/kg for each kg > 20kg ml
51MAINTENANCE REQUIREMENTS Ludan Method BODY WEIGHT (kg)TOTAL FLUID REQUIREMENT (TFR) at ml/kg/day> 3-10 kg100ml/kg/day> kg75ml/kg/day> kg50-60ml/kg/day>30-60 kg40-50ml/kg/day
52IV FLUID SELECTIONINITIAL REPLACEMENT (GOAL: Restore Intravascular volume & Tissue Perfusion)– always with an ISOTONIC SOLUTIONPNSS , PLR, PNRFOLLOW UP HYDRATION (For Ongoing Losses) – Isotonic/Hypertonic, can be Glucose containingD5LR, D5NRMAINTENANCE – Usually HypotonicD5IMB , D5NM
53FLUIDS NOT WORKING? Review medications: Dopamine Dobutamine NorepinephrineEpinephrineMilrinoneVasopressinNitroprusside
57BURNS Parkland Formula Crystalloid at 4ml/kg x % BSA burned + Maintenance requirementGive ½ over the first 8 hoursThen ½ over the next 16 hours*See Burn Assesment Chart for %BSA burned
58DENGUE PPS 2010 Recommendations NOT in ShockWith MILD DehydrationD5LR/ D5NSS/ D50.9NaCl Maintenance rate using Holliday Segar/Ludan Correct in 24 hoursD5LR/ D5NSS/ D50.9NaCl Maintenance rate (Ludan) + Mild Dehydration (Ludan) Give ½ in the first 8 hours Give the rest in the remaining 16 hours
59END NELSON’S TEXTBOOK OF PEDIATRICS HARRIET LANE PPS DENGUE 2010 GUIDELINES
60CASE1 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.
61The 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
62Last urine output noted 9 hours prior to consult; (+) Family history of BFC – paternal relatives The rest of the history was unremarkable
63PHYSICAL EXAMINATIONTemperature 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;
64Heart with regular rhythm, no murmurs; Abdomen tympanitic, soft, hyperactive bowel sounds Full and equal pulses