How are children different? 15 % turnover of body fluids (adults 5%) Limited access to fluids Easier to give inappropriate fluids
Maintenance requirements Based on calorie requirements and fluid losses from the body Insensible losses1/5 th Essential urine output1/5 th Normal urine output3/5 th
Maintenance requirements (Child) Body weight (kg) Fluid(ml/kg/d)Na(mmol/kg/d)K(mmol/kg/d)Protein(g/kg/d)Energy(kcal/kg/d) < >
Maintenance requirements (Neonates) Day of life Fluid(ml/kg)Type % dextrose 290 Na 3 mmol/kg K 2 mmol/kg 10% dextrose + additives
Deficit Deficit = abnormal losses Abnormal losses vomiting diarrhea fever tachypnea hot weather DKA 3 rd space losses % dehydration x 10 = ml/kg deficit
Supplemental Supplemental = ongoing abnormal losses Composition of body fluids (mmol/l) NaKClBicarb diarrhoea gastric small bowel
Dehydration History Age Intake Output Systemic illness Pre-illness weight comparison Rehydrated wt estimate = admission wt (kg) x % dehydration
Grades of dehydration 1(symptoms) 5% 2(signs) 7% 3(shock) 10% Clinical condition Thirsty alert restless Lethargic irritable drowsy Floppy comatose PulseNormalFastFeeble RespirationNormalDeep Deep & Rapid FontanelleNormalSunken Very sunken Systolic BP Normal Postural drop Low CRTNormal >2 seconds > 3 seconds EyesNormalSunken Very sunken Mucous memb MoistDry Very dry Urine output Normal Concentrated ConcentratedAnuria Deficit (ml/kg)
Types of dehydration Hyponatremic (< 135 mmol/l) greater loss of Na relative to water deficit exaggerated by hypotonicity seizures may occur Isonatremic ( mmol/l) equal losses of Na and water Hypernatremic (>150 mmol/l) difficult to estimate the degree of dehydration correct over 48 hours Na fall should be < 10 mmol/day
Case 1 A previously healthy 11 month old infant is referred to CAU with a 3 day history of diarrhoea and vomiting with a poor urine output She has sunken eyes, sunken fontanelle and dry mucous membranes. The pulse is rapid and easily felt. She vomits all her feeds Calculate her fluid requirements over the next 24 hours
Case 2 A 10 year old girl has been brought by ambulance in a semi-comatose state. She is found to have a non-blanching rash over her trunk, neck stiffness and an axillary temperature of 39.5°C. Her capillary return time is 7 seconds and her systolic BP is 90 mm/HG. How will you manage her fluids in the emergency setting and subsequently?
Case 3 A 6 year old boy has been referred by his GP for being unwell and wetting his bed lately. His mothers says that he has been losing weight since he came back from Pakistan 4 weeks ago. His urine shows 4+ glucose and “large” ketones and a lab blood sugar is 32. On examination he is found to be lethargic with a capillary return time of 5 seconds. He is afebrile with a dry mouth and a pulse of 120/min.Blood pressure is 110/70. What is your diagnosis? How will you write up the fluids for this child?
Case 4 A 6 month old infant of a drug addict is brought to the Children’s Ward with a history of vomiting and excessive drowsiness. The Health Visitor accompanying the infant fears that the mother may have made up the feeds wrongly over the past few days. The infant is found to have a sunken fontanelle and has not passed urine for a few hours. The S. Na+ is 165, S. K+ is 3.5, Urea is 8, Creatinine is 70. How will you manage this infant?
Case 5 A 6 week old male infant who was born at 38 weeks gestation is referred by his GP on a Saturday for non bilious vomiting after most feeds for the last two weeks. His birth weight centile was the 10 th but now is is less than the 3 rd. On examination he is alert and hungry. He looks thin and has a capillary return time of 4-5 seconds. Abdomen palpation reveals no abnormality but you notice that his nappy is wet. The lab results area as follows: Na+132 K+3.2 C1-96 HCO332 pH7.45 How will you manage the fluid and electrolyte needs of this infant?
Case 6 A 5 day old baby who was a planned home birth is seen by the Community Midwife who feels that the baby’s genitalia are odd. The baby is seen in the clinic and has an underdeveloped phallus and scrotum. No testes are palpable in the scrotum. The baby has a poor perfusion and weak cry. It is admitted from clinic. Dextrostix is 2. The lab results are back urgently: S. Na+125 S. K+7.5 (non-haemolysed sample) Blood sugar1.8 How will you manage this neonate’s fluids?