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Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance.

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Presentation on theme: "Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance."— Presentation transcript:

1 Elspeth Ferguson ST4 Paediatrics September 2011 Fluid & Electrolyte balance

2 Learning objectives Maintenance fluid requirements Deficit & Supplemental fluid requirements Grades of dehydration Types of dehydration Fluid & Electrolyte management Scenarios

3 How are children different? 15 % turnover of body fluids (adults 5%) Limited access to fluids Easier to give inappropriate fluids

4 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

5 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) <10100322.5100 10-20+50+1.5+1+1.5+75 >20+20+0.75+0.4+1+30

6 Maintenance requirements (Neonates) Day of life Fluid(ml/kg)Type 160 10% dextrose 290 Na 3 mmol/kg K 2 mmol/kg 10% dextrose + additives 3120 4150 5180

7 Deficit Deficit = abnormal losses Abnormal losses vomiting diarrhea fever tachypnea hot weather DKA 3 rd space losses % dehydration x 10 = ml/kg deficit

8 Supplemental Supplemental = ongoing abnormal losses Composition of body fluids (mmol/l) NaKClBicarb diarrhoea50404040 gastric501515040 small bowel1301511030

9 Dehydration History Age Intake Output Systemic illness Pre-illness weight comparison Rehydrated wt estimate = admission wt (kg) x 100 100 - % dehydration

10 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) 5070100

11 Types of dehydration Hyponatremic (< 135 mmol/l) greater loss of Na relative to water deficit exaggerated by hypotonicity seizures may occur Isonatremic (135-150 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

12 Types of fluids FluidNa(mmol/l)K(mmol/l)Cl(mmol/l)Calories(kcal/l) 0.9% Saline 15001500 0.45% Saline + 5% dextrose 75075200 10% dextrose 000400 0.45% Saline + 5% dextrose + KCl 754075200

13 Principles of fluid therapy Fluids are drugs : Check calculations ! Add K when U&Es are back ( 40 mmol/l) Rehydration usually corrects metabolic acidosis Monitor U&Es closely

14 To admit or not? > 5 % dehydration Persistent vomiting Need for IV therapy Failure of outpatient management Diagnosis is not clear

15 Which route? Oral when possible Dioralyte Rehidrat Nasogastric fluids IV fluids persistent vomiting severe ongoing losses Shock Oral therapy fails

16 Which fluid? Use 0.9% saline as bolus Use 0.45% saline + 5 % dextrose for all types of dehydration initially Then fluid composition is guided by U&Es

17 How much fluid? Hourly rate = Maintenance + Deficit + Ongoing losses 24

18 Monitoring Intake Output Weight CRT Pulse BP Conscious level U&Es

19 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

20 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?

21 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?

22 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?

23 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?

24 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?

25 Summary Maintenance fluid requirements Deficit & Supplemental fluid requirements Grades of dehydration Types of dehydration Fluid & Electrolyte management Scenarios

26 Questions

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