Fluid Management in Children Flashcards
In healthy kids what is maintenance fluid levels and how is it determined?
4-2-1 rule: not recommended anymore - 2/3 of this in hospitals.
Used frequently in paediatrics - asults are more resilient but need more precision in kid
4mls/kg/hr for the 1st 10kg
2mls/kg/hr for the 2nd 10kg
1mls/kg/hr for the rest
fluid given to replace insensible losses
max 100ml/hr
HOWEVER:
- kids eat and drink a lot, and stress ADH response,4:2:1 based on healthy kids.
So:
- consider 2:1:1 rule, OR 2/3 of the 4:2:1 rule.
- CNS infection, liver/kidney problems, respiratory - think less. Meningitis 1/2 normal. Fear of SIADH.
- daily electrolytes (isotonic + glucose) - 5% dextrose provides minimal nutritional support. neonates often give 10% dextrose.
- relative review
- quickly reduce once drinking
How do you assess a child with dehydration? What are you looking for?
- mucous membranes
- sunken eyes
- lethargy
- BP, HR, JVP, Frontanelles, concious state, mucous membranes, tissue turgor.
calculate volume as a percentage of total body weight
generally:
- mild = vomiting and diarrhoea
- moderate = capillary refill delay and increased RR, with decreased tissue turgor
- Severe = irritable, unconcious, deep acidotic breathing (cheynes stokes)
6-12 hourly clinical review.
Give some types of fluids in paediatrics and talk through some differences.
Children with diarrhoea can lose a disproportionate amount of potassium so might need to prescribe more.
- Hartmann’s solution
- more physiologic, sodium goes down a little (neurosurg hyponatremia causes cerebral oedema)
- lactic acidosis
- Saline
- no K - hypokalaemia (can add it).
- pH decrease (hyperchloremia)
- Plasmalyte
- expensive - but perfect within physiologic levels for everything but calcium. gluconate and acetate
What are the mechanisms of children getting hyponatremia? What are the effects?
- stress response produces ADH - cerebral oedema as water moves from ECF to ICF.
- ANP release and salt wasting
Particular at risk:
- large brain - small increase in volume to increase ICP - N/V, headache, seizure, confusion etc…
- impaired adaptive mechanism (immature Na/K ATPase)
- encephalopathy occurs at higher Na level (120 vs 111 in adults)
What are some high risk groups for fluid problems?
- Neurological disease
- Craniofacial / neurosurg =pts
- Neonates – have their own rules
- Requiring full maintenance fluids - can’t eat or drink
- Respiratory disease
A child comes in with a high fever of 39.5, poor feeding and lethargy. He was reduced wet nappies. HR 130 RR 30 SpO2 99%. 5.2kg.
What investigations would you do?
What therapy would you give?
What do you do for kids in shock?
- Septic Screen:
- FBE
- CRP
- UEC
- Urinalysis (leukocyte esterase, nitrites, blood)
- Admit patient
- Fluid assessment:
- fluids (5.2x4 = 20.8 round to 20ml/kg/hr) 4:2:1 rule
- at RCH plasmalyte + 5% dextrose
- at others Normal saline + 5% dextrose
- never just give normal saline for maintenence - sugar.
- fluids (5.2x4 = 20.8 round to 20ml/kg/hr) 4:2:1 rule
- Treatment:
- antibiotics - empiric treatment (trimethoprim 4mg/kg approx 20mg)
In shock?
- start 10ml/kg/hr - uptitrate to 20ml/kg (another 10mls/kg) - don’t go higher.
- stat - in syringe. Adult kid squeeze the bag.
What would you do to monitor someone on Fluid Management?
Fluid Assessment
- fluid balance chart (weigh them and diary of urine - 2x sick, 1 x daily)
- electrolytes (before then 8 hourly to begin with but quickly go to daily)
- Examine them and check obs (regular exam)
- HR - settle down, sacral oedema
What is the fluid that should be administered in an unwell child?
- an initial bolus to correct depletion of:
- 10-20ml/kg of 0.9% NaCl (can be repeated) - can repeat. Do not include in calculations
- maintenance (2/3 in unwell children unless dehydrated) - siADH - 4:2:1 rule.
- 0.9% NaCl + 5% glucose +/- 20mmol/L KCL
- or plasma-lyte 148 and 5% glucose
