Paediatric fluids Flashcards
Fluid of choice:
a) Neonate
b) Maintenance in children
c) Fluid bolus for shock
d) Ongoing losses
a) 10% glucose
b) 0.9% NaCl + 5% glucose
c) 0.9% NaCl
d) 0.9% NaCl + potassium (K+)
Neonates - amount each day
Day 1 - 60ml/kg
Day 2 - 90ml/kg
Day 3 - 120ml/kg
Day 4 - 150ml/kg
Add what ratios from day 2 in neonate
Na (3), K (2), Ca (1)
Children: calculating maintenance fluid volumes
a) Per day
b) Per hour
c) Approximate weight calculation formula
a) Per day.
(100 x 1st 10kg) + (50 x 2nd 10kg) + (20 x remaining kg)
b) Per hour.
(4 x 1st 10kg) + (2 x 2nd 10kg) + (1 x remaining kg)
c) Weight (kg) = (age + 4) x 2
Hydration status (NICE).
a) Normal
b) Mild-moderate (< 10%) dehydration)
c) Red flags (STAT, STAT)
d) 3 most sensitive indicators of 5% dehydration (abnormal … mnemonic: CRT)
a)
b) Restlessness or irritability. Sunken eyes (also ask the parent). Thirsty and drinks eagerly
c) Sunken eyes (sunken fontanelle in infants), Tachypnoea, Appears unwell, Tachycardia. Skin mottled/pale, Turgor reduced, Altered responsiveness (e.g, irritable, lethargic), Thready peripheral pulses
d) Cap refill time, Respiratory pattern, Turgor (skin)
Note: hypotension is a very late sign
Correction of fluid deficits.
a) Equation (for excess fluid per 24h_
b) So if they are 5% dehydrated
c) Shock (10%)
d) Three indications for IV over oral fluid replacement
a) (Weight) x (% dehydration) x 10
= additional fluid requirement over 24h
b) 5 x 10 = 50mls/kg extra per 24h
c) Fluid bolus + 100mls/kg extra per 24h
d) Shock, red flags for severe dehydration, unable to tolerate/hold down oral fluids (e.g. pyloric stenosis)
Fluid bolus for shock
When would you give reduced dosage (e.g. 10mls/kg)?
20 mls/kg 0.9% sodium chloride
DKA, trauma, head injury, NEONATES, heart failure
DKA.
a) 3 biochemical findings to diagnose
b) ABCD of management in DKA
c) IV ____ and _____ replacement; then 1-2 hours later administer IV _____.
d) When glucose falls to 12-15mmol/L, switch fluids to…?
e) Why are serum potassium levels misleading in DKA?
f) Causes of death in DKA
a) Glucose > 11 mmol/L; Venous pH < 7.3 or HCO3- < 15 mmol/L; ketonaemia and ketonuria
b) Assess GCS, administer 100% oxygen, insert IV cannulae and give fluids (10ml/kg NaCl 0.9% bolus), reassess GCS
c) Fluids and potassium; insulin
d) NaCl and 5% glucose
e)
f) Cerebral oedema
Causes of dehydration.
a) 4 pathophysiological causes
b) Common causes: i) GI, ii) Endocrine, iii) Oropharyngeal, iv) Other
a) Reduced intake, increased output (renal, gastrointestinal or insensible losses), transcellular shift (ascties, effusions), capillary leakage (burns, inflammation, sepsis)
b) i) Diarrhoea, bowel obstruction, pyloric stenosis,
ii) DKA, DI, thyrotoxicosis, CAH,
iii) Ulcers, pharyngitis, etc (may limit intake),
iv) Febrile illness, CF, burns, heat stroke
Insensible fluid losses - define
The amount of fluid lost on a daily basis from the lungs, skin, respiratory tract, and water excreted in the faeces
Monitoring during fluid replacement.
a) General
b) Infant - assess tension of the _______.
c) What indicates good response to fluids?
a) well-being, pulse rate and volume, capillary refill, blood pressure, urine output (via catheter) ECG monitoring, and blood renal function, electrolytes.
b) Fontanelle
c) Slowing of the heart rate (to the normal range for the child's age). Improved conscious state and awareness. Return of peripheral pulses, return of normal skin colour and increased warmth of extremities. Increased SBP (approximately 90 mm Hg plus twice the age in years), increased pulse pressure (above 20 mm Hg). Normalising of urine output for age
Normal urine output by age
Newborn/infant: 2 ml/kg/hour
Toddler: 1.5 ml/kg/hour
Older child: 1 ml/kg/hour
Adult: 0.5 ml/kg/hour
Oral rehydration (Dioralyte)
a) Prescribe after each large, watery stool in what 4 high risk groups/ clinical scenarios?
b) Dose (ml/kg)
a) Children younger than 1 year, particularly those younger than 6 months.
Infants who were of low birth weight.
Children who have passed more than five diarrhoeal stools in the previous 24 hours.
Children who have vomited more than twice in the previous 24 hours
b) 5 ml/kg
DKA presentation
a) May be the first…?
b) Common symptoms
c) Common signs
a) presentation of T1DM
b) Lethargy, confusion. Polyuria ± polydypsia. Weight loss. Abdominal pain ± vomiting (may mimic a surgical abdomen).
c) Dehydration. Rapid, deep sighing (Kussmaul’s respirations). Ketotic breath - fruity, pear drops smell.
Shock, coma (assess Glasgow Coma Scale). Evidence of cerebral oedema, or infection.
Metabolic acidosis.
a) Anion gap calculation and normal value
b) Causes of high anion gap metabolic acidosis (MUDPILES)
c) 2 causes of normal anion gap metabolic acidosis
a) ([Na+] + [K+]) − ([Cl−] − [HCO3−]) = 20 mEq/L
b) Methanol, Uraemia (chronic kidney failure), Diabetic ketoacidosis, Paracetamol, Infection, Iron, Isoniazid, Inborn errors of metabolism, Lactic acidosis, Ethanol, Salicylates
c) Diarrhoea, RTA
