Fluid Therapy in intensive care unit in pediatrics age group

Fluid therapy

1. Fluid THERAPY Dr. Nikita R Khot

2. INTRODUCTION Intravenous fluids (IVFs) are medication . Since the late 1950s, IVF choice has been largely guided by Holliday and Segar’s estimations of sodium requirements. Using the electrolyte composition of human milk , they calculated that the average child requires 3 mEq sodium (Na) and 2 mEq potassium (K) per 100 to 120 mL water (H2O) i.e. 30 meq of Na/1000 ml . According to their calculation, basic solute needs can be met by administering ¼ normal saline ( NS ), a hypotonic fluid. While this estimation led to a long-standing tradition in pediatric maintenance IVF (MIVF) therapy, evidence published over the past few decades culminated in new American Academy of Pediatrics (AAP) guidelines recommending isotonic fluids as the maintenance fluid of choice for the majority of hospitalized children.

3. TOTAL BODY WATER The fetus has very high TBW, which gradually decreases. It is approximately 75% of birth-weight for a term infant. Premature infants have higher TBW than term infants. During the 1 st yr of life, TBW decreases to approximately 60% of body weight and basically remains at this level until puberty. By the end of puberty TBW in males remains at 60%, but TBW in females decreases to approximately 50% of body weight. AGE PERCENT TBW TERM BABY 75% 1 YEAR 60% ADULT MALE 60% ADULT FEMALE 50%

4. FLUID COMPARTMENTS In the fetus and newborn, the ECF volume is larger than the ICF volume. The normal postnatal diuresis causes an immediate decrease in the ECF volume. This is followed by continued expansion of the ICF volume, which results from cellular growth . By 1 yr of age, the ratio of the ICF volume to the ECF volume approaches adult levels. PLASMA 5%; Interstitial 15%.

5. The balance between HYDROSTATIC AND ONCOTIC FORCES regulates the intravascular volume, which is critical for proper tissue perfusion. These forces favor movement into the interstitial space at the arterial ends of the capillaries. There is movement of fluid into the venous ends of the capillaries. Overall, there is usually a net movement of fluid out of the intravascular space to the interstitial space, but this fluid is returned to the circulation via the lymphatics . An imbalance in these forces may cause expansion of the interstitial volume at the expense of the intravascular volume.

6. In children with hypoalbuminemia , the decreased oncotic pressure of the intravascular fluid contributes to the development of edema . In contrast, with heart failure, there is an increase in venous hydrostatic pressure from expansion of the intravascular volume, which is caused by impaired pumping by the heart, and the increase in venous pressure causes fluid to move from the intravascular space to the interstitial space.

7. Sodium and chloride are the dominant cation and anion, respectively, in the ECF . Potassium is the most abundant cation in the ICF & Proteins , organic anions , and phosphate are the most plentiful anions in the ICF.

8. 2018 AAP guidelines on MIVF The administration of hypotonic maintenance IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia . The KEY ACTION STATEMENT of the subcommittee is as follows: 1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should RECEIVE ISOTONIC SOLUTIONS with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (recommendation strength: strong). This data was obtained by combining the strategies used in recent 7 systematic reviews of 11 clinical trials of maintenance IVFs in children and adolescent. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward.

9. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus , voluminous watery diarrhea, or severe burns; Most of these subsets were excluded because no specific data were documented in studies or patients were very serious. Neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded.

10. HYPOTONIC FLUIDS AND CONCERNS Hyponatremia is the most common electrolyte abnormality in hospitalized patients , affecting approximately 15% to 30% of children and adults. ‍ Patients who are acutely ill , frequently have disease states associated with arginine vasopressin ( AVP/ADH) excess that can impair free-water excretion and place the patient at risk for developing hyponatremia when a source of electrolyte-free water is supplied, as in hypotonic fluids. Nonosmotic stimuli of AVP release include pain, nausea, stress, a postoperative state, hypovolemia , medications, and pulmonary and central nervous system (CNS) disorders , including common childhood conditions such as pneumonia and meningitis.‍ These conditions can lead to the syndrome of inappropriate antidiuresis (SIADH)

11. Most hyponatremia in patients who are hospitalized is related to the administration of hypotonic IVFs in the setting of elevated AVP concentrations. The most serious complication of hospital-acquired hyponatremia is hyponatremic encephalopathy, which is a medical emergency that can be fatal or lead to irreversible brain injury if inadequately treated.‍ The reports of hospital‐acquired hyponatremic encephalopathy have occurred primarily in otherwise healthy children who were receiving hypotonic IVFs, in many cases after minor surgical procedures. Patients with hospital‐acquired hyponatremia are at particular risk for hyponatremic encephalopathy, which usually develops acutely in less than 48 hours, leaving little time for the brain to adapt. Children are at particularly high risk because of their larger brain/skull size ratio.‍

12. ISOTONIC FLUIDS AND CONCERNS HYPERNATREMIA : NO evidence of an increased risk ; although the quality of evidence was judged to be low. HYPERCHLOREMIC ACIDOSIS: No conclusive data; limited studies. [RL has less risk than NS]. 3. FLUID OVERLOAD: A combination of excessive fluid and sodium can synergistically increase retained volume, a condition that is Exacerbated in children with chronic comorbidities (such as congestive heart failure (CHF), cirrhotic hepatic failure, chronic kidney disease) and long- term steroid use. Evidence is required .

13. OSMOLALITY AND TONICITY OSMOLALITY is measured as osmoles of solute per kilogram of solvent. Serum osmolality can be estimated by the following formula: 2 × Na ( mEq / L )   + Glucose (mg/ dL )/18 + BUN (mg / dL )/2.8. TONICITY is used to describe the net vector of force on cells relative to a semipermeable membrane when in solution. TYPE OF IVF SHIFT OF WATER/IVF EFFECT ON CELL / CELLSIZE ISOTONIC NO SHIFT SAME HYPOTONIC INTO CELLS INCREASED HYPERTONIC OUT OF CELLS DECREASED

14. TONICITY (EFFECTIVE OSMOLALITY) in that tonicity relates to both the effect of a fluid on a cell and the osmolality of the fluid. The tonicity of IVF is primarily affected by the Na and K concentration; NOT BY UREA . Although glucose affects the osmolarity of IVFs, it is not a significant contributor to the tonicity or plasma osmotic pressure , because it is rapidly metabolized after entering the blood. [Exception is uncontrolled diabetes]. Osmola L ity – osmoles per KG. Osmola R ity - osmoles per LITRE.

15. REGULATION OF OSMOLALITY AND VOLUME VOLUME REGULATION IS MORE IMPORTANT for body THAN OSMOLALITY REGULATION. Regulation of VOLUME STATUS depends on regulation of SODIUM BALANCE . Maintenance of normal OSMOLALITY depends on control of WATER BALANCE .

16. The kidney regulates sodium balance by altering the percentage of filtered sodium that is resorbed along the nephron . Normally, the kidney excretes <1% of the sodium filtered at the glomerulus . The most important determinant of renal sodium excretion is the volume status of the child; it is the effective intravascular volume that influences urinary sodium excretion.

17. Sodium is unique among electrolytes because water balance, not sodium balance, usually determines its concentration. When the sodium concentration increases, the resultant higher plasma osmolality causes increased thirst and increased secretion of ADH, which leads to renal conservation of water. Both of these mechanisms increase the water content of the body, and the sodium concentration returns to normal.

18. COLLOIDS AND CRYSTALLOIDS Crystalloids are solutions having small molecules that can freely diffuse from iv to interstitial compartment  25% of infused volume remains in IV compt., while 75% diffuses into Int. space. Colloids have large solute molecules which do not pass readily from iv to interstitial fluid; create an osmotic force  oncotic /osmotic pressure. Examples of colloids: Albumin 5% and 25%, Dextran, Startch .

19. CRYSTALLOIDS COLLOIDS Particle/solute size small large Permeability to membrane good poor ECF:Interstitial fluid Distribution 1:3 3:1, 100% IV compt. Duration of effect of volume expansion Less; minutes - few hours More; hours [12-24 hours for albumin] Risk of Edema Peripheral and pulmonary Pulmonary Fluid volume per ml blood loss 3:1 1:1 others Less costly Costlier Risk of anaphylaxis,coagulopathy

20. COMMONLY USED FLUIDS ISOTONIC D% Gm/dl Na meq /L Cl meq /L K meq /L HCO3 or BUFFERS meq /L Calories [per 1000 ml] Proteins Gm/dl mOsm /L HUMAN PLASMA 0.07-0.11 135- 145 95- 105 3.5- 5 22-26 285- 295 RL 130 109 4 28 [ Lact .] 273 NS 154 154 308 PLASMALYTE 140 98 5 27[Acet.] 294 0.9 DNS 5 170 560* D5 RL 5 170 525* ALBUMIN 5% 100-160 <120 5 gm/dl 300 RL and PLASMALYTE HAVE BUFFERS i.e. BALANCED SOLUTIONS. NS,DNS, D5, D10 ARE NOT BALANCED SLOUTIONS.

21. 2. HYPOTONIC D% Gm/dl Na meq /L Cl meq /L K meq /L HCO3 or BUFFERS meq /L Calories [per 1000 ml] Proteins Gm/dl mOsm /L 1/2NS 77 77 154 D5 5 170 252 D10 10 340 505 3. HYPERTONIC 3% NaCl 513 513 1027 Mannitol 20% 1100 SodaBicarb 8% 1000 1000 2000 *1 ml CRL has 3 meq of Na

22. ORS COMPOSITON GLUCOSE Na Cl K Citrate Osmolarity Standard ORS (OLD) 111 90 80 20 10 311 Low Osmolarity ORS (LORS ) 75 75 65 20 10 245 ReSoMal 125 45 76 40 7 300 # How to prepare ReSoMal : Empty one 1-litre standard ORS packet into container that holds more than 2 litres . Measure and add 50 grams sugar. (It is best to weigh the sugar on a dietary scale that weighs to 5 g.) Measure 40 millilitres of mineral mix solution (or proper amount of CMV) in a graduated medicine cup or syringe; add to other ingredients. Measure and add 2 litres cooled, boiled water. Stir until dissolved. (Use within 24 hours).

23. WHY THE CHANGE? OLD ORS LOW OSMOLAR ORS ETIOLOGY CHOLERA BASED ROTA VIRUS BASED STOOL Na Cholera – 90 meq /l Rota – 52 meq /l Na and Water absorption faster Vomiting Less reduction Significant reduction Volume of stools Less reduction Significant reduction Need for IV therapy despite ORS Less

24. LORS IN SPECIAL SITUATIONS 1. SAM: Add 15ml of 20% KCl in 1 litre of LORS is effective in SAM with dehydration. 2. INFANTS: Insufficient evidence to recommend LORS below 2 months of age.

25. MAINTENANCE THERAPY Is used to replace ongoing losses of water under normal physiological conditions via urine, sweat, respiration and stools. Goals of Maintenance Fluids : Prevent dehydration Prevent electrolyte disorders Prevent ketoacidosis Prevent protein degradation Measurement of maintenance fluids ( Holliday – Segar Method ): Body Wt Volume per day Hourly rate 1-10kg 100ml/kg 4ml/kg/hr 11-20kg 1000ml+ 50ml/kg for every kg after 10kg 40ml/hr+2ml/kg/hr*(Wt-10) > 20kg 1500ml+ 20ml/kg for every kg after 20 kg 60ml/hr+ 1ml/kg/hr*(wt-20)

26. Body Surface Area (BSA): It is based on the assumption that caloric expenditure is related to body surface area and should not be used in children in <10 Kg. *HS method is not suitable for neonates < 2 weeks old.

27. Maintenance fluids are composed of a solution of water, glucose, sodium, and potassium . The glucose (D5) in maintenance fluid prevents the development of starvation ketoacidosis, and diminishes the protein degradation that would occur if the patient received no calories. Maintenance fluids usually contain D5 , which provides 17 calories/ 100 mL and nearly 20% of the daily caloric needs . A patient receiving maintenance intravenous fluids is receiving inadequate calories and will lose 0.5-1% of weight each day. Electrolyte requirement per day: Electrolyte Daily Requirement Na 3 – 4 mEq/kg/day K 2 –3 mEq/kg/day Cl 3 – 4 mEq/kg/day

28. Sources of water loss : Urine: 60% Insensible losses: ≈35% (skin and lungs) Stool: 5%

29. KCl in MIVFs Composition is 20 meq /L i.e. 5 ml KCl per 500 ml bag for children with normal renal function. This prevents hypokalemia and doesn’t cause hyperkalemia . In DKA , fluids should have 40 meq /L KCl , i.e. 10 ml KCl per 500ml bag. If K is above the normal range, add KCl only after patient has passed urine or K has fallen in the normal range. Patients with renal failure, TLS, rhabdomyolysis - avoid KCl , unless hypokalemic . Peripheral line max KCl : per 500 ml bag is 10 – 20 ml [40-80 meq /Litre].

30. PHASES OF FLUID THERAPY Four distinct physiology-driven time periods exist for children requiring IVFs. The resuscitative phase is the acute presentation window, when IVFs are needed to restore adequate tissue perfusion and prevent end-organ injury. The titration phase is the time when IVFs are transitioned from boluses to maintenance; this is a critical window to determine what intravascular repletion has been achieved. The maintenance phase accounts for fluids administered during the previous 2 stabilization phases and is a time when fluids should be supplied to achieve a precise homeostatic balance between needs and losses . The convalescent phase reflects the period when exogenous fluid administration is stopped, and the patient returns to intrinsic fluid regulation.

31. ROSD/ROSE Resuscitation/ Rescue Optimisation Stabilization Evacuation/De-escalation Principle Life saving Organ rescue Organ support Organ recovery PHENOTYPE Severe shock Unstable Stable Recovery Goal Correct Shock Optimize tissue perfusion 0/- ve balance Fluid mobilization FLUID THERAPY Rapid boluses Titrate; fluid challenges Maintenance IVF Oral intake Oral intake Risk Under resuscitation; Overload Under resuscitation; Overload Overload Excess removal

32. FLUID BOLUS THERAPY IN SEPSIS 2020 UPDATE [SSC-G] PLACE 1. INITIAL RESUSCITATION IN SEPTIC SHOCK COMMENTS EVIDENCE WITH ICU BACKUP up to 40–60 mL /kg in bolus fluid (10–20 mL /kg per bolus) over the first hour , titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop, USG chest and IVC assessment; CXR > Hepatomegaly > crepts . Frequent clinical assessment [HR,CRT,BP, UO, GCS] WR,LQE NO ICU AND HYPOTENSION Up to 40 mL /kg in bolus fluid (10–20 mL /kg per bolus) over the first hour with titration to clinical markers of cardiac output and discontinued if signs of fluid overload develop RESOURCE LIMITED SETTINGS WR,LQE NO ICU BUT NO HYPOTENSION Recommend against bolus fluid administration while starting maintenance Fluids SR,HQE

33. 2. Suggest using crystalloids, rather than albumin, for the initial resuscitation (weak recommendation, moderate quality of evidence). there is no difference in outcomes; cost, availability, infections, allergic reactions. 3. Suggest using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation . [ RL/PLASMALYTE >> NS BOLUSES }. [WR,VLQI] Studies and RCTs in ADULTS suggests that resuscitation with crystalloid fluids - 0.9% saline[HIGH Cl - ] is associated with HYPERCHLOREMIC ACIDOSIS, SYSTEMIC INFLAMMATION, ACUTE KIDNEY INJURY (AKI), COAGULOPATHY, AND MORTALITY when compared with resuscitation with more balanced/buffered crystalloids – RL/ plasmalyte . No paediatric RCTs; only 2 observational studies available. 4. R ecommend against using starches/gelatins in the acute resuscitation.

34. BOLUSES : AMOUNT/TYPE/TIME SR. NO. CONDITION/DISEASE AMOUNT OF BOLUS TO BE GIVEN OVER FLUID GIVEN COMMENTS 1. SEPTIC SHOCK 10 – 20 CC/KG PER BOLUS UPTO 40 – 60 CC/KG; 5 - 10 MNTS < 1 ST HOUR RL ; NS 2. HEMORRHAGIC SHOCK 20 CC/KG of NS/RL f/b BLOOD PRODUCTS WB > PRBC MTP 1 : 1 : 1 PRBC:FFP:RDP 3. CARIDOGENIC SHOCK 10 CC/KG UPTO 30 CC/KG 1 HOUR 4. DENGUE COMP. SHOCK 10 – 20 CC/KG 1 HOUR 5. DENGUE HYPO. SHOCK DSS – CAT IV 10 - 20 CC/KG; REPEAT IF NO IMPROVEMENT 15-30 MNTS [PER BOLUS] SOS PRBC 5 CC/KG; WB 10 CC/KG

35. SR. NO. CONDITION/DISEASE AMOUNT OF BOLUS TO BE GIVEN OVER FLUID COMMENTS 6. DKA WITH SHOCK 20 CC/KG; SOS 10 CC/ KG UPTO 40 CC/KG 15 MNTS NS 7. DKA ; NO SHOCK 10 CC/ KG 1 HOUR NS 8. SAM WITH SHOCK 15 CC/KG 1 HOUR RL; 5%RL; ½ DNS 9. SAM WITH DEHYDRATION; NO SHOCK MANAGE ORALLY; AVOID IV

36. FLUID OVERLOAD Intensive care patients receive substantial amounts of fluids. Fluid overload as > 5 - 10% increase in body water assessed according to fluid balances, changes in body weight. [unclear defn .] [>25% of ICU patients]. Large fluid input, capillary leak, and acute kidney injury (AKI ) with accompanying oliguria often results in sodium chloride and water accumulation leading to fluid overload . Large iatrogenic sodium load is contributing to development of fluid overload. The kidneys have a limited capacity to excrete sodium and adapts slowly (days) to substantial changes in sodium intake.

37. Fluid overload affects all organs Fluid overload greater than 10% has been associated with increased mortality and poor outcomes. HEART IMPAIRED FUNCTION/CONTRACTILITY LUNGS Alveolar and Interstitial PULMONARY EDEMA, precipitating respiratory Failure KIDNEY AKI GI INCREASES HEPATIC CONGESTION; AFFECTS INTEST. PERFUSION CNS Altered mental status

38. MANAGING FLUID OVERLOAD: JUDICIOUS USE OF FLUIDS. are limited to fluid restriction, [M.C] ? Sodium restriction , Diuretics [M.C], Aminophylline + Diuretics [ oliguria refractory to loop diuretics] renal replacement therapy (RRT) [DIALYSIS]. The evidence is very uncertain about the effect of loop diuretics on mortality and serious adverse events in adult ICU patients with fluid overload. [2022 , Systematic review of RCTs with MA].

39. IMPACT OF IVFs ON ACID BASE STATUS OF A CRITICALLY ILL CHILD Regardless of the type and content of the fluid entering the body through an intravenous route, it may impair the acid-base balance depending on the rate, volume, and duration of the administration. The most typical example is NS -related hyperchloremic acidosis ; observed during the treatment of diabetic ketoacidosis . Resuscitation with unbalanced fluids is associated with the risk of acidosis , whereas the acid- base balance is better preserved with the use of balanced fluids . Hyperchloremia >110 meq /l; or Cl:Na ratio > 0.76. The acidosis is due to a reduction in the strong anion gap by an excessive rise in plasma chloride as well as excessive renal bicarbonate elimination.

40. Formulations : Oral formulations: A vailable via powder, 325 mg, and 650 mg oral tablets. 1 mEq NaHCO3 is 84 mg. 1000 mg = 1 gram of NaHCO3 contains 11.9 mEq of sodium and bicarbonate ions. One 650 mg tablet of NaHCO3 has 7.7 mEq of sodium and bicarbonate ions. IV Formulations: 7.5% concentration = 44.6 mEq NaHCO3 in 50 mL. 7.5% concentration supplies 75 mg/mL, which also consists 0.9 mEq/mL for each sodium and bicarbonate. 8.4% concentration = 50 mEq in 50 mL. 8.4% concentration supplies 84 mg/mL, which also consists 1 mEq/mL for each sodium and bicarbonate. Correction:

41. COLLOIDS ALBUMIN 5%, 25% Hydroxyethyl Starch (HES) GELATIN DEXTRAN FFP Compared to crystalloids, stays intravascularly more ; less volume required and expansion of plasma volume superior; may be salt sparing But also, more costly, risk of coagulopathy , anaphylaxis, infection transmission, may not be available immediately.

42. ROLE OF COLLOIDS IN SHOCK - CURRENT STATE A meta analysis and systematic review in 2019 [Greg Martin et al, J Crit Care adult] concluded that crystalloids were less efficient than colloids at stabilizing resuscitation endpoints as CVP, MAP ; NS may be more effective than balanced crystalloids; evidence is inconclusive. HES was the only colloid associated with increased mortality vs. crystalloids. Urgent need regarding when to administer colloids to ensure proper resuscitation in critically ill; more studies are needed.

43. 2018 COCHRANE review of 65 RCTs, 4 quasi RCTs – showed that colloids vs. crystalloids probably makes little or no difference to mortality. [ADULT] 2020 SSCG in pediatric sepsis/shock : We suggest using crystalloids, rather than albumin, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, moderate quality of evidence). This suggestion was based on FEAST trial which showed no difference in mortality comparing human albumin solution to 0.9% saline .

44. ALBUMIN: Albumin is the most abundant protein in the blood and accounts for about 50% of all plasma proteins. It gets synthesized by the liver and secreted immediately without storage. The physiological regulators of albumin are the colloid osmotic pressure and nutritional status. Indications: Hypovolemia with shock : During fluid resuscitation in patients with hypovolemia, intravenous albumin is suggested as a second-line therapy if there is an inadequate response to crystalloids.  Hypoalbuminemia is a common clinical finding in critically ill patients, malnutrition, and other diseases.  Nephrotic syndrome with shock (decreased oncotic pressure). Burn hypovolemia : The current recommendation suggests it may be useful in terms of decreasing fluid volume requirements.  Extensive hemodialysis : Albumin 5% is used as second-line therapy when hypotension does not respond to crystalloids. Spontaneous bacterial peritonitis (SBP) is a significant cause of mortality in cirrhotic patients. Administration of albumin 1.5 g/kg within 6 hours and 1 g/kg on day three and antibiotics have a better effect on preventing renal impairment and reducing mortality.

45. Administration : There are two formulations available that differ on the albumin concentration; albumin 5% and 25%. In general terms, albumin 25% is the therapeutic choice when either sodium or fluid is restricted or in cases of oncotic deficiencies. Albumin 5% use is more common in situations of volume loss as dehydration.

46. FLUID THERAPY IN SOME COMMON SCENARIOS AGE DENGUE SAM NEPHROTIC SYNDROME RENAL FAILURE HEART RELATED CONDITIONS ALF DKA RAISED ICP BURNS HYPERHYDRATION

47. ACUTE GASTROENTERITIS:

48. REPLACEMENT FLUIDS The gastrointestinal (GI) tract is potentially a source of considerable water loss. GI water losses are accompanied by electrolytes and thus may cause disturbances in intravascular volume and electrolyte concentrations. GI losses are often associated with loss of potassium , leading to hypokalemia. Because of the high bicarbonate concentration in stool , children with diarrhea usually have a metabolic acidosis , which may be accentuated if volume depletion causes hypoperfusion and a concurrent lactic acidosis . Emesis or losses from an NG tube can cause a metabolic alkalosis.

49. Third space losses, which manifest as edema and ascites, are due to a shift of fluid from the intravascular space into the interstitial space, may lead to intravascular volume depletion. Replacement of third space fluid is empirical but should be anticipated in patients who are at risk, such as children who have burns or abdominal surgery. Third space losses and chest tube output are isotonic; thus, they usually require replacement with an isotonic fluid, such as NS or RL .

50. Deficit Therapy Gastroenteritis is one of the commonest cause of dehydration in children, which can be managed by oral dehydration. Children with mild to moderate hyponatremic or hypernatremic dehydration can be managed with oral rehydration . The first step in caring for the child with dehydration is to assess the degree of dehydration , which dictates both the urgency of the situation and the volume of fluid needed for rehydration. Determining the fluid deficit necessitates clinical determination of the percentage of dehydration and multiplication of this percentage by the patient’s weight; For eg a child who weighs 10 kg and is 10% dehydrated has a fluid deficit of 1 L.

51. APPROACH TO SEVERE DEHYDRATION The child with dehydration needs acute intervention to ensure that there is adequate tissue perfusion. Acute intervention to ensure that there is adequate tissue perfusion . This resuscitation phase requires rapid restoration of the circulating intravascular volume and treatment of shock with an isotonic solution , such as normal saline (NS) or Ringer lactate (RL). The child is given a fluid bolus, usually 20 mL/kg of the isotonic fluid, over approximately 20 min. In severe dehydration, multiple boluses might be needed depending on the clinical assessment. If there is known or probable metabolic alkalosis (the child with isolated vomiting), RL should not be used because the lactate would worsen the alkalosis. Colloids, such as blood, 5% albumin, and plasma, are rarely needed for fluid boluses. Blood can be used in cases of severe anemia or acute blood loss , plasma can be used for coagulopathy , 5% albumin for hypoalbuminemia .

52. The initial resuscitation and rehydration phase is complete when the child has an adequate intravascular volume. Typically manifested by clinical improvement , including a lower HR, normalization of BP, improved perfusion, better urine output, and a more alert affect . With adequate intravascular volume, it is appropriate to plan the fluid therapy for the next 24 hr. In isonatremic or hyponatremic dehydration, the entire fluid deficit is corrected over 24 hr ; a slower approach is used for hypernatremic dehydration . The volume of isotonic fluids that the patient has received is subtracted from this total & remaining fluid volume is then administered over 24 hr.

53. MONITORING AND ADJUSTING THERAPY All calculations in fluid therapy are only approximations. It is important to monitor the patient during treatment and to modify therapy on the basis of the clinical situation. Signs of dehydration on physical examination suggest the need for continued rehydration. Signs of fluid overload , such as edema and pulmonary congestion, are present in the child who is overhydrated. An accurate daily weight measurement is critical for the management of the dehydrated child. There should be a gain in weight during successful therapy.

54. ISONATREMIC DEHYDRATION

55. HYPONATREMIC DEHYDRATION

56. The pathogenesis of hyponatremic dehydration usually involves a combination of sodium and water loss and water retention to compensate for the volume depletion . There is pathological increase in fluid loss which has sodium but at lower concentration. So, patient with only fluid loss have hypernatremia . The volume depletion stimulates synthesis of antidiuretic hormone , resulting in reduced renal water excretion which leads to further hyponatremia since mechanism to prevent hyponatremia i.e. increase renal water excretion is blocked. The initial goal in treating hyponatremia is correction of intravascular volume depletion with isotonic fluid (NS or RL) .

57. Patients with neurologic symptoms (seizures) as a result of hyponatremia need to receive an acute infusion of hypertonic (3%) saline to increase the serum sodium concentration rapidly. The patient’s sodium concentration is monitored closely to ensure appropriate correction, and the sodium concentration of the fluid is adjusted accordingly. An overly rapid (>12 mEq /L over the first 24 hr ) or overcorrection in the serum sodium concentration (>135 mEq /L) is associated with an increased risk of central pontine myelinolysis .

58. HYPERNATREMIC DEHYDRATION

59. Hypernatremia can lead to central nervous system hemorrhages and thrombosis due to the movement of water from the brain cells into the hypertonic extracellular fluid, causing brain cell shrinkage and tearing blood vessels within the brain . Symptoms of hypernatremic dehydration are often lethargy and irritable when touched. Hypernatremia may cause fever, hypertonicity, and hyperreflexia . More severe neurologic symptoms may develop if cerebral bleeding or thrombosis occurs. With overly rapid lowering of the extracellular osmolality during the correction of hypernatremia , an osmotic gradient may be created that causes water movement from the extracellular space into the cells of the brain, producing cerebral edema . Symptoms of the resultant cerebral edema can range from seizures to brain herniation and death. To minimize the risk of cerebral edema during the correction of hypernatremic dehydration, the serum sodium concentration should not decrease by >12 mEq/L every 24 hr.

60. Signs of increased intracranial pressure or impending herniation may develop quite rapidly Acutely, increasing the serum concentration via an infusion of 3% sodium chloride can reverse the cerebral edema. Each 1 mL/kg of 3% sodium chloride increases the serum sodium concentration by approximately 1 mEq/L. An infusion of 4 mL/kg often results in resolution of the symptoms. The rate of decrease of the serum sodium concentration is roughly related to the “free water” delivery. Free water is water without sodium. NS contains no free water, half-NS ( 1 2 NS) is 50% free water, and water is 100% free water. Madias formula is used to calculate the amount of free water to be given, to achieve the desired drop in sodium.

61. DENGUE FEVER :

62. The IV fluid should be isotonic and similar to electrolyte concentrations lost into the pleural and peritoneal spaces, e.g., normal saline solution (NSS), lactate Ringer's solution (LR) . IV fluid with addition of 5% dextrose is preferred because these DHF/DSS patients usually have poor appetite and marginal levels of blood sugar.

63. Indication for Colloidal Solutions : Colloidal solutions are indicated with DHF/DSS patients with overt signs of fluid overload (i.e., puffy eyelids, tachypnea, dyspnea, distended abdomen, or respiratory distress ) persistently elevated Hct despite IV fluid administration a history of hypotonic solutions administration before shock. Colloidal solutions should be plasma expanders such as 10% Dextran-40. Dextran-40 is hyper-oncotic (osmolarity = 400 mOsm ), has high osmolarity compared with plasma (280-300 mOsm ), and is designed to draw interstitial fluid into vascular space . Patients should be monitored closely during the first few minutes of the dextran infusion because severe anaphylactoid reactions have been reported in patients with hypersensitivity. Fluid overload with oliguria after dextran infusion may be treated with furosemide. Dextran-40 should not be used for initial resuscitation if the patients had not received IV fluid before.

64. FLUIDS IN SEVERE ACUTE MALNUTRITION ( As per MoHFW by GOI): Dehydration in SAM : The main diagnosis comes from the HISTORY rather than from the examination. There needs to be: A definite history of significant recent fluid loss - usually diarrhoea which is clearly like water (not just soft or mucus) and frequent with a sudden onset within the past few hours or days. There should also be a HISTORY of a recent CHANGE in the child’s appearance . If the eyes are sunken then the mother must say that the eyes have changed to become sunken since the diarrhoea started.

65. If the child has had watery diarrhea or vomiting, assume dehydration and give ORS . Signs of over hydration - Stop ORS if any of the following signs appear: Increased respiratory rate and pulse. (Both must increase to consider it a problem -increase of Pulse by 15 & RR by 5). Jugular veins engorged. Puffiness of eye. Stop ORS as soon as possible if the child has 3 or more of the following signs of improved hydration status: Child no longer thirsty Less lethargic Slowing of respiratory and pulse rates from previous high rat Skin pinch less slow Tears

66. After rehydration, offer ORS after each loose stool. If diarrhoea continues, give ORS after each loose stool to replace stool losses and prevent dehydration: For children less than 2 years, give approximately 50 ml after each loose stool. For children 2 years and older, give 100 ml after each loose stool. SHOCK IN SAM : The severely acute malnourished child is considered to have shock if he/she : Has cold hands with Slow capillary refill (longer than 3 seconds), AND Weak and fast pulse (For a child 2 months up to 12 months of age, a fast pulse is 160 beats or more per minute and For a child 12 months to 5 years of age, a fast pulse is 140 beats or more per minute).

67. Broad spectrum antibiotic should be administered immediately to all SAM with septic shock. Packed RBCs 10ml/ kg should be given over 4-6 hours if Hb is less than 4 gm/dl or active bleeding. If there is no improvement with fluid bolus start dopamine at 10 μ g/kg/min. If there is no improvement in next 24-48 hours upgrade antibiotics.

68. NEPHROTIC SYNDROME: Fluids are restricted, strict input and output monitoring should be done. Patients with oliguria should receive fluids 400ml/m 2 + prev day urine output, if administered IV give 0.9 DNS without potassium unless hypokalemic. Hypovolaemia / Severe Oedema : Infusion of 5% Albumin (10-15 ml/Kg) or 20% Albumin are useful in patients who do not respond to two boluses of saline. Intravenous Albumin 20% (Used in decreased oncotic pressure): 1g/kg (5mL/kg) administered over 4-6 hours. However in patients with a raised serum creatinine may have difficulty excreting 20% albumin and are at risk of active pulmonary edema. Volume repletion with sodium chloride 0.9% or albumin 4% may be required.

69. Fluids in Renal Failure: Patients may be over hydrated hence, fluid therapy has to be individualized. Patients with renal failure with Oliguria: Should receive 400ml/m 2 + prev day urine output as 0.9 DNS without potassium unless hypokalemic. Polyuria: Fluid for replacement of urinary loss is as per urinary sodium Once dialysis initiated, fluids may be liberalized. 75 0.45 NS 120 RL 150 0.9 NS

70. PD FLUID Na [ Meq /L] Cl HCO3 Ca Mg Dextrose [Gm/100ml] Osmol . Composition 130 100 35 1.5 0.75 1.7% 363 HYPERTONIC PD 3% [Add50 ml 25%D in 1L PD fluid] 4.5% [add 100 ml of 25%D in 1 L of PD fluid]

71. Fluids in raised ICP: Maintainence fluids given as NS/ 0.9 DNS. Maintain euvolemia . Avoid hypotonic fluids. Studies have showed better outcome with negative fluid balance. Hypertonic solutions such as 3% Nacl given, as it helps with cerebral edema.

72. DIABETIC KETOACIDOSIS (As per BSPED Guidelines 2020): DKA with Shock : Patients presenting with shock should receive a 20 ml/kg bolus of 0.9% saline over 15 minutes. Following the initial 20 ml/kg bolus patients should be reassessed and further boluses of 10 ml/kg may be given if required to restore adequate circulation up to a total of 40 ml/kg at which stage inotropes should be considered . Boluses given to treat shock should NOT be subtracted from the calculated fluid deficit. DKA without shock : All patients with DKA (mild, moderate or severe) in whom intravenous fluids are felt to be indicated should receive an initial 10 ml/kg bolus over 60 minutes . This bolus SHOULD be subtracted from the calculated fluid deficit

73. FLUIDS IN DKA : Use 0.9% sodium chloride with 20 mmol potassium chloride in 500 ml (40 mmol per litre ) until blood glucose levels are less than 14 mmol /l. PlasmaLyte 148 has been suggested as an alternative as it has a lower chloride content and hyperchloraemic acidosis is therefore less likely. Additional potassium will need to be added to PlasmaLyte 148 as it only contains 5mmol /l Potassium. Once circulating blood volume has been restored and the child adequately resuscitated, calculate fluid requirements as follows: Requirement = Deficit + Maintenance Fluid Deficit : Estimation of the fluid deficit should be based on the initial blood pH. The fluid deficit should be replaced over 24 - 48 hours alongside maintenance fluids. Assume a 5% fluid deficit in children and young people in mild DKA (indicated by a blood pH 7.2-7.29 &/or bicarbonate <15). Assume a 7% fluid deficit in children and young people in moderate DKA (indicated by a blood pH of 7.1- 7.19 &/or bicarbonate <10). Assume a 10% fluid deficit in children and young people in severe DKA (indicated by a blood pH <7.1 &/or bicarbonate <5).

74. The deficit should be replaced evenly over 48 hours alongside appropriate maintenance fluids. i.e Hourly rate = ({Deficit – initial bolus} / 48hr) + Maintenance per hour Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA until ketosis is resolving and there is no nausea or vomiting.

75. HEART RELATED CONDITIONS: With CCF : Do not give boluses. Diuresis . Manage on oral diet or 2/3 rd IVF. 2. CARDIOGENIC SHOCK: very important to differentiate signs and symptoms of cardiac “shock” vs “failure”; initial treatment varies. Bolus of 5 – 10 cc/kg slowly over 1 hour; f/b same if required. Early inotropes /vasodilators– milrinone / levosimendan / dobut ; furosemide infusion once shock resolved.

76. SUGGESTED HEART FAILURE AND SHOCK MANAGEMENT. LUNGS SKIN NO CONGESTION [DRY] CONGESTION [WET] ADEQUATE PERFUSION [WARM] WARM + DRY TARGET PROFILE WARM + WET DIURESIS + STANDARD Rx HYPOPERFUSION [COLD SHOCK] COLD + DRY INOTROPES [ADR/VASOP] + VENTILATION SOS COLD + WET INODILATORS + DIURETICS

77. COLD AND WET CATEGORY: VASODILATORS – NTG or Nesiritide [hr BNP] has shown less mortality than milrinone / dobut in adults. No pediatric data . Using inotropes is based on clinical assessment and NOT on 2D echo . Avoiding inotropic agents when possible appears to be beneficial.

78. 3. TOF/ R L shunts with CYANOTIC SPELLS: Hyperhydrate with repeated boluses of 20 kg of normal saline/ Ringers lactate. This corrects the shock and acidosis as well as decrease hyperviscosity which improves pulmonary blood flow.

79. ACUTE LIVER FAILURE In the absence of shock, total IVF = 90% of MIVF ; avoid over and under hydration. Fluid type D10 , 1/2NS +15 meq KCl /L .. Maintain sugars between 90-120 mg% [HIGH GIR 10-15 mg kg min maybe reqd.] Sos PO4 supplementation to maintain serum PO4 level>3 mg/dl. Ref: NASPGHAN POSITION PAPER ON DX AND MX OF PEDIATRIC ALF 2021.

80. HEMORRHAGIC SHOCK ESTIMATED BLOOD VOLUME AS PER AGE PRETERMS 90-100 ml/kg TERMS – 3 MONTHS 80-90 >3 MONTHS 70 OBESE 65

81. CLASSIFICATION OF HS

82. The goal is to stop bleeding. By the time a patient has lost greater than 40% total blood volume (class IV), they become lethargic and may lose consciousness. Hypotension is a late finding in children. The initial management is the prompt delivery of 20 mm/kg of crystalloid fluid. This may be repeated, but if the patient remains hemodynamically unstable or has clinical evidence of continued hemorrhage , resuscitation efforts should be transitioned to cellular blood products .

83. In emergency, O negative unmatched PRBC should be given 10 cc/kg. Rate depends on status of the patient. Target Hb is >7gm/dl. In severe TBI , target Hb > 10 gm/dl. Activate Massive Transfusion Protocol if you expect patient requires >40cc/kg of blood products in 24 hours.

84. 1:1:1 of PRBC: FFP: RDPs WHOLE BLOOD already has ideal ratios of RBCs,FFP,platelets  minimizes dilutional coagulopathy and restores what was lost; should be considered if available. VOLUME: 20 cc/kg . Availability is a big issue, especially in emergencies where O- ve WB is needed. Tranexamic acid should be given in MTP; shown to decrease mortality . Use TEG [ thromboelastography ] if available.

85. BURNS : In general, loss of circulating volume after burns injury is proportional to the severity of the burns. After burns injury, increased vascular permeability leads to significant fluid shifts resulting in intravascular volume depletion. Patients often have reduced vascular resistance and can experience systemic inflammatory response syndrome, leading to an initial period of myocardial depression. For minor burns, oral hydration may be acceptable. Any pediatric burn with greater than 10% TBSA requires i.v. fluid replacement. If TBSA < 20%, give fluids 1.5 times the maintenance therapy. Any TBSA > 20%, fluids administered via Parkland or Modified Brookes Formula: Parkland formula : This is 4 ml kg −1 ×TBSA % burns over a 24 h period. Half the total is given over the first 8 h from the time of burn, and half over the following 16 h. Fluid of choice is Ringer’s lactate for resuscitation along with daily maintenance in the form of dextrose saline.

86. M odified Brooke formula : 2 ml kg −1 ×TBSA % burns over the same time period as the Parkland formula. In addition to resuscitation fluids, maintenance fluids should also be given to children. Adding glucose for those who are hypoglycaemic , or at risk of hypoglycaemia , is essential. Daily maintenance fluid is given in the form of N/2 dextrose saline or N/4 dextrose saline and is calculated as per the weight of the child. The initial half of replacement fluids calculated, have to given within first 8 hrs of burn. Adequacy of the fluid resuscitation is assessed by measuring urine output which should be at least 1 mL/kg/h and it is the most practical method in any kind of clinical setting.

87. ‘Fluid Creep’ is a complication worsened by excessive fluid resuscitation itself. Consequence of this increased fluid administration include airway swelling, secondary abdominal compartment syndrome, soft tissue edema in the extremities necessitating more frequent escharotomies and even fasciotomies , elevated intraocular pressures, and an overall increased risk of death. Role of Colloids: In first 24 hours, colloids are not indicated except if fluid requirement is very high in extensive burns to increase the oncotic pressure. Colloids are given in the form of 5% albumin or plasma in the volume of 0.3–0.5 mL/kg/% BSA. Generally, Colloid is usually instituted 8-24 hr after the burn injury. After 24 hours, colloids may be added only if plasma oncotic pressure is very low despite adequate fluid replacement by crystalloids or if serum protein falls below 4 g/dL.

88. A 5% albumin infusion may be used to maintain the serum albumin levels at a desired 2 g/dL. The following rates are effective: for burns of 30–50% of total BSA, 0.3 mL of 5% albumin/kg/% BSA burn is infused over 24 hr; for burns of 50–70% of total BSA, 0.4 mL/kg/% BSA burn is infused over 24 hr; for burns of 70–100% of total BSA, 0.5 mL/ kg/% BSA burn is infused over 24 hr.

89. PATIENTS AT A RISK FOR DECREASED CIRCULATING VOLUME FROM FLUID/ BLOOD LOSS, CAPILLARY LEAK: Isotonic crystalloids( NS/RL) to replace ongoing losses, customize to patients HR, Perfusion, Mental status, urine output. Administer 2/3 rd maintenance volume of 0.9 DNS with 20mEq potassium/L.

90. HYPERHYDRATION IN PATIENT ON CHEMOTHERAPY: Most children with a new diagnosis of leukaemia are clinically stable at initial presentation. However, there are a number of life-threatening complications that haveto be considered and monitored for. These complications include sepsis, tumor lysis syndrome , mediastinal masses, bleeding and pain. TLS is a metabolic disturbance resulting from the breakdown of tumour cells. Management of TLS is largely anticipatory to prevent its development. In acute leukaemia , some children with low count disease and without bulky disease can be managed with maintenance fluids, which can be oral or intravenous. Others at higher risk will require hyperhydration even prior to starting chemotherapy, with intravenous fluids of at least 2.5 L/m2/day. The fluid rate may be increased if there is any evidence or significant risk of TLS. Potassium should not be added to fluids due to the risk of hyperkalaemia , even if potassium levels are very low. Children should be monitored for fluid overload, particularly children with severe anaemia and infants.

91. HYPERHYDRATION IN HYPERCALCEMIA : The initial basic tenet of is to restore intravascular volume (as hypercalcemic patients are typically dehydrated) and to enhance renal excretion, which can be accomplished by administration of normal saline at two to three times maintenance fluid rate [2-3 mIVF ] . [severe symptoms >15 mg/dl] If the patient is adequately rehydrated and calcium levels do not decrease, loop diuretics may be administered to enhance renal excretion of calcium but should be done judiciously to avoid intravascular volume depletion.

92. HYPERHYDRATION IN HYPERPHOSPHATEMIA: The basic tenets of treatment are to improve renal filtration and excretion of phosphate through intravascular volume expansion with normal saline and to stop intake of excess phosphate. Dialysis is effective in decreasing phosphate in renal failure patients with severe hyperphosphatemia . Age Ca-PO4 product[mg/dl] INFANTS >80 SMALL CHILDREN >60 OLDER CHILDREN >40

93. HYPERHYDRATION IN RHABDOMYLOSIS : The goals of management in a patient with rhabdomyo­lysis are 2­ fold: Treatment of the underlying cause of the ill­ness and avoidance of kidney function deterioration. Fluid therapy increases renal perfusion, inhibits cast formation, and prevents further ischemic damage to the kidney. Al­though no specific management guidelines exist for pediatric cases, initial fluid resuscitation may include correcting hypovolemia using 10 to 20 mL/kg fluid boluses as needed. Fluid at 2 – 3 mIVF may be required depending on CPK levels and severity of rhabdomyolysis .

94. Thank You