Maintenance and replacement fliud therapy

.

1. MAINTENANCE
&
REPLACEMENT
FLUID THERAPY
MAINTENANCE
&
REPLACEMENT
FLUID THERAPY

Presented by: Tamiru Abera(C-II)

Modulator: Dr.Kussia (pediatrician)
Yekateet 30, 2009/March 9,
2017
prepared and presented by Tamiru Abera
1

2. OBJECTIVES
To know the definition of maintenance fluid.

To know the Goals of maintenance fluid
therapy.
Able to Calculate total fluid requirement & do
monitoring of the patient.
To know Variations in maintenance water &
electrolytes.
To order Replacement fluids in “common”
situations.
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
2

3. DEFINITION -IS INTRAVENOUS FLUIDS ARE USED IN A CHILD WHO CANNOT BE
FED ENTERALLY
.
WHOMTOGIVEMAINTENANCEFLUIDS
?
-
Infants who are sick & whose oral intake is
uncertain.
-
Babies who are kept NBM for the surgery, with
respiratory distress etc.
-
neonates kept under radiant warmer.
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
3

4. WHYTHEINFANTS AREMORE
VULNERABLE?
*

Physiological inability to concentrate urine.

Higher metabolic rate & larger surface
area.

Can’t express thirst for more fluids.

Larger turnover.
*
IAP text book of Pediatrics 5
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
4

5. GOALS OFMAINTENANCEFLUIDS
*

Prevent dehydration

Prevent electrolyte disturbance

Prevent ketoacidosis

Prevent protein degradation
*
Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
5

6.
Maintenance fluids consists of-
i.
Water
ii.
Glucose
iii.
Sodium
iv.
Potassium

Advantages –

Simplicity, long shelf life, low cost,
compatibility.

Prototypical maintenance therapy fluid
doesn’t provide
calcium
,
phosphorus
,
magnesium
or
bicarbonate
.*
*
Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
6

7. CONCEPTOFMAINTENANCEOFWATER
Crucial component of maintenance fluid
therapy.

Maintenance water =
Measurable loss of water
65%
(Urine 60%, stools 5%) +
Insensible of
water
35%
(skin & lungs)
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
7

8. FLUIDLOSSESININFANTS
LUNGS
URINE, FECES
SKIN
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
8

9. FLUIDREQUIREMENTOFNEWBORNIN
ML/KG/D
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
9

10. MAINTENANCEREQUIREMENTS
*
WeightRequirement
0-10 kg100cc/kg/24hr
11-20 kg1000 +
50cc/kg/24hr
>20 kg1500 +
20cc/kg/24hr
NB:1cc=1ml
Upper limit 2400cc/24hrs
*
Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
10

11. Maintenance Fluids
Hourly Maintenance Fluid Requirement
*
“4 -2 -1 rule”
WEIGHT FLUID
0 -10 kg 4 ml/kg/hr
10 -20 kg 40ml/hr + 2 ml/kg/hr
> 20 kg 60ml/hr + 1 ml/kg/hr
Upper limit 100cc/hr
*
Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
11

12. CONCEPTOFMAINTENANCEOF
ELECTROLYTES

Insensible water loss contains no
electrolytes
*

So, sodium & potassium present in the
urine, stools & sweat would be the amount
to be replaced plus the sodium & potassium
required for normal metabolism of the
body.

3mEq of sodium
in 100 cc of fluid
&

2mEq of potassium
in 100 cc of fluid
*
IAP text book of Pediatrics 5
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
12

13.
Maintenance fluids usually contains 5%
dextrose (5 gm/100ml) providing 17 calories/
100 ml of fluid.

Which is approx.
20%
of the daily caloric
needs.

Prevents ketoneproduction.
CONCEPTOFMAINTENANCEOF
GLUCOSE*
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
13

14. COMMONLYUSEDFLUIDSFOR
MAINTENANCE*
I.
0.9% Normal Saline –Think of it as ‘Salt and
water’

Principal fluid used for intravascular resuscitation and
replacement of salt loss e.g diarrhoea and vomiting
Contains: Na+ 154 mmol/l, Cl
-
- 154 mmol/l; K+ - Absent,
But K+ is often added

IsoOsmolar compared to normal plasma

Distribution: Stays almost entirely in the Extracellular
space
Does not provide free water or calories. Restores NaCl
deficits.
*The Harriet Lane Handbook 19
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
14

15. CONTENTS OFIV FLUIDPREPARATIONS
*
Na
(mEq/L)
K
(mEq/L
)
Cl
(mEq/L)
HCO3
(mEq/L)
Dextrose
(gm/L)
mOsm/L
NS
154 154308
DNS
154 154 50
564
½ NS
77 77
143
5%D +
1/2NS
77 77 50
350
D5W50 278
Ringers
Lactate
(RL)
130 4 109 28 50273
Iso P 23 20 23 30 50 367
Iso M 37 35 37 30 50 415.5
*
The Harriet Lane Handbook 19
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
15

16. II.
Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L.

Contains 130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate,
and 4 mEq/L K+, 3 mEq/L Ca++
Lactate is used instead of bicarb because it's more stable in
IVF during storage.
Lactate is converted readily to bicarb by the liver.

Has minimal effects on normal body fluid composition and
pH. More closely resembles the electrolyte composition of
normal blood serum.

Does not provide calories.
COMMONLYUSEDFLUIDSFOR
MAINTENANCE
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
16

17. HOWTOCHOOSE
?*
0.9% sodium chloride Suitable for initial volume resuscitation in
hypovolaemia and for ongoing fluid therapy in older
children with normal serum glucose. Fluid of choice
in patients with head injury
5% dextrose + 0.9%
sodium
chloride
Suitable for ongoing fluid therapy in infants
and children, including post-operative cardiac
patients. Use in head injured patients with
hypoglycaemia.
5% dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in infants and
children, including post-operative cardiac patients
10%dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in neonates or
older infants who are hypoglycaemic, including post-
operative cardiac patients
*
www.Medscape.com
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
17

18. MONITORINGWHILEADMINISTERING
FLUIDS
*

Child should be
weighed prior
to the
commencement of therapy, and daily afterwards.

Children with ongoing dehydration/
ongoing
losses may need 6 hourly weightsto assess
hydration status

All children on IV fluids should have serum
electrolytes and glucose checked before
commencing the infusion (typically when the IV
is placed) and again within 24 hours if IV
therapy is to continue.
*
www.Medscape.com
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
18

19. MONITORINGWHILEADMINISTERING
FLUIDS
*

For more unwell children, check the electrolytes
and glucose 4-6 hours after commencing, and
then according to results and the clinical
situation but at least daily.

Pay particular attention to the
serum sodium
on
measures of electrolytes. If <135mmol/L (or falling
significantly on repeat measures) If >145mmol/L
(or rising significantly on repeat measures)

Children on iv fluids should have a fluid
balance
chart
documenting input, ongoing losses and
urine output.
*
www.Medscape.com
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
19

20. MAINTENANCEFLUIDS&
HYPONATREMIA*

Production of ADH leading to water retention
leading to water intoxication.
Patients producing ADH due to subtle volume
depletion can be safely treated with fluids
containing higher sodium concentration,
decrease in fluid rate or the combination of
both.

Persistent ADH production due to underlying
disease requires less than total maintenance
fluids

Individualization & careful monitoring is must.
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
20

21. REPLACEMENTFLUIDS
In addition to normal maintenance fluid
requirements, unwell children may need:

Fluid resuscitation for shock

Replacement of pre-existing fluid losses

Replacement of ongoing fluid losses
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
21

22. REPLACEMENTFLUIDS*
GI losses are accompanied with loss of
potassium, bicarbonate leading to
metabolic acidosis.

Impossible to predict the loses for next 24
hrs, so measure & replace excess GI losses
as they occur.

So each ml of the diarrheal stool or the
vomitusshould be replaced by the same
amount every 1 to 6 hourly.
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
22

23. REPLACEMENTFLUIDS Replacement fluid for Diarrhea* Average composition of Diarrheal stools (except cholera)
Na 55 mEq/l
K 25 mEq/l
Bicarbonate 15 mEq/l
Approach to Replacement of Ongoing Losses
D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl
Replace stools ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
23

24. REPLACEMENTFLUIDS Replacement fluid for Emesis or Nasogastric losses* Average composition of Gastric Fluid
Na 60 mEq/l
K 10 mEq/l
Chloride 90 mEq/l
Approach to Replacement of Ongoing Losses
NS + 10 mEq/l KCl
Replace Output ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
24

25. REPLACEMENTFLUIDS Replacement fluid for Altered Renal Output* Oligouria / Anuria
Place patient on insensible fluids (25 to 40% of ma intenance)
Replace Urine output ml/ml by half NS
Polyuria
Place patient on insensible fluids (25 to 40% of ma intenance)
Measure urine electrolytes
Replace Urine output ml/ml by solution based on measured urine
electrolytes
*Nelsons Text book of pediatrics 20
th
edition
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
25

26. CASE EXAMPLE
5 day old baby boy weighing 3 kg having
total billirubin18.0 is to be kept under
phototherapy.Baby having no other risk
factors & accepts DBM well.

What fluid at what rate should we
prescribe?
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
26

27. ANSWER

Rate Day 5 (150 ml/kg/day)

Weight 3 kg

So,

150 * 3 = 750 ml is the total maintainence.

For the babies under phototherapy we
should give half of the maintainence.

So 375 ml/24 hrs i.e125 ml / 8hrly

Fluid of choice is
5% dextrose + 0.45% NS
or
isoP will also be suitable.
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
27

28. DEFICITTHERAPY

Dehydration, most often due to gastroenteritis, is a
common problem in children.

Most cases can be managed with oral rehydration.
Even children with mild to moderate hyponatremic
or hypernatremicdehydration can be managed with
oral rehydration.
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
28

29. VOMITING
e
Metabolic Alkalosis
e
Loss of acid from stomach
e
pH
e
HCO
3
e
H
+
e
Treatment: Prevent further losses and replace lost
electrolytes
Yekateet 30,
2009/March 9, 2017
prepared and presented by Tamiru
Abera
29

30. DIARRHEA
e
Metabolic Acidosis
e
loss of HCO
3
from G.I. Tract
e
pH
e
HCO
3
e
Treatment: Correct base
deficit, replace losses of
with NaHCO
3
Yekateet 30,
2009/March 9, 2017
prepared and presented by Tamiru
Abera
30

31. •DEHYDRATIONOCCURS WHENYOULOSE
MORE FLUIDTHANYOUTAKE IN
.
CAUSES OFDEHYDRATION

Intense
diarrhea, vomiting, fever or
excessive sweating.

Inadequate intake of water
during hot
weather or exercise also may cause
dehydration.

Young children, older adults and people with chronic illness are most at risk
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
31

32.
Classification of dehydration(DHN) :atleast2 of
the following No Dehydration Some Dehydration Severe
Dehydration
Alert
(
mental status)
Restless,irritable Lethargic or
unconscious
No sunken eyes
(
eye ball)
sunken eyes sunken eyes
Drinking normally
(
Drinking)
Eager to drinkUnable to drink
Normal skin turgor
(
Skin turgor)
Skin pinch returns
slowly
Skin pinch
returns very
slowly
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
32

33. LABORATORY FINDINGS
Several laboratory findings are useful for
evaluating the child with dehydration

Na and K

Urea and creatinine

pH/ Bicarb.

Urinalysis
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
33

34. T
REATMENTDHN
Assess the child for signs of dehydration and give fluids
according to Treatment Plan A, B or C as appropriat e.
Principle of management….. Plan A -
Give extra fluid ………ORS(two packets at home)
-
Zink Supplementation
a
.½ tablet
for those below 6mo.
b.
1 tablet
for those above 6mo.
-
Continue feeding
Breastfeed frequently and for longer at each feed.
– If the child is exclusively breastfed, give ORS or clean water in
addition to breastmilk.
– If the child is not exclusively breastfed, give one or more of the
following: ORS solution, food-based fluids (such as soup, rice
water, and yoghurt drinks), or clean water.
-
When to return…see him/her in 2days
come back immediately if the child becomes sick(unable to
drink,sicker,fever,dysentery)
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
34

35. Plan B
35

36. TAKEHOMEMESSAGE

Fluid is like “prescription” so give it with caution.

Children are more vulnerable for rapid fluid loss.

Maintenance calculation by “4-2-1” rule or
Holliday Sega
r’s
formula.

Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM
SODIUM CONCENTRATION while giving fluid is must.
As far as possible try to give maintenance fluid
requirement orally.
0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the
children requiring maintenance therapy.
Replacement of fluids should be prompt & appropriate.
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
36

37. RRRR
EFERENCES EFERENCES EFERENCES EFERENCES
N
NELSON TEXT BOOK OF PEDIATRICS 20 NELSON TEXT BOOK OF PEDIATRICS 20 NELSON TEXT BOOK OF PEDIATRICS 20 NELSON TEXT BOOK OF PEDIATRICS 20
THTHTH TH
EDITION EDITION EDITION EDITION
N
IAP PEDIATRICS 5 IAP PEDIATRICS 5 IAP PEDIATRICS 5 IAP PEDIATRICS 5
THTHTH TH
EDITION EDITION EDITION EDITION
N
THE HARRIET LANE HANDBOOK 19TH EDITION THE HARRIET LANE HANDBOOK 19TH EDITION THE HARRIET LANE HANDBOOK 19TH EDITION THE HARRIET LANE HANDBOOK 19TH EDITION
N
WWW.MEDSCAPE.COM WWW.MEDSCAPE.COM WWW.MEDSCAPE.COM WWW.MEDSCAPE.COM
N
NICU Traitning Participants’ Manual,2014 (FMOH)
Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
37

38. Yekateet 30, 2009/March
9, 2017
prepared and presented by Tamiru Abera
38