Management of Fluids in Children - Nurses

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Fluid Management in Children

• Dr Tina Williams
• Paediatric Consultant

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Outline

• Fluid Distribution in Children
• Dehydration
• Overhydration
• Fluid Charts
• Electrolytes and Types of Fluids
• Specific Fluid Scenarios and calculations

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Children ? Little Adults

• Total Body Water
• Neonates 80 85mls/kg
• 3kg baby, his blood volume is 240mls
• 10kg 1 year old, blood volume is 700mls
• Adults 60-75mls/kg
• 70kg man, blood volume is 4200-5000
• Dehydrate easily
• A small volume is a large proportion of
• intravascular space
• Fluid overload easily

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Cardiac Arrest in Children

• What is the usual cause?
• Pump Failure
• Respiratory Failure
• Circulatory Failure

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Cardiac Arrest in Children

• What is the usual cause?
• PUMP
• Respiratory Failure
• Circulatory Failure

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Body Water
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Measuring Dehydration

• 1000g in weight 1000mls
• Previous weight helpful to accurately say how
  much weight/fluid lost
• 5 Dehydration
• 5/100 x 1000mls x Weight
• 50mls/kg
• In a 10kg child
• 500mls

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Shock

• Inadequate organ perfusion
• Usually from
• inadequate intravascular fluid volume
  (hypovolaemia)
• Gastroenteritis with severe dehydration
• Burns
• Blood loss in trauma
• fluid in the wrong body compartment
  (maldistributed)
• Sepsis
• Intra-abdominal pooling obstruction, infarction
• Nephrotic Syndrome
• Treated separately and urgently before addressing
  dehydration

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Overhydration

• Not as common
• Children with
• Renal Failure
• Heart failure
• Or
• Excessive intravenous fluids
• Maldistribution Nephrotic syndrome, Sepsis with
  vascular leak, Neonates after Hypoxic ischaemic
  episode

• Remember the fluid has to pool somewhere!
• Peripheral Tissues facial puffiness, dependent
  oedema
• Lungs Pulmonary Oedema
• Heart Congestive failure
• Brain Cerebral oedema

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Insensible Losses

• We often Forget about this
• Not seen
• Sweat
• Respiration
• Measured as output in addition to what is seen
• 500mls/m2
• Increased by 12.5 for every degree increase in
  temperature over 380C
• Increased on a hot ward, hot weather!
• Increased with increased Resp rate

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What we need to do as Medical Staff

• Recognise signs of Fluid loss or overhydration
• Monitor fluid intake/ Output
• Measure urine output accurately weigh nappies
  if necessary
• Remember NGT drainage or other drains!
• Be aware of Insensible losses
• Dont just record a beautiful fluid balance
  chart, Take action!

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What Should a Fluid Chart Look like?
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Remember

• Input includes
• IV Fluids
• Drinks
• Oral meds
• Soups
• IV antibiotics
• Flushes
• Output Includes
• Stools
• Urine
• Vomits
• Drains
• Insensible Losses at top of daily chart

• Frequency of summary depends on how ill child is.
• 4 12 hourly And action!
• Weights 12 hourly

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Replacing Fluids

• Calculations
• Maintenance
• Deficit
• Ongoing Losses
• Route
• Oral Best unless contraindicated
• NGT
• Intravenous

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Electrolytes

• Hypertonic or Hyperosmolar plasma
• Fluid shift from tissues to plasma
• (Brain is major organ)

• Sodium
• Hypernatraemia Hypertonic/ Hyperosmolar
• Hyponatraemia
• Potassium
• Hypokalaemia
• Hyperkalaemia
• Glucose
• Hyperglycaemia Hypertonic/ Hyperosmolar
• Hypoglycaemia

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Types of Fluids

• Oral Hydration Satchets/ Solution
• Flat Coke/ Apple Juice
• 0.9 Saline
• 0.9 Saline / 5 Dextrose
• 0.9 Saline / 10Dextrose
• 10 Dextrose
• Additives Na (2-4mmols/kg/day),
• K (1-2mmols/kg/day)

• Hartmans
• 4.5 Human Albumin Solution
• Blood
• 3 Saline
• Breast Milk

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Specific Scenarios
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Healthy Child admitted pre-op

• Maintenance Fluids
• Isotonic Fluids
• Additives Na, K if electrolytes normal

• Calculations for 24 hrs fluids
• 100mls/kg 1st 10kg
• 50mls/kg 2nd 10kg
• 20mls/kg every kg afterward
• Divide total by 24 to give mls/hr
• Use0.9 Saline/5 Dextrose

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Gastroenteritis

• Calculate
• Maintenance Fluids Backgound 0.9 saline/5
  Dextrose
• Deficit Assess degree of dehydration and
  replace deficit over 12-24 hours
• Ongoing losses volume of each vomit or lose
  stool

• Keep an eye on balance closely especially in
  small infant or if frequent loose stools
• Hyper or Hyponatraemic dehydration
• Secretory diarrhoea
• Oral rehydration or NGT best!
• Wean IV as oral intake increases

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Diabetic Ketoacidocis

• Watch out for signs of Cerebral oedema as you
  treat!
• Calculate Deficit Divide by 48hrs
• Calculate Maintenance Divide by 24 hrs
• Give the total hourly over 48hrs
• Monitor Electrolytes/ Glucose closely

• Treat Shock 10mls/kg aliquots
• Maintenance as usual over 24 hrs
• Replace deficit over 48 hours
• Dont start insulin till an hour of hydration
• Start with 0.9 Saline Swap to 0.9 Saline/ 5
  Dextrose once Glucose 11-14mEq/L
• Add K to bag as soon as Insulin started

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Renal

• Nephrotic Syndrome
• Look puffy and gain weight but intravascular
  space depleted
• Lose albumin in urine
• Plasma Oncotic pull is low and fluid leaks out of
  vessels

• 8 12 hourly input/output
• Weigh daily
• Monitor pulse, capill refill and BP
• Urinary Na indicates need for fluid/albumin bolus
• Fluids Maintenance Previous day output
  Insensible losses

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Questions?