Paediatric Fluid Management

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Paediatric Fluid Management

• Sheffield Childrens NHS Foundation Trust
• PCCU

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Aims

• To provide normal maintenance requirements
• To replace pre-existing deficits and on-going
  fluid losses
• To prevent hypovolaemia
• To maintain normoglycaemia and normal electrolyte
  balance

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Importance during pandemic

• Children with influenzae may present with
  diarrhoea and vomiting
• Shock has been a feature of severe cases
• Fluid restriction, diuresis and renal support has
  been effective in those with severe respiratory
  failure

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Clinical assessment

• History
• Frequency of vomiting and stools
• Tolerence of enteral fluids
• Urine output/wet nappies
• Thirst
• Clinical signs
• Mild dehydration (lt5lt50ml/kg)
• No clinical signs
• Moderate dehydration (5-1050-100ml/kg)
• Reduced weight
• Increased CRT, cool peripheries, increased HR
• Severe dehydration
• Reduced skin turgor
• Irritability/lethargy
• Dry mucous membranes
• Sunken fontanelle
• Hypotension, tachypnoea

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Who needs fluids?

• Children who are unable to maintain their fluid
  intake due to
• Breathlessness
• Fatigue
• Gastroenteritis

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Which route?

• Enteral route is preferable
• NGT may be required
• Enteral meds can be given via NGT
• Calibre of NGT should be as small as practicable
• IV fluids may be required in severely ill
  children
• Not tolerating
• Severe respiratory distress
• Imminent intubation
• Shock

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Monitoring

• Fluid input and output chart
• Daily weights
• UEs at least daily if on IV fluids
• Blood glucose
• Urinary catheterisation may be required

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How much?

• Well children with normal hydration require
  maintenance fluid
• Unwell children require adjusted maintenance
  any deficit ongoing losses
• Aim for 1ml/kg/h urine in infants and children
  and 0.5ml/kg/h in adolescents

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Maintenance

• Term neonates
• Day 1 60ml/kg/d
• Day 2 90ml/kg/d
• Day 3 120ml/kg/d
• Day 4 - 150ml/kg/d
• 1-6 months - 120ml/kg/d
• 6 months upwards
• 5-65kg
• 100ml/kg/d for the 1st 10kg
• 50ml/kg/d for the 2nd 10kg
• 20ml/kg/d for each additional kg
• gt65kg
• 2400ml/d

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Fluid adjustments

• Humidified gases
• Reduce by 20
• Fever
• Increase by 10 for each degree of fever
• Inappropriate secretion of ADH
• Reduce by 20-40
• Ongoing gastrointestinal losses
• Match estimated loss

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What fluid?

• Maintenance
• Enteral feed is best
• IV
• 0.45 sodium chloride 5 glucose potassium
• 0.9 sodium chloride 5 glucose potassium
• 0.9 sodium chloride potassium
• Hartmans
• Deficit
• 0.9 sodium chloride /- potassium

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IV sites

• Lower limb cannulae are safe in children
• The scalp can be used in neonates
• External jugular can be useful
• Care of IV cannulae as for adults
• Use transparent dressings and check site
  regularly
• Remove splints/bandages when using the line for
  bolus meds

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Shock

• Maintaining normovolaemia and adequate
  circulation is vital
• H1N1 patients can present with shock
• Provide 20ml/kg 0.9 sodium chloride over 10
  15mins and re-assess
• If fluid required after giving 40ml/kg consider
  addition of vaso-active drugs

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Diuretics

• May be required in patients ventilated for
  respiratory failure
• Fluid restriction to 80 maintenance should be
  first line
• Further fluid restriction may be required but can
  compromise nutrition
• Start with frusemide 0.5mg/kg bd qds
• Monitor potassium and consider adding
  spironolactone
• Increase to 1mg/kg qds and then consider infusion
  up to 1mg/kg/h

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Questions