Fluid and electrolyte therapy

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Fluid and electrolyte therapy

• Dr Ed Simmonds
• Consultant Paediatrics
• UHCW

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Case 1

• Four year old weighing 15 Kgs, 24 hour history
• of D V. Looks unwell/dehydrated. Trial of oral
• fluids initially not tolerated.
• Admitted for management with fluids.
• How will you proceed?

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General principles

• Maintenance fluid replaces usual losses of fluid
  and electrolytes
• Deficit designed to replace abnormal losses due
  to disease
• Supplemental fluid replaces measured or
  estimated continuing abnormal losses (eg loose
  stools)

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Normal maintenance requirements
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Calculate maintenance requirements
100mls/kg x 10 1000mls 50mls/kg x 5
250mls Total 1250mls/24hrs Prescription
52mls/hr
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Dehydration
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Diarrhoea and vomiting in children under
5 Assessing dehydration slides
Implementing NICE guidance
2009
NICE clinical guideline 84
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Symptoms of increasing severity of dehydration Symptoms of increasing severity of dehydration Symptoms of increasing severity of dehydration
No clinically detectable dehydration Clinical dehydration Clinical shock
Appears well Appears to be unwell or deteriorating
Alert and responsive Altered responsiveness Decreased level of consciousness
Normal urine output Decreased urine output
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
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Signs of increasing severity of dehydration Signs of increasing severity of dehydration Signs of increasing severity of dehydration
No clinically detectable dehydration Clinical dehydration Clinical shock
Alert and responsive Altered responsiveness Decreased level of consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Eyes not sunken Sunken eyes -
Moist mucous membranes Dry mucous membranes -
Normal heart rate Tachycardia Tachycardia
Normal breathing pattern Tachypnoea Tachypnoea
Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses
Normal capillary refill time Normal capillary refill time Prolonged capillary refill time
Normal skin turgor Reduced skin turgor -
Normal blood pressure Normal blood pressure Hypotension
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Dehydration symptoms/signs

• Clinical dehydration 5
• Shock 10

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Calculate deficit

• 5 dehydration
• 15kg 15,000mls
• 1 150mls
• 5 750mls

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Case 1 - fluid volume prescription

• Maintenance plus deficit prescribed over 24 hours
• 1250 750 2000mls
• 83mls/hr

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Normal maintenance requirements
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Oral or nasogastric fluids

• Rehydrate with low osmolarity rehydration
  solution (ORS)
• Hypo-osmolar to prevent osmotic diarrhoea
• 60mmol Na per litre
• 20mmol K
• 60mmol Cl
• 90mmol Glucose

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Intravenous fluids

• 0.9 sodium chloride

150mmol/litre Na
0.45 sodium chloride/5 glucose
75 mmol /litre Na 5 grams glucose
0.9 sodium chloride/5 glucose
150mmol/litre Na 5 grams glucose
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Case 2

• Two year old weighing 12 Kgs.
• 48 hour history of D V.
• Drowsy, cold hands and feet.
• HR 180, RR 40, CRT 4 seconds
• How will you proceed?

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Management of shock

• ABC
• Oxygen
• Venous access bloods for glucose and renal
  biochemistry (minimum)
• 20mls/kg of 0.9 saline
• Subsequent rehydration

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Calculations

• Maintenance
• 10 x 100 1000
• 2 x 50 100
• Total 1100
• Deficit
• 10 of 12,000 1200
• Total 2300mls/24hrs 96mls/hr
• 0.9 sodium chloride/5 glucose

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Electrolyte results

• Hyponatraemia lt130mmol/litre
• Normal 135 145mmol/litre
• Hypernatraemia gt145mmol
• Hypokalaemia lt3.5mmol/litre
• Normal 3.5 5.0mmol/litre
• Hyperkalaemia gt5.0mmol/litre

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Hypernatraemic dehydration

• Cautious fluid replacement
• Suggested replace deficit over 48hrs
• Reduce plasma Na by no greater than
• 0.5mmol/hr
• Concern re cerebral oedema

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Diabetic ketoacidosis

• Cautious fluid replacement
• If shocked initial bolus 10ml/kg (repeat if felt
  necessary).
• Subtract fluid bolus from deficit calculations
• Suggested replace deficit over 48hrs
• Reduce plasma Na by no greater than
• 0.5mmol/hr

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Potassium

• Usually 20mmol/litre for maintenance fluids
• When treating dehydration add 20mmol/litre
  potassium chloride to fluids when happy that
  passing urine

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