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Fluid and electrolyte therapy

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Fluid and electrolyte therapy Dr Ed Simmonds Consultant Paediatrics UHCW * Normal maintenance requirements Intravenous fluids 0.9% sodium chloride Calculations ... – PowerPoint PPT presentation

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Title: Fluid and electrolyte therapy


1
Fluid and electrolyte therapy
  • Dr Ed Simmonds
  • Consultant Paediatrics
  • UHCW

2
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?

3
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)

4
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5
Normal maintenance requirements
6
Calculate maintenance requirements
100mls/kg x 10 1000mls 50mls/kg x 5
250mls Total 1250mls/24hrs Prescription
52mls/hr
7
Dehydration
8
Diarrhoea and vomiting in children under
5 Assessing dehydration slides
Implementing NICE guidance
2009
NICE clinical guideline 84
9

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
10

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
11
Dehydration symptoms/signs
  • Clinical dehydration 5
  • Shock 10

12
Calculate deficit
  • 5 dehydration
  • 15kg 15,000mls
  • 1 150mls
  • 5 750mls

13
Case 1 - fluid volume prescription
  • Maintenance plus deficit prescribed over 24 hours
  • 1250 750 2000mls
  • 83mls/hr

14
Normal maintenance requirements
15
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

16
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
17
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?

17
18
Management of shock
  • ABC
  • Oxygen
  • Venous access bloods for glucose and renal
    biochemistry (minimum)
  • 20mls/kg of 0.9 saline
  • Subsequent rehydration

19
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

20
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

21
Hypernatraemic dehydration
  • Cautious fluid replacement
  • Suggested replace deficit over 48hrs
  • Reduce plasma Na by no greater than
  • 0.5mmol/hr
  • Concern re cerebral oedema

22
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

23
Potassium
  • Usually 20mmol/litre for maintenance fluids
  • When treating dehydration add 20mmol/litre
    potassium chloride to fluids when happy that
    passing urine

24
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