Maintenance and replacement fliud therapy
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Transcript of Maintenance and replacement fliud therapy
MAINTENANCE
&
REPLACEMENT
FLUID THERAPY
MAINTENANCE
&
REPLACEMENT
FLUID THERAPY
� Presented by: Tamiru Abera(C-II)
� Modulator: Dr.Kussia (pediatrician)
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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.
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DEFINITION
-IS INTRAVENOUS FLUIDS ARE USED IN A CHILD WHO CANNOT BE
FED ENTERALLY.
WHOM TO GIVE MAINTENANCE FLUIDS?
� 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.
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WHY THE INFANTS ARE MORE
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 5th edition
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GOALS OF MAINTENANCE FLUIDS*
� Prevent dehydration
� Prevent electrolyte disturbance
� Prevent ketoacidosis
� Prevent protein degradation
*Nelsons Text book of pediatrics 20th edition
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� 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 20th edition
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CONCEPT OF MAINTENANCE OF WATER
� Crucial component of maintenance fluid
therapy.
� Maintenance water = Measurable loss of water
65% (Urine 60%, stools 5%) + Insensible of
water 35% (skin & lungs)
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FLUID LOSSES IN INFANTS
LUNGS
URINE, FECES SKIN
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FLUID REQUIREMENT OF NEWBORN IN
ML/KG/D
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MAINTENANCE REQUIREMENTS*
Weight Requirement
0-10 kg 100cc/kg/24hr
11-20 kg 1000 + 50cc/kg/24hr
>20 kg 1500 +
20cc/kg/24hr
NB:1cc=1mlUpper limit 2400cc/24hrs
*Nelsons Text book of pediatrics 20th edition
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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 20th edition
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CONCEPT OF MAINTENANCE OF
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 5th edition
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� 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 ketone production.
CONCEPT OF MAINTENANCE OF
GLUCOSE*
*Nelsons Text book of pediatrics 20th edition
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COMMONLY USED FLUIDS FOR
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 NaCldeficits.
*The Harriet Lane Handbook 19th edition
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CONTENTS OF IV FLUID PREPARATIONS*Na
(mEq/L)
K
(mEq/L)
Cl
(mEq/L)
HCO3
(mEq/L)
Dextrose
(gm/L)
mOsm/L
NS 154 154 308
DNS 154 154 50 564
½ NS 77 77 143
5%D +
1/2NS
77 77 50 350
D5W 50 278
Ringers
Lactate
(RL)
130 4 109 28 50 273
Iso P 23 20 23 30 50 367
Iso M 37 35 37 30 50 415.5
*The Harriet Lane Handbook 19th edition
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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.
COMMONLY USED FLUIDS FOR
MAINTENANCE
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HOW TO CHOOSE?*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
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MONITORING WHILE ADMINISTERING
FLUIDS*
� Child should be weighed prior to the
commencement of therapy, and daily afterwards.
� Children with ongoing dehydration/ongoing
losses may need 6 hourly weights to 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
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MONITORING WHILE ADMINISTERING
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
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MAINTENANCE FLUIDS &
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 20th edition
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REPLACEMENT FLUIDS
� 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
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REPLACEMENT FLUIDS*
� 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
vomitus should be replaced by the same
amount every 1 to 6 hourly.*Nelsons Text book of pediatrics 20th edition
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REPLACEMENT FLUIDS
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 20th edition
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REPLACEMENT FLUIDS
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 20th edition
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REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria / Anuria
Place patient on insensible fluids (25 to 40% of maintenance)
Replace Urine output ml/ml by half NS
Polyuria
Place patient on insensible fluids (25 to 40% of maintenance)
Measure urine electrolytes
Replace Urine output ml/ml by solution based on measured urine
electrolytes
*Nelsons Text book of pediatrics 20th edition
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CASE EXAMPLE
� 5 day old baby boy weighing 3 kg having
total billirubin 18.0 is to be kept under
phototherapy. Baby having no other risk
factors & accepts DBM well.
� What fluid at what rate should we
prescribe?
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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.e 125 ml / 8hrly
� Fluid of choice is 5% dextrose + 0.45% NS or iso P will also be suitable.
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DEFICIT THERAPY
� 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 hypernatremic dehydration can be managed with
oral rehydration.
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VOMITING� Metabolic Alkalosis
� Loss of acid from stomach
� pH
� HCO3
� H+
� Treatment: Prevent further losses and replace lost electrolytes
Yekateet 30,
2009/March 9, 2017
prepared and presented by Tamiru
Abera29
DIARRHEA
�Metabolic Acidosis
� loss of HCO3 from G.I. Tract
� pH
� HCO3
�Treatment: Correct base deficit, replace losses of with NaHCO3
Yekateet 30,
2009/March 9, 2017
prepared and presented by Tamiru
Abera30
•DEHYDRATION OCCURS WHEN YOU LOSE
MORE FLUID THAN YOU TAKE IN.
CAUSES OF DEHYDRATION
� 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
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� Classification of dehydration(DHN) :atleast 2 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 drink Unable to drink
Normal skin turgor
(Skin turgor)Skin pinch returns slowly
Skin pinch returns very slowly
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LABORATORY FINDINGS
� Several laboratory findings are useful for
evaluating the child with dehydration
� Na and K
� Urea and creatinine
� pH/ Bicarb.
� Urinalysis
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TREATMENT DHNAssess the child for signs of dehydration and give fluids
according to Treatment Plan A, B or C as appropriate.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 feedingBreastfeed 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)
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Plan B
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TAKE HOME MESSAGE
� 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 Segar’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.
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RRRREFERENCESEFERENCESEFERENCESEFERENCES
�NELSON TEXT BOOK OF PEDIATRICS 20NELSON TEXT BOOK OF PEDIATRICS 20NELSON TEXT BOOK OF PEDIATRICS 20NELSON TEXT BOOK OF PEDIATRICS 20THTHTHTH EDITIONEDITIONEDITIONEDITION
�IAP PEDIATRICS 5IAP PEDIATRICS 5IAP PEDIATRICS 5IAP PEDIATRICS 5THTHTHTH EDITIONEDITIONEDITIONEDITION
�THE HARRIET LANE HANDBOOK 19TH EDITIONTHE HARRIET LANE HANDBOOK 19TH EDITIONTHE HARRIET LANE HANDBOOK 19TH EDITIONTHE HARRIET LANE HANDBOOK 19TH EDITION
�WWW.MEDSCAPE.COMWWW.MEDSCAPE.COMWWW.MEDSCAPE.COMWWW.MEDSCAPE.COM
� NICU Traitning Participants’ Manual,2014 (FMOH)
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