Slide 1 Intravenous Fluids in Children NPSA Guidelines Dr Pam Cupples SPAN Meeting Friday the 20 th...
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Transcript of Slide 1 Intravenous Fluids in Children NPSA Guidelines Dr Pam Cupples SPAN Meeting Friday the 20 th...
Slide 1
Intravenous Fluids in ChildrenIntravenous Fluids in Children
NPSA GuidelinesNPSA Guidelines
Dr Pam CupplesDr Pam CupplesSPAN Meeting Friday the 20SPAN Meeting Friday the 20thth of April 2007 of April 2007
DunkeldDunkeld
Slide 2
AimsAims
Historical approach to fluid management Historical approach to fluid management based on Holliday & Segar’s ‘4/2/1’ formulabased on Holliday & Segar’s ‘4/2/1’ formula
Problems with hypotonic fluids in the Problems with hypotonic fluids in the Paediatric PopulationPaediatric Population
NPSA guidelinesNPSA guidelines
Slide 3
Maintenance Fluid RequirementsMaintenance Fluid Requirements
Maintenance fluid requirements parallel energy Maintenance fluid requirements parallel energy metabolismmetabolism
Energy Expenditure - using tables and nomogramEnergy Expenditure - using tables and nomogram Darrow et Pratt, JAMA 1950Darrow et Pratt, JAMA 1950
Body surface Area – Body surface Area – Crawford et al, Pediatrics 1950Crawford et al, Pediatrics 1950 Age - Age - Wallace, Am. J. Clin. Path. 1953Wallace, Am. J. Clin. Path. 1953 WeightWeight – – Holliday & Segar, Pediatrics 1957Holliday & Segar, Pediatrics 1957
Slide 4
Holliday & Segar’s FormulaHolliday & Segar’s Formula
‘ ‘healthy’ infants and healthy’ infants and childrenchildren
Energy expenditure at rest Energy expenditure at rest and during activityand during activity
Energy expenditure Energy expenditure equated to water equated to water requirementsrequirements
1ml of water required to 1ml of water required to burn 1 calorieburn 1 calorie
• 1.2mls water are consumed1.2mls water are consumed• 0.2mls water are produced0.2mls water are produced
3mmols/kg of Na3mmols/kg of Na 2mmol/kg of K2mmol/kg of K
Infants require ~ 100cal/kg/dayInfants require ~ 100cal/kg/day Older Children ~ 75cal/kg/dayOlder Children ~ 75cal/kg/day Adults ~ 35cal/kg/dayAdults ~ 35cal/kg/day
Calorie RequirementsCalorie Requirements100cal/kg/day100cal/kg/day <10kg<10kg50cal/kg/day50cal/kg/day 10-20kg10-20kg20cal/kg/day20cal/kg/day >20kg>20kg
Hypotonic fluid
0.18% NaCl with 4% Dextrose
Slide 5
How we got the ‘4-2-1’ ruleHow we got the ‘4-2-1’ rule
Calorie Requirements Based on Weight
0-10kg: 100cal/kg/day
10-20kg: 1000cal + 50cal/kg/day for each kg over 10kg
> 20kg: 1500cal + 20cal/kg/day for each kg over 20kg
Water Requirements – ‘ 4-2-1 rule’Water Requirements – ‘ 4-2-1 rule’
0-10kg: 100 water/kg/day
( 4ml / kg/ hour)
10-20kg: 1000 water + 50 water/kg/day for each kg over 10kg
( 2ml/kg/hour)
> 20kg: 1500 water + 20 water/kg/day for each kg over 20kg (1ml/kg/hour)
Slide 6
Holliday & Segar - the flawsHolliday & Segar - the flawsThe Maintenance Need for Water in Parenteral Fluid The Maintenance Need for Water in Parenteral Fluid
TherapyTherapy– – Pediatrics 1957Pediatrics 1957
WEIGHTWEIGHT
Illner et al 2000Illner et al 2000 - - resting energy expenditure is resting energy expenditure is based on fat free massbased on fat free mass
Accounts for 80% of the BMR but only 7% of the Accounts for 80% of the BMR but only 7% of the total body masstotal body mass
Calculating energy expenditure based on weight Calculating energy expenditure based on weight significantly over estimates the calorie significantly over estimates the calorie requirements and hence the water requirementsrequirements and hence the water requirements
Slide 7
Energy ExpenditureEnergy Expenditure
No allowance for the different energy expenditure in No allowance for the different energy expenditure in acute disease / post surgeryacute disease / post surgery
Actual energy expenditure is 50% lower than Actual energy expenditure is 50% lower than values used by Holliday & Segarvalues used by Holliday & Segar– Briassoulis et al, 2000Briassoulis et al, 2000– Lindahl et al, 1988Lindahl et al, 1988
Lower energy requirements due to :Lower energy requirements due to :– 50% of calorie expenditure allowed for growth50% of calorie expenditure allowed for growth– Catabolic stateCatabolic state– InactivityInactivity– PICU setting – IPPV / sedated and paralysedPICU setting – IPPV / sedated and paralysed
Exceptions – fever,sepsis & burnsExceptions – fever,sepsis & burns
Slide 8
Water LossesWater Losses
Insensible water losses 27ml/kg/day Insensible water losses 27ml/kg/day – Heeley & Talbot , 1955Heeley & Talbot , 1955
50% of this value –50% of this value – Lamke, 1977Lamke, 1977– Skin 7ml/kg/daySkin 7ml/kg/day– Lungs 5ml/kg/dayLungs 5ml/kg/day
Urinary lossesUrinary losses– 50-60ml/kg/day 50-60ml/kg/day Holliday & Segar, 1957Holliday & Segar, 1957
No allowance for non-osmotic stimuli for ADHNo allowance for non-osmotic stimuli for ADH– Stress, pain, surgery, feverStress, pain, surgery, fever– Drugs – opioids, NSAIDsDrugs – opioids, NSAIDs– Urinary volume reduced to 25ml/kg/dayUrinary volume reduced to 25ml/kg/day
Endogenous water production from tissue catabolism Endogenous water production from tissue catabolism
in acute illnessin acute illness
Slide 9
Slide 10
Hazards of Hypotonic FluidsHazards of Hypotonic FluidsAcute Hospital Acquired HyponatraemiaAcute Hospital Acquired Hyponatraemia
Prescription of hypotonic fluidsPrescription of hypotonic fluids Provision of excess free water in conditions Provision of excess free water in conditions
where patient unable to excrete the excess where patient unable to excrete the excess water loadwater load
Non – osmotic stimuli for ADHNon – osmotic stimuli for ADH
Slide 11
Non Osmotic Stimuli for ADH Non Osmotic Stimuli for ADH SecretionSecretion
– StressStress– PainPain– Post-operative periodPost-operative period– SepsisSepsis– PyrexiaPyrexia– Nausea & vomitingNausea & vomiting– Co-existing medical Co-existing medical
conditionsconditions• CNS infectionsCNS infections• Respiratory disordersRespiratory disorders• Metabolic & endocrine Metabolic & endocrine
disordersdisorders
DrugsDrugs MorphineMorphine NSAID’sNSAID’s SSRI’sSSRI’s BarbituratesBarbiturates CarbamazepineCarbamazepine ClofibrateClofibrate IsoprenalineIsoprenaline ChlorpropamideChlorpropamide VincrisitineVincrisitine
Slide 12
Hazards of Hypotonic FluidsHazards of Hypotonic FluidsAcute Hospital Acquired HyponatraemiaAcute Hospital Acquired Hyponatraemia
Acute HyponatraemiaAcute Hyponatraemia– Na < 136mmols/L occurring within 48 hoursNa < 136mmols/L occurring within 48 hours– Severe hyponatraemia if Na < 130mmols/LSevere hyponatraemia if Na < 130mmols/L– Or any level of hyponatraemia associated with clinical signsOr any level of hyponatraemia associated with clinical signs– Risk groupRisk group
• ChildrenChildren• Premenopausal womenPremenopausal women• HypoxiaHypoxia
– Hyponatraemic encephalopathy Hyponatraemic encephalopathy • 50% of children with Na<125mmol/L50% of children with Na<125mmol/L• 8% mortality rate8% mortality rate
– Risk of developing hyponatraemia with hypotonic fluids is Risk of developing hyponatraemia with hypotonic fluids is 17.2 times than with isotonic fluids17.2 times than with isotonic fluids
• Choong et al, 2006Choong et al, 2006– Children have a poorer outcome than adults for a given level Children have a poorer outcome than adults for a given level
of hyponatraemiaof hyponatraemia
Slide 13
Acute Hospital Acquired Acute Hospital Acquired Hyponatraemia – children at riskHyponatraemia – children at risk
Common symptomsCommon symptoms HeadacheHeadache Nausea & vomitingNausea & vomiting WeaknessWeakness
Advanced signsAdvanced signs SeizuresSeizures Respiratory arrestRespiratory arrest Dilated pupilsDilated pupils Decorticate posturingDecorticate posturing ComaComa Pulmonary oedemaPulmonary oedema
Slide 14
Risks of Hypotonic FluidsRisks of Hypotonic Fluids
50 cited cases of child death or neurological 50 cited cases of child death or neurological injury in the international literatureinjury in the international literature
4 deaths and 1 ‘near miss’ in the UK since 4 deaths and 1 ‘near miss’ in the UK since 20002000
Post-op setting in previously healthy childrenPost-op setting in previously healthy children Minor surgical proceduresMinor surgical procedures
Slide 15
ConclusionsConclusions
Hypotonic fluids are not benign but potentially Hypotonic fluids are not benign but potentially dangerousdangerous– 17.2 times more likely to develop hyponatraemia with 17.2 times more likely to develop hyponatraemia with
hypotonic fluids than with isotonichypotonic fluids than with isotonic Isotonic fluids offer a safe alternative to hypotonic Isotonic fluids offer a safe alternative to hypotonic
fluids with no risk of hypernatraemiafluids with no risk of hypernatraemia Fluid regimes should be tailored to the individualFluid regimes should be tailored to the individual Appropriate monitoringAppropriate monitoring
– Weight, baseline U&E’sWeight, baseline U&E’s
Slide 16
Background to the NPSA Background to the NPSA
March 2003March 2003 – RCA asked by the RCPCh to issue – RCA asked by the RCPCh to issue warning re. The use of 0.18% Saline in 4% warning re. The use of 0.18% Saline in 4% DextroseDextrose
November 2004November 2004 – Inquiry set to investigate the – Inquiry set to investigate the deaths of 3 children from hyponatraemia following a deaths of 3 children from hyponatraemia following a documentarydocumentary
Audit in 2004/2005Audit in 2004/2005 – few anaesthetists had seen – few anaesthetists had seen the warningthe warning
NPSA – advice to healthcare professionals on how NPSA – advice to healthcare professionals on how to reduce risk develop solutions and introduce them to reduce risk develop solutions and introduce them into clinical practiceinto clinical practice
Slide 17
NPSA Plan of ActionNPSA Plan of Action
July 2005July 2005 – form an internal working group to – form an internal working group to assess problemassess problem
August 2005August 2005 – External working group appointed – External working group appointed after after
October to November 2005October to November 2005 – meetings of the – meetings of the external group to discuss evidence collectedexternal group to discuss evidence collected
Dec 2005Dec 2005 – draft of the safe practice – draft of the safe practice recommendationsrecommendations
Jan-Feb 2006Jan-Feb 2006 – Wide stakeholder consultation on – Wide stakeholder consultation on draftdraft
April 2006April 2006 – publish NPSA guidance – publish NPSA guidance
Slide 18
NPSA – Patient safety alert 22: Reducing the risk NPSA – Patient safety alert 22: Reducing the risk of hyponatraemia when administering intravenous of hyponatraemia when administering intravenous
infusions to children (Alert 5 of 5)infusions to children (Alert 5 of 5)Applies to all paediatric patients from 1 month to 16 yearsApplies to all paediatric patients from 1 month to 16 years
2828thth March 2007 March 2007
Remove 0.18% NaCl / 4%Dextrose from general Remove 0.18% NaCl / 4%Dextrose from general stockstock
Produce and disseminate clinical guidelines for the Produce and disseminate clinical guidelines for the fluid management of paediatric patientsfluid management of paediatric patients
Adequate training and supervision of staffAdequate training and supervision of staff Reinforce safe practiceReinforce safe practice Promote the recording and reporting of hospital Promote the recording and reporting of hospital
acquired hyponatraemiaacquired hyponatraemia Audit programme to ensure that the NPSA Audit programme to ensure that the NPSA
recommendations are being adhered torecommendations are being adhered to
Slide 19
NPSA guidelinesNPSA guidelines
Template for developing local guidelines for Template for developing local guidelines for the prescription & monitoring infusions in the prescription & monitoring infusions in childrenchildren
Importance of rigorous clinical and laboratory Importance of rigorous clinical and laboratory monitoringmonitoring
Prescription of fluids same importance and Prescription of fluids same importance and consideration as other medicinesconsideration as other medicines
Fluids must be individualisedFluids must be individualised Calculate fluid balance and monitor plasma Calculate fluid balance and monitor plasma
NaNa
Slide 20
Oral fluids preferable to ivOral fluids preferable to iv Resuscitation Fluids – Resuscitation Fluids –
bolus of bolus of 0.9% saline0.9% saline Deficit – calculated and Deficit – calculated and
replaced as replaced as 0.9% saline0.9% saline or or 0.9% saline with 5% 0.9% saline with 5% dextrosedextrose Replace over 24 hoursReplace over 24 hours
Maintenance – do not use Maintenance – do not use 0.18% saline with 4% 0.18% saline with 4% dextrosedextrose 0.45%saline with 5% 0.45%saline with 5%
dextrosedextrose
Children at high risk – only isotonic fluids
Peri and post operative Na levels lower end of normal or
<135mmol/L Volume depleted Hypotension CNS infection Head injury Bronchiolitis Sepsis Excessive gastric / GI losses Chronic conditions – CF,IDDM Salt wasting syndromes
Slide 21
NPSA GuidelinesNPSA Guidelines
Ongoing lossesOngoing losses Assessed 4 hourly Assessed 4 hourly Replacement fluid should reflect the Replacement fluid should reflect the
type of electrolyte composition of the type of electrolyte composition of the fluid being lostfluid being lost
Isotonic safest choiceIsotonic safest choice
MonitoringMonitoring Robust regimeRobust regime Weight of childWeight of child Baseline and daily measurements of Baseline and daily measurements of
Na, K, urea & CrNa, K, urea & Cr More frequent if Na already low or More frequent if Na already low or
clinical picture changesclinical picture changes
TrainingTraining E-modules to assess current E-modules to assess current
level of competencies & level of competencies & knowledgeknowledge
Doctors in training (80-90%)Doctors in training (80-90%) Review their fluid Review their fluid
prescriptionsprescriptions
IV Prescription ChartsIV Prescription Charts Review & redesign – include Review & redesign – include
guidelines on fluid presciptionsguidelines on fluid presciptions Monitoring data requiredMonitoring data required How to calculate fluid How to calculate fluid
requirementsrequirements
Slide 22
Slide 23
www.npsa.nhs.uk/health/alerts
Slide 24
Arieff et al, BMJ 1992Arieff et al, BMJ 1992 Prospective clinical case Prospective clinical case
study study 16 children who died or 16 children who died or
developed permanent developed permanent neurological damageneurological damage
0.34% incidence of post-op 0.34% incidence of post-op hyponatraemiahyponatraemia(83 affected out of 24,412 (83 affected out of 24,412 patients)patients)
8.4% mortality rate8.4% mortality rate((7 deaths)7 deaths)
Halberthal et al, BMJ Halberthal et al, BMJ 20012001
23 patients23 patients– 13 hyponatraemic in post-op 13 hyponatraemic in post-op
periodperiod– 15 referred to critical care15 referred to critical care
• 11 from wards and 4 from 11 from wards and 4 from other institutesother institutes
– Seizures (18) and vomiting Seizures (18) and vomiting (17)(17)
– 5 had Rx withdrawn due to 5 had Rx withdrawn due to brainstem herniationbrainstem herniation
– 1 patient sustained 1 patient sustained permanent, severe permanent, severe neurological damageneurological damage
– 16 / 23 receiving 16 / 23 receiving maintenance fluids at 50% maintenance fluids at 50% more than recommended more than recommended valuesvalues
Slide 25
Paut et al, Paut et al, Ann Fr Anesth Reanim 2000Ann Fr Anesth Reanim 2000 7 Children 3-6 years7 Children 3-6 years ASA 1-2ASA 1-2 Scheduled surgical Scheduled surgical
proceduresprocedures Vomiting, seizures, status Vomiting, seizures, status
or or GCS (5/7) GCS (5/7) 1 respiratory arrest with Na 1 respiratory arrest with Na
120mmol/L120mmol/L All had hypotonic fluidsAll had hypotonic fluids 3/7 IPPV3/7 IPPV Rx – fluid restriction, NaClRx – fluid restriction, NaCl 1 death1 death
McRae et al, Int J Pediatr McRae et al, Int J Pediatr Otorhinolaryngol 1994Otorhinolaryngol 1994
3 post-op tonsillectomy 3 post-op tonsillectomy patientspatients
2 deaths2 deaths
Slide 26
Choong et al, 2006Choong et al, 2006
Systematic reviewSystematic review 6 studies satisified inclusion criteria6 studies satisified inclusion criteria
– 2 unmasked RCT2 unmasked RCT– 1 non randomised CT1 non randomised CT– 3 observational studies3 observational studies
Mean Na in hypotonic group –3.39mmol/LMean Na in hypotonic group –3.39mmol/L Small number of studies with small group sizeSmall number of studies with small group size
– Total of 404 patientsTotal of 404 patients
Slide 27
Holliday & SegarHolliday & Segar
0-10kg: 100cal/kg/day
10-20kg: 1000cal + 50cal/kg/day for each kg over 10kg
> 20kg: 1500cal + 20cal/kg/day for each kg over 20kg