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Fluid and electrolyte therapy

Fluid and electrolyte therapy. Dr Ed Simmonds Consultant Paediatrics UHCW. 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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Fluid and electrolyte therapy

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  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. Normal maintenance requirements

  5. Calculate maintenance requirements 100mls/kg x 10 = 1000mls 50mls/kg x 5 = 250mls Total = 1250mls/24hrs Prescription 52mls/hr

  6. Dehydration

  7. Diarrhoea and vomiting in children under 5 Assessing dehydration slides Implementing NICE guidance 2009 NICE clinical guideline 84

  8. Dehydration symptoms/signs • Clinical dehydration = 5% • Shock = 10%

  9. Calculate deficit 5% dehydration 15kg = 15,000mls 1% = 150mls 5% = 750mls

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

  11. Normal maintenance requirements

  12. 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

  13. 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

  14. 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

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

  16. 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

  17. Electrolyte results • Hyponatraemia <130mmol/litre • Normal 135 – 145mmol/litre • Hypernatraemia >145mmol • Hypokalaemia <3.5mmol/litre • Normal 3.5 – 5.0mmol/litre • Hyperkalaemia >5.0mmol/litre

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

  19. 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

  20. 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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