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Pediatric Fluid Therapy Dr. Radi M. A. Hamed Consultant Pediatric Nephrologist Amman - Jordan

Pediatric Fluid Therapy Conditions. GastroenteritisFeverDeprivationDiabetes (Insipidus, mellitus - DKA)BurnsComaDiureticsIntestinal DrainageCystic fibrosis. Pediatric Fluid Therapy Principles. Maintenance H2O needs:Weight in KgH2O fluid needs1-10100cc /kg /day11-201000 50cc

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Pediatric Fluid Therapy Dr. Radi M. A. Hamed Consultant Pediatric Nephrologist Amman - Jordan

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    1. Pediatric Fluid Therapy Dr. Radi M. A. Hamed Consultant Pediatric Nephrologist Amman - Jordan

    2. Pediatric Fluid Therapy Conditions Gastroenteritis Fever Deprivation Diabetes (Insipidus, mellitus - DKA) Burns Coma Diuretics Intestinal Drainage Cystic fibrosis

    3. Pediatric Fluid Therapy Principles Maintenance H2O needs: Weight in Kg H2O fluid needs 1-10 100cc /kg /day 11-20 1000 + 50cc/kg/day > 20 1500 + 20cc/kg/day Add 12 % for every 0C

    4. Na+ & K+ Daily Needs Na+ = 2-3 meq / kg / day K+ = 1-2 meq / kg / day Notice: Daily fluid maintenance in pediatrics: 0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc

    5. Serum Osmolality Defined as the number of particles per liter. May be approximated by: 2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8 Normal range: 275-295 mOsm/L

    6. Insensible Fluid Losses 300-500 cc/M2/day Less in patients on the ventillator

    7. Composition of Body Fluids

    8. IV fluids D5W (5 g sugar/100 ml) 252 mOsm/L D10W (10 g sugar/100 ml) 505 mOsm/L NS (0.9% NaCl) 154 mEq Na/L 308 mOsm/L 1/2 NS (0.45% NaCl) 77 mEq Na/L 154 mOsm/L D5 1/4 NS 34 mEq Na/L 329 mOsm/L 3% NaCl 513 mEq Na/L 1027 mOsm/L 10% NaCl 1.7 mEq/cc 20% NaCl 3.4 mEq/cc 8.4% NaHCO3 (1 meq/cc Na & HCO3) 2000 mOsm/L

    9. IV fluids Lactated Ringers 0-10 gram glucose/100cc Na 130 mEq/L NaHCO3 28 mEq/L as lactate K 4 mEq/L 273 mOsm/L

    10. IV fluids Amino acid 8.5 % 8.5 gm protein/100 cc 880 mOsm/L Albumin 25% (salt poor) 25 gm protein/100 cc Na 100-160 mEq/L 300 mOsm/L Intralipid 2.25 gm lipid/100cc 284 mOsm/L

    11. Pediatric Fluid Therapy Principles Assess water deficit by: 1. weight: weight loss (Kg) = water loss (L) OR 2. Estimation of water deficit by physical exam: Mild moderate severe Infants < 5 % 5 - 10 % >10 % Older children < 3 % 3 - 6 % > 6 %

    12. Physical Signs of Dehydration

    13. Pediatric Fluid Therapy Principles Moderate to severe dehydration: IV push 10-20 cc / Kg Normal saline (5 % albumin) May repeat. Half deficit over 8 hours, and half over 16 hours. If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed).

    14. Correction of Dehydration Estimate Fluid Deficit (% :- Mild, Moderate, Severe). Find Type of Dehydration (Isonatremic, Hyponatremic, Hypernatremic). Give daily Maintenance. Give Deficit as follows: Half volume over 8 hours, half volume over 16 hours (Exception: in Hypernatremic Dehydration, replace deficit over 48 hours).

    15. Isonatremic Dehydration Normal serum Na+, Decreased total body Na+. Estimated deficit of Na+ = Mild 2-4 meq/ kg body weight Moderate 6-8 meq/ kg body weight Severe 8-12 meq/ kg body weight

    16. Example: In a 10 kg infant, with moderate dehydration (10% dehydration) Maintenance = (10)(100) = 1000cc Deficit = (10)(100) = 1000cc Total = 2 L Na+ maintenance = (3)(10) = 30 meq Na+ deficit = (10)(8) = 80 meq Total = 110 meq 110 meq Na+ in 2L = 55 meq Na+ / L = 0.3 saline

    17. Hyponatremic Dehydration Total Na+ Deficit = (Desired Na+) (Actual Na+) Body Wt Kg 0.6 + Deficit similar to Isonatremic Dehydration

    18. Symptomatic Hyponatremia Convulsions Rapid Intravenous administration of Na+ 3% saline infusion (1-12cc/kg body weight)

    19. Hypernatremic Dehydration Doughy skin Significant morbidity & high mortality Dehydration / Salt intoxication Risk: Hypocalcemia Hypo / hyperglycemia Acidosis Cerebral hemorrhage Cerebral venous thrombosis

    20. Hypernatremic Dehydration Serum Na+ > 150 meq/L (up to 213) Deficit replacement over 48 hours 0.18% 0.3% saline Regular daily maintenance Fluid evenly distributed over time Dialysis option in severe hypernatremia

    21. Potassium Daily requirement: 1-2 meq / kg body weight. Usually add 10-20 meq KCl / L of IV fluid. Added only once the urine output is established. In Hypokalemia, add: 30 meq / L of IV fluid 40 meq / L of IV fluid 50 meq / L of IV fluid 60 meq / L of IV fluid 70 meq / L of IV fluid ECG monitoring Frequent testing

    22. Hypokalemia Management Maximum IV infusion rate: 1 mEq/kg/hr Marked hypokalemia: Monitor serum K closely 0.5-1 mEq/kg/dose given as an infusion of 0.5 mEq/kg/hr for 1-2 hour

    23. Acidosis Factors Renal (Dehydration). Lactic Acidosis (severe Dehydration). Direct losses of HCO3- (Diarrhea). Hypernatremic Dehydration.

    24. Acidosis Usually Resolves with Hydration In severe acidosis: Alkali therapy (NaHCO3) IV Calculation: (Desired HCO3- - Actual HCO3-) body wt Kg 0.45

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