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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)
5
Normal maintenance requirements
First 10kg body weight – 100mls/kg/day 4mls/kg/hour Second 10kg weight 50mls/kg/day 2mls/kg/hour Subsequent weight 20mls/kg/day 1ml/kg/hour
Calculate maintenance requirements
6
100mls/kg x 10 = 1000mls
50mls/kg x 5 = 250mls
Total = 1250mls/24hrs
Prescription 52mls/hr
Diarrhoea and vomiting in children under 5
Assessing dehydration slides
Implementing NICE guidance
2009
NICE clinical guideline 84
Symptoms of increasing severity of dehydration
No clinically detectabledehydration
Clinical dehydration Clinical shock
Appears well Appears to be unwell or deteriorating
–
Alert and responsive Altered responsiveness
Decreased level ofconsciousness
Normal urine output Decreased urine output –
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Signs of increasing severity of dehydrationNo clinically detectabledehydration
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
Case 1 - fluid volume prescription
Maintenance plus deficit prescribed over 24 hours
1250 + 750 = 2000mls
83mls/hr
13
Normal maintenance requirementsWt (kg) Na
(mmol/kg/dy) K (mmol/kg/dy)
First 10 kg 2-4 1.5-2.5
Second 10 kg 1-2 0.5-1.5
Subsequent kg
0.5-1 0.2-0.7
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 Glucose15
Intravenous fluids
0.9% sodium chloride
150mmol/litre Na
0.45% sodium chloride/5% glucose75 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?
Management of shock
ABC Oxygen Venous access – bloods for glucose
and renal biochemistry (minimum) 20mls/kg of 0.9% saline Subsequent rehydration
18
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
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
Hypernatraemic dehydration
Cautious fluid replacement Suggested replace deficit over 48hrs Reduce plasma Na by no greater than
0.5mmol/hr
Concern re cerebral oedema
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
Potassium
Usually 20mmol/litre for maintenance fluids
When treating dehydration add 20mmol/litre potassium chloride to fluids when happy that passing urine