maintenance and replacement fliud therapy

MAINTENANCE

REPLACEMENT

FLUID THERAPY

MAINTENANCE

REPLACEMENT

FLUID THERAPY

� Presented by: Tamiru Abera(C-II)

� Modulator: Dr.Kussia (pediatrician)

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.

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.

WHY THE INFANTS ARE MORE

VULNERABLE?*

� Physiological inability to concentrate urine.

� Higher metabolic rate & larger surface

� Can’t express thirst for more fluids.

� Larger turnover.

*IAP text book of Pediatrics 5th edition

GOALS OF MAINTENANCE FLUIDS*

� Prevent dehydration

� Prevent electrolyte disturbance

� Prevent ketoacidosis

� Prevent protein degradation

*Nelsons Text book of pediatrics 20th edition

� 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.*

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)

FLUID LOSSES IN INFANTS

URINE, FECES SKIN

FLUID REQUIREMENT OF NEWBORN IN

ML/KG/D

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

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

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

� 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*

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

CONTENTS OF IV FLUID PREPARATIONS*Na

(mEq/L)

Dextrose

(gm/L)

mOsm/L

NS 154 154 308

DNS 154 154 50 564

½ NS 77 77 143

77 77 50 350

D5W 50 278

Ringers

Lactate

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

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

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

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

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

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.

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

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

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

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

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

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?

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.

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.

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

� Classification of dehydration(DHN) :atleast 2 of

the following

No Dehydration Some Dehydration Severe Dehydration

(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

LABORATORY FINDINGS

� Several laboratory findings are useful for

evaluating the child with dehydration

� Na and K

� Urea and creatinine

� pH/ Bicarb.

� Urinalysis

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)

Plan B

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.

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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