CHANGING TRENDS:

PEDIATRIC MAINTENANCE IVF

DR. MAULIK SHAH MD(Ped)

A Maulik Shah Presentation

Prescribe a maintenance IV fluid

Age 2 years, wt. 10 kg admitted for pneumonia

With resonably stable vitals except mild tachypnea.

Answer :

1litre of IVF over 24 hrs.

IVF= ISOLYTE – P

ISOLYTE – P : Dextrose 5% + 26 Na + + 20 K +

A Maulik Shah Presentation

NPSA – Patient safety alert 22: Reducing the risk of hyponatraemia

when administering intravenous infusions to children (Alert 5 of 5)

Remove 0.18% NaCl / 4%Dextrose from general stock

Produce and disseminate clinical guidelines for the fluid management of paediatric patients

Adequate training and supervision of staff

Reinforce safe practice

Promote the recording and reporting of hospital acquired hyponatraemia

Audit programme to ensure that the NPSA recommendations are being adhered to

Applies to all paediatric patients from 1 month to 16 years 28th March 2007

A Maulik Shah Presentation

Recommendation -NPSA

Oral fluids preferable to ivf

Resuscitation Fluids –

bolus of 0.9% saline

Deficit – calculated and replaced as

0.9% saline or 0.9% saline with 5% dextrose Replace over 24 hours

Maintenance – do not use 0.18% saline with 4% dextrose

0.45%saline with 5%dextrose(D5-½NS)

A Maulik Shah Presentation

What about other countries…?

Royal children hospital, Melbourne. Which Fluid?

0.18% NaCl with 4% glucose with KCl 20mmol/L is NOT the appropriate initial fluid for unwell children.

Three good fluid solutions for sick children include:

Fluid Alternative names

0.9 NaCl Normal Saline

0.9 NaCl with 5% Dextrose Normal saline with glucose

0.45 NaCl with 5% Dextrose ½Normal saline with glucose

A Maulik Shah Presentation

But Why do we require to change…

Hoorn et al. Hoorn et al. Pediatrics 2004

“the most important factor contributing to hospital acquired

hyponatremia was administration of hypotonic fluid (case control) “

Choong et al Choong et al. Arch Dis child 2006

”the use of hypotonic fluids increased the odds of developing

hyponatremia by 17 times when compared to isotonic

(systematic review).

A Maulik Shah Presentation

Hazards of Hypotonic FluidsAcute Hospital Acquired Hyponatraemia

Acute Hyponatraemia

Na < 136mmols/L occurring within 48 hours

Severe hyponatraemia if Na < 130mmols/L

Or any level of hyponatraemia associated with clinical signs

Hyponatraemic encephalopathy

50% of children with Na<125mmol/L

8% mortality rate

Children have a poorer outcome than adults for a given level of hyponatraemia

Acute Hospital Acquired Hyponatraemia – children at risk

Common symptoms

Headache

Nausea & vomiting

Weakness

Advanced signs

Seizures

Respiratory arrest

Dilated pupils

Decorticate posturing

Coma

Pulmonary oedema

child’s brain has a higher

brain /intracranial volume ratio

Slide courtesy:

Heinrich Werner, M.D.

Pediatric Critical Care

University of Kentucky

A Maulik Shah Presentation

Hyponatremic encephlalopathy kills…!

Slide courtesy:

Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky

A Maulik Shah Presentation

That means...

Hypotonic fluids are not benign but potentially dangerous.

Isotonic fluids offer a safe alternative to hypotonic fluids with no risk of hypernatraemia

Fluid regimes should be tailored to the individual

Appropriate monitoring Weight, baseline U&E’s

Hyponatremia

Volume Status

Hypovolemia

Renal losses“””””“””””“””””

Extrarenal losses“””””“”””””“””””

Euvolemia

SIADH

Hypervolemia

“””””“””””“””””

Most common cause of hyponatremia

in hospitalized patients

Slide courtesy:

Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky

SIADH and Hyponatremia

Inappropriate AVP level Free water intake exceeds output

Symptomatic Hyponatremia

Typically done by you and me !

Appropriate ADH Secretion Inappropriate ADH Secretion

Decreased Renal Water Secretion

Hypotonic Fluid

Hyponatremia

A Maulik Shah Presentation

Osmolality : ADH level and Thirst

From:

Berl T, Robertson GL. Pathophysiology of Water

Metabolism. In: Brenner AM, ed. Brenner and Rector's

The Kidney. 6th ed. Philadelphia: W.B. Saunders;

2000:873.

Osmolality is the prime stimulus for ADH release or suppression.

A Maulik Shah Presentation

Non Osmotic Stimuli for ADH Secretion

Stress

Pain

Post-operative period

Sepsis

Pyrexia

Nausea & vomiting

Co-existing medical conditions CNS infections Respiratory disorders Metabolic & endocrine disorders

Drugs

Morphine

NSAID’s

SSRI’s

Barbiturates

Carbamazepine

Clofibrate

Isoprenaline

Chlorpropamide

Vincrisitine

A Maulik Shah Presentation

Which hospitalized

child is not at risk

for SIADH ?

Slide courtesy:

Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky

A Maulik Shah Presentation

But why hypotonic fluid held responsible ?

IV SOLUTIONS Na(mEq/L) %EFW

5% Dextrose 0 100

ISOLYTE -P 26 84%

0.45% NS 77 50%

0.45 % NS in 5% Dextrose 77 50%

0.9 % NS in 5% Dextrose 154 0

Ringer Lactate 131 16%

0.9% NS 154 0

EFW = Electrolyte Free Water

A Maulik Shah Presentation

But what does EWF do ?

Sodium Principles

Sodium ions do

not cross cell

membranes as

quickly as water

doesNa+

H2O

H2O H2O

H2O

H2O

Na+

A Maulik Shah Presentation

So do we accept the change ?

Not fully – Why…?

We live in tropics-hot climate –free water loss more.

Our children are treated most often in non A/C ICU.

Our indian data is in-sufficient for conclusion.

BUT then summer and winter fluid has to be different.!!!

A Maulik Shah Presentation

So is “ISOLYTE- P” out ??

Not fully – Why…?

Hypotonic solutions should be administered if the goal is to create a positive balance for EFW:

1. To match daily loss of EFW in sweat in a patient with PNa > 138mM

2. PNa > 145

3. Ongoing free water losses (Renal, GI, skin) or a free water deficit

so use in

NEONATES.

Established third space overload : e.g. congestive heart failure,

nephrotic syndrome, cirrhosis

Let’s Share our views on this…

DR.MAULIK SHAH MD.(PED)

ASSOCIATE PROFESSOR

DEPARTMENT OF PEDIATRICS

M.P.S.M.C – JAMNAGAR(GUJARAT-INDIA)

maulikdr@gmail.com

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