Post on 27-Dec-2015
Fluid management at the ER
some practical tips
Objectives
□ initial fluid management of some very challenging ER disorders (perioperative cases and severe malnutrition in shock)
□ rationale
Hydration status. Normal clinical parameters.
sensorium Alert,awake,oriented
Heart rate N for age
Nature of pulses Full
crt < 2 sec
temperature Normothermic
Skin color Pink. No mottling/pallor
uo 1 – 2 cc/k/hr or 500 – 600 ml/bsa/24 hrs
BP N for age
examination 3% - 5% Mild dhn
6% - 10% Moderate dhn
10% - 15% Severe dhn
Skin turgor normal tenting Tenting
Skin by touch normal dry Clammy
lips moist dry Cracked
eyes normal Deep set Sunken
tears present reduced None
fontanelle flat soft Sunken
sensorium consolable irritable Obtunded
Pulse rate Normal to inc increased Very rapid
Pulse quality nomal Weak Non-palpable
crt nomal 2 – 3 sec > 3 sec
uo normal decreased anuric
Physiologic parameters of abnormal hydration status.
Berman (2000) and Oski (1999).
Fluid and electrolyte management
• Maintenance fluids + measurable losses + non-measurable losses
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
Maintenance fluids + measurable loss + non-measurable loss
Holliday-Segar Method
first 10 kg 4 ml/k/hr
11 - 20 kg 2 ml/k/hr
>20 kg 1 ml/k/hr
Maintenance fluids + measurable loss + non-measurable loss
• From tube drains (ogt, ctt, etc) + gastrostomy + urethral catheter + etc
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
Maintenance fluids + measurable loss + non-measurable loss
Clinical state modifying factor
fever 0.13 per C >38 degrees
Simple trauma 0.20
Multiple trauma 0.40
Burns 0.5 – 1.0
electrolyte composition of body fluids
fluid Na (meq/L) k (meq/L) cl (meq/L) protein
gastric 20 - 80 5 - 20 100 - 150
pancreatic 120 - 140 5 - 15 90 - 120
small bowel 100 - 140 5 - 15 90 - 130
bile 120 - 140 5 - 15 80 - 120
ileostomy 45 - 135 3 - 15 20 - 115
diarrhea 10 - 90 10 - 80 10 - 110
burn 140 5 110 3 - 5 g/dL
sweat 10 - 30 3 - 10 10 - 35
Some commonly used fluids
solutions Na (mEq/L) K (mEq/L)
PLR/D5LR 130 4
PNSS 154
D50.45NaCl 77
D50.3NaCl 51
D5IMB 25 20
D5NM 40 13
D5NR 140 5
13
Fluids
plasma
Na (meq/L)
141
K
4
Mg
2
Buffer
bicarb
Ph
7.4
Osm
289
0.9%Nacl 154 5.7 308
LR 130 4 lactate 6.4 273
Normosol-R / plasmalyte
140 5 3 Acetate & gluconate
7.4 295
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
examination 3% - 5% Mild dhn
6% - 10% Moderate dhn
10% - 15% Severe dhn
Skin turgor normal tenting Tenting
Skin by touch normal dry Clammy
lips moist dry Cracked
eyes normal Deep set Sunken
tears present reduced None
fontanelle flat soft Sunken
sensorium consolable irritable Obtunded
Pulse rate normal increased Very rapid
Pulse quality nomal Weak Non-palpable
crt nomal 2 – 3 sec > 3 sec
uo normal decreased anuric
Physiologic parameters of abnormal hydration status.
Berman (2000) and Oski (1999).
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
POST OPERATIVE FLUID MANAGEMENT
i. Surgery, pain, nausea and vomiting are all potent causes of ADH release. Arecent NPSA alert has recommended that hypotonic fluids should not be used forpostoperative maintenance as this may cause hyponatraemia due to retention offree water released after metabolism of dextrose from the solution.
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
ii. Consensus was not agreed on the maintenance fluid rate in the postoperative period.Some would use the full rate as calculated using Holliday and Segar’s formula, whileothers would fluid restrict to 60-70% of full maintenance and additional boluses ofisotonic fluid given as required.
iii. In the postoperative period ongoing losses from drains or nasogastric tubesshould be replaced with an isotonic fluid such as 0.9% sodium chloride with orwithout added KCl.
iv. Losses should be measured hourly and replaced every 2 to 4 hours depending onthe amount.
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
MONITORING OF FLUID THERAPYi. Serum electrolytes do not need to be measured pre-operatively in healthychildren prior to elective surgery where IV fluids are to be given.
ii. Serum electrolytes need to be measured pre-operatively in all childrenpresenting for elective or emergency surgery who require IV fluid to beadministered prior to surgery.
iii. Children should be weighed prior to fluids being prescribed and given.
iv. Serum electrolytes should be measured every 24 hours in all children on IVfluids or more frequently if abnormal.
v. Although ideally children should be weighed daily while on IV fluids, practicallythis is difficult in older children, or those who have undergone major surgery.Use of a fluid input/output chart will help with fluid management.
APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007
www.imtf.org/_uploads/emergency-wall-chart.doc
Severe Dehydration with Shock Dr. Shinjini Bhatnagar, Center forDiarrheal Disease and Nutrition Research
www.imtf.org/_uploads/emergency-wall-chart.doc
Treatment• give oxygen• give sterile 10% glucose (5 ml/kg) by IV• give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s
lactate with 5% dextrose; or half-normal saline with 5% dextrose; or half-strength Darrow’s solution with 5% dextrose
• measure and record pulse and respiration rates every 10 minutes
• give antibiotics
Treatment
If with signs of improvement:• repeat IV 15 ml/kg over 1 hour; then switch to
oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h for up to 10 hours. (Leave IV in place in case required again);
• Give ReSoMal in alternate hours with starter F-75, then continue feeding with starter F-75
TreatmentIf the child fails to improve after the first hour of
treatment (15 ml/kg),• assume that the child has septic shock. In this
case:• give maintenance IV fluids (4 ml/kg/h) while
waiting for blood,• when blood is available transfuse fresh whole
blood at 10 ml/kg• slowly over 3 hours; then begin feeding with
starter F-75 (step 7)
Treatment• A blood transfusion is required if: Hb is less than 4 g/dl or if there is respiratory distress and Hb is
between 4 and 6 g/dl• whole blood 10 ml/kg body weight slowly over 3
hours• child has signs of cardiac failure, transfuse packed
cells (5-7 ml/kg) rather than whole blood.
Thank you!