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)
http://matrutvanikediae.blogspot.com/
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