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Fluids and Rehydration
Maintenance Fluids (MIVF)
Why does maintenance ml/kg decrease?
MIVF
(ml/kg)
Decreased BSA/Volume ratio
Wt
Basic Concepts
- Includes insensible losses (Humidification of inspired air), urine output, and metabolism
- Estimated* as 100ml/kg/day for kg 1-10, 50ml/kg/day for kg 10-20, and 25ml/kg/day for kg >20
- Rounded to 4, 2, 1 ml\kg/hr
*Same as calorie requirements
Dehydration
What three individual factors are statistically associated with dehydration?
Capillary Refill
Skin Turgor
Abnormal Respirations
But did you know?
What one basic lab value has high Sensitivity for dehydration(low FN rate)?
Bicarb <18
Rehydration
- There are detailed equations to calculate fluid and electrolyte deficits
- However, with few exceptions* we usually begin rehydration with fluid boluses
*Sodium pathology-SIADH, DI, and Cerebral salt wasting
- Boluses are generally* 20ml/kg
*May use 10ml/kg or 5ml/kg in select cases when fluid overload is a concern-e.g. Cardiac disease, DKA
- Right amount of Fluid?
Rehydration
Enough; after 3 boluses though, consider other interventions
Referene: Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice
Guideline: Maintenance Intravenous Fluids in Children.
Pediatrics. 2018;142(6):e20183083
Ways to get fluids in
PIV
PICC
CL (Broviac EG) tunneled vs not
How fluids?
PO
NG/OG/ND
G-tube (GJ)
PIV
PICC
CL (Broviac EG) tunneled vs not
Port
IO
Hypodermoclysis
Rectal
What Fluid do I use?
Surgeon's fluid of choice.
Less acidotic.
Isotonic-Used for boluses.
Used to be more expensive
historically for MIVF
and now for Maintenance
Historically, the most common fluid in Peds has been 1/2 NS w/20meq KCl, however data indicates using isotonic fluids, i.e. NS or LR, is more appropriate, and it is now recommended to use those fluids firstline after 1m of age
Lets talk Fluids
3-4meq/kg/d
Maintenance
Na?
K?
Cl?
2-3meq/kg/d
2(Na) + glucose/18 + BUN/2.8
*Do not add KCl unless patient is peeing!
Example Problem
1yr infant presents with 2 days of vomiting and diarrhea. Is now 9kg, down from 10kg at last WCC. Admitted for dehydration and fluid resuscitation. What do you do next?
BMP Na is 132.
Need to calculate Na and fluid deficit.
Fluid deficit = weight loss, which in this case is 1kg
Example
If*-Na> 150 give 2-5meq Na/kg, correct over 48 hours
Na 130-150, give 7-11meq Na/kg, correct over 24hrs
Na < 130, give 10-14meq Na/Kg, give 1/2 over 8hrs, rest over 16hrs
*Correct hyponatremia and hypernatremia slowly to avoid central pontine myelinolysis and cerebral edema, respectively
FWD= {([Na+]high – 140) ÷ 140 }TBW1
Sodium deficit (meq) = Normal TBW * (140 - sNa)
TBW = Wt (kg) x 0.6 for males
TBW = Wt (kg) x 0.5 for females.
(8.4 mEq/L of sodium loss per 100 mL of water loss)
Why do we care about isotonic, hyper/hypotonic and correction of Na slowly?
Brain Serum
H2O
But why?
NaNa
Na
NaNa
Na
The Maths
Fluid Na K
Baseline Wt 10kg
MIVF
Deficit
1000ml 40 30
1000ml 85+40
The real Example
2000ml 165 40
Total(over 24hr)