CONSENSUS STATEMENTS ON PARENTERAL FLUID THERAPY IN INFANTS, CHILDREN, & ADOLESCENTS Task Force on Fluid and Electrolyte Therapy Philippine Pediatric Society, Inc. 2017| Disclaimer... Committee Members. Abbreviations. Definition of Terms... Summary Statements and Figures on Parenteral Fluid Therapy | Stakeholders... In Infants, Children, and Adolescents. PPS Consensus Statements on Parenteral Fluid Therapy -. General Considerations in Parenteral Fluid Therapy... Statements on Resuscitatior Statements on Rehydration and Redistribution Statements on Replacement.SUMMARY STATEMENTS ON PARENTERAL FLUID THERAPY IN INFANTS, CHILDREN, AND ADOLESCENTS ~ Always assess the ability of an infant, child, or adolescent to take in oral rehydrating fMuids. Ifthe individual cannot tole Fate, initiate parenteral fluid therapy. Atall times prior to the initiation of parenteral fluid therapy, assess the hydration status ofan infant, child, or adolescent using the following equation: Pre-illness weight (kg) — admission weight (kg) x 100 = (%) degree of fluid deficit Pre-illness weight (kg) If pre-illness weight data is unknown, assess the antecedent fluid deficit using the following guidelines: 3.1. If two or more signs including one major sign in column A are present, he has Mild Fluid Deficit. 3.2. If two or more signs including one major sign in colurnn B are present, he has Moderate Fluid Deficit. 33. If two or more signs including one major sign in column C are present, he has Severe Fluid Deficit M Skin turgor ‘Modified classification of dchpdration from WHO Clinical Pracice Guidlines on The Treatment of Diarrhoea, 2005 and NICE (Chica! Guideline on Diarrhoea and vomiig cused bypastroemeia: gros, aesimen and management chuldtor ome than 3 ears 2009 Ht 4. Measure serum sodium and blood glucose concentrations prior to the initiation of parenteral fluid therapy and at least 24 hours after or more frequently if the individual has biochemical abnormalities. Consider the following initial laboratory examinations if necessary: ‘Complete blood count BUN, serum creatinine, potassium, chloride Urinalysis Urine electrolytes Chest x-rayMonitor the following parameters: * _Pre-breakfast weight atleast every 24 hours pr git i Input, output, and fluid balance at least every & hours foguir |, Blood pressure at least every 4 hours or more frequently as needed YS4 Always use the pre-ilness weight in calculating for maintenance water and. clectrolyte requirements, and (luid deficit. If pre-illness weight is not available, it can be derived from the acral weight using the following formula: Pre-illness weight (in kg) = actual weight (in kg) x 100 100- (%) deficit Ina previously healthy and well-nourished infant, child or adolescent with moderate to severe uid deficit and requiring parenteral fuid resuscitation, use a dextrose-free crystalloid solution that contains sodium in the range of 130-154 mmol given asa Bolus dose of 20 mUkg in 5-20 minutes via “push-pull” technique using the largest bore catheter possible. = =~ {na previously healthy, well-nourished infant, child, or adolescent with fluid deficit requiring initia. Parenteral fluid rehydration, use a dextrose-containing crystalloid solution that has sodium in the range of 77-140 mmol/l with dail ly total volume computed as the sum of antecedent net deficit fluid Joss and maintenance water requirement. In a previously healthy, well-nourished infant, child, or adolescent with on-going fluid losses, attempt replacement via the enteral route first using reduced osmolarity oral rehydration solution/ORS (osmolarity 210-268 mmol/, glucose 75mmol/l, sodium 30-75 mmol/, potassium 20 mmol/l, chloride 65 mmoV/, citrate 10 mmol/l) to be given v volume per volume every 1-4 hours or until concurrent losses cease. . In a previously healthy, well-nourished infant, child, or adolescent on parenteral fluid for more than 24 hours, routinely assess the need for continued IVF therapy.ALGORITHM 1: FLUID THERAPY FOR*” MODERATE TO SEVERE DEFICIT RESUSCITATION PHASE. s Use a dextroseree crystalloid solution that contains sodium in the range of 130-154 mmol given as a bolus dose of 20 mikg in 5-20 minutes. via ‘push-pul” technique using the largest bore catheter © Mbd- ota en a i fu Tu ua COTTE YES | Proyide fuids and han i Coenen eG eee yah l (maximum of 60 mig in an Mahle Sof eleclytes per orem. D5 ofc nas Orie ; Deen 7 femw G tian REHYDRATION PHASE am POR + oF apo - D Stobid wha, Use a dextrose-contaning crystalloid solution that poe has sodium in the range of 77-140mmoll with daily E he hydentis, pe total volume computed as the sum of antecedent net Mileionl Res deft uid loss (Statement 3.1.3 and maintenance water requirement(Statoments 3.1.48 3.1.4.2in24 hours. ety De ea) deficit? ~ fers nr | OIE) Seek expert advise for intensive fuid Cray management and start vasoactive agents. Consider other causes of shock, Fluid-related refractory shock may be due to the following: ‘STABILIZATION PHASE t Sepsis Replace with reduced osmolarity ORS to be given volume per volume , AW T-hird-spacing / tamponade (Statement 4.1.1.) or a dextrose-free crystalloid solution that has sodium SY ‘Actrenal crisis in the range of 130-154 mmol if ORS not tolerated every 1-4 hours or Bleeding until concurrent losses cease.tk quit Discontinue any IV volume per volume replacement, or consider to? = If blood glucose is(iowyinfuse 2mikg of | | giving diuretics. ose DiaW over 5 minutss. If blood glucose Is high, reduce concentration of dextrose solution, REHYDRATION PHASE fa 6035" If the serum sodium_<_135_mmol Continue infusion of dextrose- 1p) Sorel decrease drip_rate ei 50-60% containing crystalloid solution that has { (Mi Mrantefence water requrement Cerca sodium in the range of 77-140 mmot/l Cr with daily total volume computed @s the ‘sum of antecedent net deficit fluid loss and maintenance water requirement in rate plus 30-50 mlkg x 48 for edvise 24 hours. ‘the patient to drink ad libitum. Na 2140 Discontinue parenteral fluids as soon as the individual is able to tolerate UR + Wefhy | «Fon Mea ‘ ALGORITHM 2: ASSESSMENT AND MONITORING Provide fuids and electrolytes per orem. Coon Creat erring rected crane Replace with reduced ‘osmolarity ORS to be siven volume per volume. (Statement 4.1.1.) REMOVAL PHASE Decrease sodium content of current parenteral fuid. Parnes ye maintenance water requirement via enter Or AeA Resear ieee) Ve (MB1, General considerations on parenteral 1.1 Always assess the abil the individual cannot tolerate, ity of an infant, child, or adoles tate parenteral fuid therapy: ——_ \uid therapy cent to take in oral rehydrating fluids. If 1 2, Atal times prior to the initiation of parenteral fluid therapy, assess the hydration status of an infant, child, or. adolescent the following equation: preilless weight (kg) - admission weight (ke) 100 = (&4) degree of fluid deficit Pre-illness weight (kg) 1.3.1f pre-liness weight data is unknown, assess the antecedent fluid defisit using the following guidelines: 13.1. If two or more sign Fluid Deficit. 1.3.2. Iftwo or more signs inc Fluid Deficit. ' including one major sign in column A are Juding one major sign i present, he has Mild .ncolumn Bare present, he has Moderate he has Severe 1.33. Iftwo or more signs including one major sien In column C are present, Fluid Defic eas ns D Slow Te , ‘Skin turgor ‘Normal 3 Capillary refill <2sec Increased Increased © [reine aan ae Tape’ | Dec toret_| Mucous membranes Day lips Dry Very dry. cracked Eyes Slightly sunken Sunken orbits Deeply " sunken orbits M Sensor Alert Irvitable Lethargic A Systolic blood pressure Normal Normal, orthostatic | Very low — | (© Peripheral pulse ‘Slightly rapid Rapid Rapid, weak ra — ___|_ Rapids we ij as Moderate ery thirsty oF Thirst Slightly increased eee t00 lethargic to Infrequent, , ae o infrequent, Urine output concented __ Markey decreased Anuria spa tnscanon of dedanon fom WTEO Chica Practice Guideline om The Treatment of aren Fi an Diarhoee and vom cased by gosroonterins dignosis asessment SS years, 2008 es ge ‘and management in children younger | Measure serum sodium and blood glucose concentrations pri i fluid therapy and at least 24 hours ‘ft or more eeqoaily primp fen ‘normalities. Consider the following initial laboratory examinations if necessary: — ‘© Complete blood count yr BUN, serum creatinine, potassium, chloride Urinalysis, Urine electrolytes Chest x-ray eee 1.5. Monitor the following parameters: « Pre-breakfast weight at least every 24 hours © Input, output, and fluid balance at least every 8 hours 5