Medical Affairs

Department of Pediatrics

Clinical Practice Guideline

FLUID THERAPY IN PEDIATRICS

Document # PEDS-GENERAL # 004

Date CPG Formulated Oct 2007

Date CPG Reviewed June 2009

Next Review Date June 2011

Scope:
All facility and personnel managing children (less than 15 years) with dehydration.

Aim:
To unify and co-ordinate care of children presenting with dehydration across Tawam Hospital medical facilities, among
personnel with different level of training.

Indication:
Children under treatment of Dehydration.

Background:
™ Total body water forms 60% of B.Wt. in which 40% intracellular ( IC) & 20% extra cellular (EC) which is further
divided to 15% interstitial & 5% intravascular.

™ Cellular membrane forms the barrier between the E C & I C which is freely permeable to water but impermeable to
electrolyte & protein except by active transport.

™ Vascular endothelium forms the barrier between intravascular & interstitial which is freely permeable to water &
electrolyte but impermeable to protein.

™ Two forces regulate fluid movement; Hydrostatic & Oncotic pressure.

™ Parenteral fluid is generally designed to have an osmolality that is either close to plasma osm.(285) or greater.

Type of fluid therapy:

1.Oral ;can be given by mouth or through NG.
2.Parenteral ; can be given IV or IO.

Oral Rehydration ;
Indication ; Mild dehydration, moderate dehydration if no persistent vomiting &even can be tried in sever dehydration
after giving the bolus.
Amount ;
Mild dehydration; 50 ml/kg 4-6 hrs.
Mod. Dehydration; 100 ml/kg 4-6 hrs.
In addition to 10 ml/kg of ORS for each diarrhoeal stool as replacement for ongoing loss regardless of the degree of
dehydration.
Parenteral therapy;
1. Crystalloid : 0.9% NS, Ringer lactate.
2. Colloid : Albumin 5%, FFP.
3. Synthetic colloid: Dextran.

Na Cl K Ca lactate
mEq/L mEq/L mEq/L mEq/L mEq/L
0.9% Na 154 154

0.45% NS 77 77

0.22% NS 38.8 38.8

Ringer lact. 130 109 4 3 28

Rehydration phases:
1. Initial or emergency therapy (bolus);
Indication: whenever there is impairment of perfusion.
Amount : 20 ml/kg of 0.9% of NS within 20-30 min. and can be repeated up to 60 ml/kg (until intravascular
volume restored).
2. Deficit therapy;
Indication: whenever there are signs of dehydration.
Amount : calculated as (% of dehyd. X BWt in kg X 10).
Eg. For 20 kg of 10% deficit = 10 x20 x 10 = 2000 ml.

3.Maintenance therapy;
Indication: to patient who can not be fed enterally or on NPO eg. Pre op.
Amount : calculated as follow;
™ Per BWt
1St 10 kg 100 ml/kg 4 ml/kg/hr.
2nd 10 kg 50 ml/kg 2 ml/kg/hr.
any kg>20 20 ml/kg 1 ml/kg/hr.

™Per body surface area(BSA)

1500 ml/m2
SA = (BWt x 4) + 7 or BSA = √ Height(cm) x Wt(kg)
BWt + 90 3600
Maintenance fluid : D5% 0.22 NS + 20 mEq/L kcl 0r D5% 0.45NS + 20 mEq/l kcl.

Monitoring during rehydration:

Looking mainly for signs of under hydration or over hydration.

™ Physical assessment;
- Vital signs (HR, Bp, and peripheral perfusion).
- Mucous memb., skin turgor.
- Level of consciousness.
™ Urine output; adequate fluid resuscitation is indicated by a urine production rate of 1 – 2 ml/kg/hr.
™ BWt.
™ Lab. Tests; S. electrolytes after 4 – 6 hrs.
™ Reassessment is required.
Fluid management of Hypo & isonatremic dehyd.
1. Basic work up (UEG, CBC).
2. Hyponatremic dehyd.(S.Na < 130 mEq/l), Isonatrmic (S.Na 130 – 150 mEq/l).
3. Restore intravascular vol. by 20 ml/kg 0.9% NS over 20 – 30 min.(repeat till
Intravascular vol. restored).
4. Calculated 24 hrs. water & electrolyte
Total = maintenance + deficit
5. Use D5% 0.45 NS with 20 mEq/l kcl.
6. As a general rule KCl should only be added after urination.
7. Administered ½ the calculated fluid during the 1st 8 hrs. After subtracting any boluses from this amount, the
remainder over the next 16 hrs.
8. Replacement of the ongoing loss i.e stool vomits usually by 0.45 or 0.9 NS + kcl in equal volume to the previous
1 – 4 hrs. Loss.
 Fluid therapy in hypernatremic dehyd.
™ S.Na > 150 mEq/l
™ Rehyd. Should be slow over 48 hrs. Aiming to reduce S.Na NOT MORE THAN 10 mmol/l/day.
™ Total fluid needed ;
- Bolus if required by 0.9% NS.
- Deficit + (2 days maintenance) + ongoing loss if needed.
™ Constant rate over 48 hrs.
™ Type of fluid; D5% 0.22NS + kcl.
Fluid therapy in burn
™ Needed if > 10% SA burned.
™ Day one: ringer lactate (4 x % burned SA x BWt) + maintenance.
™ ½ over first 8 hrs. (From onset of burn) the other ½ over next 16 hrs.
™ Children < 5 years may require the addition of 5% dextrose in the 1st 24 hrs.
™ Day two: 50% of day one of fluid requirement as ringer lactates in 5% dextrose.
™ Urine output should be between 1 – 1.5 ml/kg/hr.
™ No kcl should be added to the fluid for first 48 hrs.
Fluid therapy in established acute renal failure
™ Place the patient on insensible fluid loss (1/3 maintenance or 400 ml/m2/24hrs. + An amount of fluid equal to
urine output for that day.
™ Glucose containing sol. Eg. D10% without electrolytes are used.
Fluid therapy in SIADH
™ Intracranial pathology eg head injury.
™ Pulmonary pathology: IPPV, asthmatic attack.
™ Hyponatremia, low plasma osmolality, hypertonic urine, urinary Na >20mmol/L.
™ Fluid restriction to 2/3 maintenance.

Referance
1-Robert KB: fluid and electrolytes: parenteral fluid therapy.
Pediatr Rev 2001:22:112.
2-Oral rehydration / emergency physicians and practice paramerers.
Pediatrics 2002:109.259-61
3-AAP: practice parameter. The management of acute gasteroenteritis in young children. Pediatrics
1996:97:424-43
4-Fleisher G Ludwigs: textbook of pediatric emergency medicine, Baltimane Willams and Wilkins 2000
5-The Advanced life support Group 2001 ,The practical approach . 3rd edn. BMJ publishing Group
Prepared by Dr. Hussein Matlik, Specialist paed, MRCPCH, CABP, DCH.

Approval:

Name Signature Date

Head of the Department: Dr. Walid Kaplan

Other Involved Department Head/Manager:

Dr. Hussam Bakrli
Chief Medical Officer Dr. Riad Abdulkarim
Reviewed By Johns Hopkins Member:
Yes No

Johns Hopkins Member