Pediatrics Fluid and Electrolyte

Prepared by :
NURUL HADAWIAH BINTI MISRAN
ADPN 2/2019 (K)-0050
SILAH HAYATI BINTI ROMLI
ADPN 2/2019 (K)-0054
 Learning Outcome
• Describe assessment on hydration status of
child.
• Demonstrate calculation and administration of
fluid maintenance/Resuscitation
 Well children with normal hydration

• Children who are well rarely require intravenous fluids (IV)

• Whenever possible, use an enteral (oral) route for fluids
• These guidelines apply to children who are unable to
tolerate enteral fluids
• The safe use of IV fluids therapy in children requires
accurate prescribing of fluids and careful monitoring
because incorrectly prescribed or administered fluids are
hazardous
• Iv fluid therapy is required then maintenance fluids
requirements should be calculated using the Holliday and
Segar formula based on weight.
 Continue.

• However this should be only be used as a starting point

and the individual’s response to fluid therapy should be
monitored closely by
- clinical observation
- Fluid balance
- Weight
- Minimum daily electrolyte profile
 Prescribing intravenous fluids

Fluids are given intravenously for the following reasons:

• Circulatory support in resuscitating vascular collapse.
• Replacement of previous fluid and electrolyte deficit.
• Maintenance of daily fluid requirement.
• Replacement of ongoing losses.
• Severe dehydration with failed nasogastric tube fluid
replacement (eg. Ongoing profuse losses, diarrhoea or
abdominal pain)
• Certain co-morbidities particularly GIT conditions (short
gut or previous gut surgery )
SOLUTION/IV DRIP
Continue.
1. For resuscitation
• Bolus
• 0.9% Sodium Chloride
• Alternatively and ONLY under direction of specialist:
other crystalloids, e.g. balanced salt solutions or
colloids may be used
2. For replacement
• Dehydration or ongoing losses
• 0.9% Sodium Chloride for Ringer’s/ Hartmann’s
solution
Continue.

3. For maintenance
• 0.9% Sodium Chloride + 5% Glucose +/- Potassium
Chloride 20mmol/L
• Alternatively and ONLY under direction of specialist:
0.45% Sodium Chloride + 5%% Glucose +/- Potassium
Chloride 20mmol/L or balanced solution
Clinical manifestations of dehydration
Manifestation Isotonic (loss of water Hypotonic (loss of salt Hypertonic (loss of
and salt) in excess of water) water in excess salt)
Color Gray Gray Gray
Temperature Cold Cold Cold or hot
Turgor Poor Very poor Fair
Feel Dry Clammy Thickened, doughy
Mucous membrane Dry Slightly moist Parched
Tearing and salivation Absent Absent Absent
Eyeball Sunken Sunken Sunken
Fontanel Sunken Sunken Sunken
Body temperature Subnormal or elevated Subnormal or elevated Subnormal or elevated
Pulse Rapid Very rapid Moderately
Respiration Rapid Rapid Rapid
Behavior Irratable to lethargic Lethargic or comatose, Marked lethargy with
convulsions extreme
hyperirritability on
stimulation
Sunken Fever
fontanelle

Sunken eyeball
 MILD MODERATE SEVERE
Weight loss
Infants 3%-4% 6%-8% > 10%
Child 3%-5% 6%-8% 10%

Pulse Normal Slightly Increased Very increased

Respiratory Normal Slightly Hyperpnea (deep-
tachypnoea(rapid) rapid)
Blood Pressure Normal Normal to Orthostatic to shock
orthostatic
Behaviour Normal Irritable, more Hyperirritable to
thirsty lethargic
Thirsty Slight Moderate Intense
Mucus Membrane Normal Dry Parched

Anterior Fontanel Normal Normal to sunken Sunken

Tear Present Dry Absent

Skin CRT >2sec CRT (2-4 SEC) CRT >4 SEC
Resuscitation

Fluids appropriate for bolus administration are:

crystalloids 0.9% Normal Saline

Ringer’s Lactate @
Hartmann,s solution.
Sterofundin ,
Plasmacytes
Colloids Gelafundin
4.5% albumin solution
Blood products Whole blood, blood
components
Continue.

• Fluid deficit sufficient enough to cause impaired tissue

oxygenation
• Always reassess circulation – give repeat boluses as
necessary.
• Look for the cause of circulatory collapse – blood loss,
sepsis, etc. this helps decide on the appropriate
alternative resuscitation fluid
• Fluid boluses of 10mls/kg in selected situations – eg.
Diabetic ketoacidosis intracranial pathology or trauma
• If associated cardiac conditions, the use aliquots of 5-
10mls/kg
 Continue.

• Avoid low sodium-containing (hypotonic) solutions for

resuscitation as this may cause hyponatremia
• Measure blood glucose: treat hypoglycemia with 2mls/kg of
10% Dextrose solution.
• Measure Na, K and glucose at the beginning and at least 24
hourly from then on (more frequent testing is indicated for ill
patients or patients with co-morbidities). Rapid results of
electrolytes can be obtained from blood gases
measurements.
• Consider septic work-up or surgical consult in severely
unwell patients with abdominal symptoms (ie.
gastroenteritis)
 Fluid Maintenance

• Maintenance fluid is the volume of daily

fluid intake. It includes insensible losses
(breathing, perspiration and in the
stool),and allows for excretion of the daily
production of excess solute load (urea,
creatinine, electrolytes) in the urine.
• 0.45% sodium chloride +/- glucose 5%
may be used as maintenance fluid and is
restricted to specialized area.
• Children at high risk of hyponatremia should be given
isotonic solutions(0.9% saline± glucose) with careful
monitoring to avoid iatrogenic hyponatremia.
• These include children with:
 Per-or post operative
 Require replacement of ongoing losses
 CNS infection
 Head injury
 Bronchiolitis
 Sepsis
 Excessive gastric or diarrhoeal losses

Peadiatric Protocol 4th edition page 27

 Calculating of Maintenance Fluid
Requirements

*Holliday –Segar Calculator

 Intravenous therapy
calculation of required therapy
1. Fluid deficit
* fluid deficit (mls)= percentage dehydration x body
weight in grams
2. Maintainence fluid therapy
* type of fluid solution :
1/5 saline 5% dextrose or ½ saline 5% dextrose with or
without added KCL
* volume of fluid required:
<6 mo 150 mls/kg/d
6-12 mo 120 mls/kg/d
Continue

• More than 1 year

* 1st 10 kg = 100 ml/kg
* 10-20 kg = 1000 ml for first 10 kg + 50 ml/kg for next
10 kg
* >20 kg = 1500 ml for first 20 kg + 20 ml/kg for any
subsequent kg
• Resuscitation
* if in shock give normal saline/Ringer’s lactate 20
ml/kg iv over 30 min to 1 hour and repeat necessarily till
perfusion improves
 Deficit

• A child’s water deficit in mls cab be calculated following an

estimation of the degree of dehydration degree of dehydration
expressed as % of body weight.
• Example: A 10kg child who is 5% dehydration has a water
deficit of 500mls.
• Maintenance
100mls/kg for first 10 kg = 10 × 100 = 1000mls
Infusion rate/hour = 1000mls/24 hr = 42mls/hr
• Deficit (give over 24hours)
5% dehydration (5% of body water): 5/100 × 10kg × 1000mls =
500mls
Infusion rate/hour (given over 24 hrs) = 500mls/24 hr = 21mls/hr
 On going losses

• Example from drain, ileostomy, profuse diarrhoea.

• These are best measured and replaced. Any fluid
losses>0.5ml/kg/hr needs to be replace.
• Calculating may be based on each previous hour,or
each 4 hour period depending on the situation.Eg
200mls loss over the previous 4 hours will be
replace with a rate of 50mls/hr for the next 4hours
CONTINUE

• Ongoing losses can be replaced with 0.9%

Normal saline or Hartmann’s solution.
• Fluid loss with high protein content leading to
low serum albumin.(eg:burn) can be replace
with 5% hUman albumin.
 QUESTION
1.An 18 month old girl with a 2 day history of vomiting,
diarrhea and decreased oral intake, is seen in clinic, doctor
estimate her to be 5% dehydrated. Doctor order to give IVD
N/saline maintenance and replacement in 24H.
a) Calculate the maintenance drip and replacement to A,
using Holliday Segar calculator.
b) Describe your responsibility when administering iv drip
to patient.
 REFFERENCE
• https://mpaeds.my/paediatric-protocols-for-m
alaysian-hospitals-4th-edition-2019/
• Chattri GL (2010),Pediatric Drug
Doses,USA:Jaypee Brothers Medical Publishers
(P) Ltd.
• Hockenberry, MJ,& Wilson, D.( 2015).Wong ‘s
Nursing care of infants and children (10th
ed.).Canada; Elsevier.