fluid management at the er some practical tips. objectives □ initial fluid management of some very...

Fluid management at the ER

some practical tips

Objectives

□ initial fluid management of some very challenging ER disorders (perioperative cases and severe malnutrition in shock)

□ rationale

Hydration status. Normal clinical parameters.

sensorium Alert,awake,oriented

Heart rate N for age

Nature of pulses Full

crt < 2 sec

temperature Normothermic

Skin color Pink. No mottling/pallor

uo 1 – 2 cc/k/hr or 500 – 600 ml/bsa/24 hrs

BP N for age

examination 3% - 5% Mild dhn

6% - 10% Moderate dhn

10% - 15% Severe dhn

Skin turgor normal tenting Tenting

Skin by touch normal dry Clammy

lips moist dry Cracked

eyes normal Deep set Sunken

tears present reduced None

fontanelle flat soft Sunken

sensorium consolable irritable Obtunded

Pulse rate Normal to inc increased Very rapid

Pulse quality nomal Weak Non-palpable

crt nomal 2 – 3 sec > 3 sec

uo normal decreased anuric

Physiologic parameters of abnormal hydration status.

Berman (2000) and Oski (1999).

Fluid and electrolyte management

• Maintenance fluids + measurable losses + non-measurable losses

APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT INCHILDREN v 1.1 September 2007

Maintenance fluids + measurable loss + non-measurable loss

Holliday-Segar Method

first 10 kg 4 ml/k/hr

11 - 20 kg 2 ml/k/hr

>20 kg 1 ml/k/hr


• From tube drains (ogt, ctt, etc) + gastrostomy + urethral catheter + etc


Clinical state modifying factor

fever 0.13 per C >38 degrees

Simple trauma 0.20

Multiple trauma 0.40

Burns 0.5 – 1.0

electrolyte composition of body fluids

fluid Na (meq/L) k (meq/L) cl (meq/L) protein

gastric 20 - 80 5 - 20 100 - 150

pancreatic 120 - 140 5 - 15 90 - 120

small bowel 100 - 140 5 - 15 90 - 130

bile 120 - 140 5 - 15 80 - 120

ileostomy 45 - 135 3 - 15 20 - 115

diarrhea 10 - 90 10 - 80 10 - 110

burn 140 5 110 3 - 5 g/dL

sweat 10 - 30 3 - 10 10 - 35

Some commonly used fluids

solutions Na (mEq/L) K (mEq/L)

PLR/D5LR 130 4

PNSS 154

D50.45NaCl 77

D50.3NaCl 51

D5IMB 25 20

D5NM 40 13

D5NR 140 5

13

Fluids

plasma

Na (meq/L)

141

K

4

Mg

2

Buffer

bicarb

Ph

7.4

Osm

289

0.9%Nacl 154 5.7 308

LR 130 4 lactate 6.4 273

Normosol-R / plasmalyte

140 5 3 Acetate & gluconate

7.4 295

examination 3% - 5% Mild dhn

6% - 10% Moderate dhn

10% - 15% Severe dhn

Skin turgor normal tenting Tenting

Skin by touch normal dry Clammy

lips moist dry Cracked

eyes normal Deep set Sunken

tears present reduced None

fontanelle flat soft Sunken

sensorium consolable irritable Obtunded

Pulse rate normal increased Very rapid

Pulse quality nomal Weak Non-palpable

crt nomal 2 – 3 sec > 3 sec

uo normal decreased anuric

Physiologic parameters of abnormal hydration status.

Berman (2000) and Oski (1999).

POST OPERATIVE FLUID MANAGEMENT

i. Surgery, pain, nausea and vomiting are all potent causes of ADH release. Arecent NPSA alert has recommended that hypotonic fluids should not be used forpostoperative maintenance as this may cause hyponatraemia due to retention offree water released after metabolism of dextrose from the solution.


ii. Consensus was not agreed on the maintenance fluid rate in the postoperative period.Some would use the full rate as calculated using Holliday and Segar’s formula, whileothers would fluid restrict to 60-70% of full maintenance and additional boluses ofisotonic fluid given as required.

iii. In the postoperative period ongoing losses from drains or nasogastric tubesshould be replaced with an isotonic fluid such as 0.9% sodium chloride with orwithout added KCl.

iv. Losses should be measured hourly and replaced every 2 to 4 hours depending onthe amount.


MONITORING OF FLUID THERAPYi. Serum electrolytes do not need to be measured pre-operatively in healthychildren prior to elective surgery where IV fluids are to be given.

ii. Serum electrolytes need to be measured pre-operatively in all childrenpresenting for elective or emergency surgery who require IV fluid to beadministered prior to surgery.

iii. Children should be weighed prior to fluids being prescribed and given.

iv. Serum electrolytes should be measured every 24 hours in all children on IVfluids or more frequently if abnormal.

v. Although ideally children should be weighed daily while on IV fluids, practicallythis is difficult in older children, or those who have undergone major surgery.Use of a fluid input/output chart will help with fluid management.


www.imtf.org/_uploads/emergency-wall-chart.doc

Severe Dehydration with Shock Dr. Shinjini Bhatnagar, Center forDiarrheal Disease and Nutrition Research

www.imtf.org/_uploads/emergency-wall-chart.doc

Treatment• give oxygen• give sterile 10% glucose (5 ml/kg) by IV• give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s

lactate with 5% dextrose; or half-normal saline with 5% dextrose; or half-strength Darrow’s solution with 5% dextrose

• measure and record pulse and respiration rates every 10 minutes

• give antibiotics

Treatment

If with signs of improvement:• repeat IV 15 ml/kg over 1 hour; then switch to

oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h for up to 10 hours. (Leave IV in place in case required again);

• Give ReSoMal in alternate hours with starter F-75, then continue feeding with starter F-75

TreatmentIf the child fails to improve after the first hour of

treatment (15 ml/kg),• assume that the child has septic shock. In this

case:• give maintenance IV fluids (4 ml/kg/h) while

waiting for blood,• when blood is available transfuse fresh whole

blood at 10 ml/kg• slowly over 3 hours; then begin feeding with

starter F-75 (step 7)

Treatment• A blood transfusion is required if: Hb is less than 4 g/dl or if there is respiratory distress and Hb is

between 4 and 6 g/dl• whole blood 10 ml/kg body weight slowly over 3

hours• child has signs of cardiac failure, transfuse packed

cells (5-7 ml/kg) rather than whole blood.

Thank you!

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