FLUIDS ANDELECTROLYTES IN

PEDIATRICSInshirah qadri

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Objectives▪ To recognize of the proper procedure of peripheral IV

access in pediatrics. identify▪ To review types of IV fluids used in children.▪ To identify basics fluid maintenance and requirement of

fluid ,electrolyte, & nutrition according to age.▪ To identify of the proper procedure of IV-formula

preparation and administration in pediatrics.▪ To identify basic concept of fluid balance in pediatrics.▪ To recognize Common complication of IV therapy.

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Proper Procedure ofPeripheral IV Access in

Children• Important Concepts

• All procedures at a treatment room• The site selected for peripheral intravenous

perfusion depend on accessibility andconvenience.

• To Get Better IV access you can…• Number of IV access Attempts…

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Developmental Considerations• INFANT

• Handle infant gently, speak softly• Avoid arm used for thumb sucking• Hold immediately after insertion• Don’t feed immediately prior to insertion• Avoid presence of extra personnel to

minimize stranger anxiety

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Developmental Considerations• TODDLER/ PRESCHOOLER:

• Prepare child immediately prior toprocedure

• Give simple explanations in concreteterms

• Explain that you will help child hold still• Emphasize that the IV is not punishment

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DevelopmentalConsiderations• SCHOOL-AGER

• Prepare child ahead of time, but on theday of insertion only

• Give the child choices as appropriate• Give positive reinforcement after

completion

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DevelopmentalConsiderations

• ADOLESCENT

▪ Prepare teenager several hours to a daybefore procedure

▪ Approach discussions on a more adultlevel

▪ Discuss fears related to procedure▪ Include teenager in decisions

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Pediatric Optimal Locations• Hands• Forearm• Feet• Scalp

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Pediatric Catheter Gauges• Use the largest catheter you can successfully insert• Catheter Sizes:

Newborn: 24, 22 gaugeInfant < 1 year: 24, 22 gauge1 – 8 years: 22, 20, 18 gauge8 years and older: 20, 18, 16 gauge

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EMLA Cream• EMLA Cream is a topical anesthetic• Minimizes or prevents pain from needle puncture for an

IV, blood sample, or implanted port access.• Apply EMLA cream to the selected site 60 minutes before

the procedure.• Cover at least two sites in case the first attempt is not

successful.

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Basic Concept :-Osmotic Pressure

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Basic Concept :-Osmolality of the bloodIsotonicity of Blood ~ 275-315 mOsm/L

• Solutions having the same osmotic pressure asthat of blood are said to be isotonic with blood.

• Solutions with a higher osmotic pressure thanbody fluids are called hypertonic

• Solutions with a lower osmotic pressure arecalled hypotonic.

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Types of IV fluids in children▪ 5% glucose in water (G/W or D/W)▪ G/W 10%, 20%.Give only via a central line as 1-2ml/kg bolus for hypoglycemia.

Monitor blood glucose▪ 25% or 50% glucose in water

Never as an infusionOnly used in NICU and at low vol. e.

g.: 1-2mls/hr via central line

▪ 0.9% NaCl(Normal Saline)

▪ 0.45% NaCl

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Types of IV fluidsCont….▪ Glucose saline; G/S (G/W+ electrolytes)

different concentration of electrolytes, but all prepared in5% G/W

▪ G/S; 0.18% ,fifth (1/5 ) NaCL▪ G/S; 0.45%, half (1/2 ) NaCL

G/S 0.18% , G/S0.45%: Pediatric formulas most commonused in pediatric floors.

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Types of IV fluids Cont….⚫ Ringer Lactate :

0-10 gram glucose/100ccNa 130 mEq/LNaHCO3 28 mEq/L as lactate

K 4 mEq/L273 mOsm/L

⚫ Water for injection

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IVF - basic ConceptsCorrect :▪ Patient Name▪ Type▪ Dose▪ Route▪ Check IV site▪ Time▪ Documentation

IVF Calculation: according to the setFlow rate =total volume X dropping factor time in minutes

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IV formulas – Practice

• Microdropper

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Maintenance Electrolyte Requirements

• Maintenance KRequirements:

1-2 mEq/100ml /day OR 1-2mEq/kg/day

• Maintenance CaRequirements:

IV: 60 to 100 mg/kg/day

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Daily Nutritional RequirementProtein

(g/kg/d)Calories

(kcal/kg/d)Age

1.5601-3days2.712010 days

1.6-21253- 12mo.1901- 4Yr

0.9804 -7Yr0.9707 - 10Yr0.86013 - 18Yr0.850Adult

1 gm glucose = 3.4 calorie inIVF

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Calculation of Maintenance FluidRequirements…the Holliday-Segar

Method

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Calculation of Maintenance FluidRequirements…

A 9 –kg child would require ?14- kg child would require ??A 32-kg child would require???

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Examples

• Weight

8Kg

15Kg

27Kg

• Maintenance fluid

100ml/Kg/day=800ml/day

1000ml+(50ml/kg*5)=1000+250=1250 ml/day 1500ml+(20ml/Kg*7)=1500+140=1640 ml/day

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Class activity• A 7 –kg child would require ?

• 13- kg child would require ??

• A 34-kg child would require???

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Phase I: Resuscitation usingIsotonic Fluids (NS/LR) at 20ml/kg.

Re-evaluation until urine outputand dehydration signs improved

Phase II: Calculate maintenance &deficit fluid

Determine if Isotonic, Hypotonic orHypertonic Dehydration

HypotonicNa <130

Isotonic130< Na <150

HypertonicNa >150Replace

fluids over48hrs**

Deficits28

Resuscitation phaseGoal: Restore circulation, re-perfuse brain, kidneys

▪ Mild-Moderate 20 mL/kg bolus given over 30 – 60 minutes.

▪ Severe May repeat bolus as needed (ideally up to60ml/kg)Fluids – something isotonic such as Normal saline (NS) orlactated ringers (LR)

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Replacement PhaseStabilization Phase

(For Isotonic/Hypotonic Dehydration)• Goal: Replace deficit of fluids and electrolytes according

to Holliday Segar formula

ReplacementPhase1st 8 hrs

Stabilization PhaseNext 16 hrs

MIVF andMaint Na

1/3 2/3

Deficit Fluid &Deficit Na

1/2 1/2

Kathleen Asas, MD.MPH

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Clinical signs Mild Moderate Severe

Thirst Slight Moderate Intense

Behavior Alert, restless Irritable to touchmaybe lethargic

Hyperirritable tolethargic, maybecomatose

Mucus membrane Normal Dry Very dry

Tears Present +/- Absent

Eyes Normal Sunken Grossly sunken

Skin elasticity(pinch retracts)

Immediately Slowly Very slowly

Skin color Normal Pale Mottled or gray

Anterior fontanelle Normal Sunken Very sunken

Weight loss 3-5% 8-10% 12-15%

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CaseOmer admitted to pediatric floor as case of dehydration ,mother said baby had poor sucking and hypoactivity ,weight loss 2 kg , current weight 12kg .

▪ Identify the level of dehydration▪ Calculate the fluid deficit.▪ Calculate replacement phase(1st 8 hrs).▪ Calculate Stabilization Phase(Next 16 hrs).▪ Calculate micro-drop of fluid deficit for both phases.▪ Write additional signs of dehydration.

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Fluid deficit …… Case answer

Level of dehydration= Wt. loss/ Wt.× 100% 2/14 × 100% =14.3% Severe dehydration

Fluid Loss(L)= current Wt. (Kg) × % dehydration 12kg × 0.143 = 1.72 L × 1000Resuscitation phase 12 × 20 =240mL over 30 or 60 min 1720 - 240 = 1480 mL Fluid Maintenance 10 × 100 + 2 x 50 = 1100mL

• Replacement Phase

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Case answer• Replacement Phase(1st 8 hrs)1/3(Fluid Maintenance) + ½ (Remain fluid deficit)1/3 × 1100 mL + ½ × 1480 mL= 366mL + 740 = 1106 mL /8hrs

1106 mL / 8 hr = 138 mL/hr →138/60x60=138microdrop/min

• Stabilization Phase(Next 16 hrs) 2/3(Fluid Maintenance) + ½ (Remain fluid deficit) 2/3 × 1100 mL + ½ x1480 mL = 733 + 740 mL = 1473mL /16 hrs

• 1473mL / 16 hr = 92mL/hr → 92/60x60=92microdrop/min

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Case answer• Intense thirst , Hyperirritable to lethargic, maybe

comatose, mottled or gray of skin color & poor elasticity, very dry mucus membrane, grossly sunken eyes & absent

tears, Very sunken anterior fontanel if less 2years old,

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Common complication of PediatricIV therapy

• Mechanical factors shorten IV infusion dwellingtime

Insertion siteLength of catheterSize of vesselVessel fragilityActivity level of the patientForceful administration of boluses of fluidInfusion or irritants through small vessels.

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I. Infiltration :- accumulation of fluid inthe tissue surrounding an IV needle site.

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Cause :- penetration of the vein wall by the needle.

Signs & symptoms:-1� Flow rate may or may not be slow OR no flow of

solution .2� Infusion site is cool & hard to touch.3� Patient complain of pain, tenderness, burning or

irritation at infusion site.4� Fluid leaking around infusion site.

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Common complication of IVtherapy cont….Corrective actions:-1� Stop IV infusion immediately & remove needle.2� Elevate extremity.3� IF noticed within 30 minutes of onset apply ice to the

swelling.4� IF noted later than 30 minutes of onset, apply warm

compresses to encourage absorption.5� Notify supervisor about infiltration.6� Restart IV in another location.7� Document observations & actions.

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Common complication of IVtherapy cont….

II. Phlebitis:- (inflammation of the wall of thevein)

Causes:-1� Injury to the vein during puncture.2� From later needle movement.3� Irritation to vein as a result of long –term therapy.

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Signs and symptoms:-1� Swelling around the infusion site.2� Patient complains of pain and tenderness.3� Redness and warmth along the vein.

Correctives actions:-1� Stop IV infusion immediately.2� Report observations to supervisors.3� Document observations and actions.

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III. Air embolism :-The obstruction of blood vessels usually occurring

in the lungs or the heart by air carried via theblood stream.

❖ Causes:-1� Failure to remove air from tubing.2� Allowing the solution to run dry.3� Disconnected IV tubing.

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Signs & symptoms:-1� Weak, rapid pulse.2� Cyanosis.3� Chest pain.

Corrective actions:-1� Notify supervisor & physician immediately.2� Immediately place patient on Lt side with feet elevated

to allow the pulmonary artery to absorb small airbubbles.

3� Administer O2 as needed.

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Common complication of IVtherapy cont….IV. Circulatory over load:- An increased blood volume resulting from

excessive IV fluid being infused too rapidlyinto the vein.

Causes:-1. Fluid delivered too fast.2. Reduced kidney function.3. Congestive heart failure or cardiac

insufficiency.

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Signs & symptoms1. High blood pressure.2. Distended neck veins.3. Rapid breathing, shortness of breath, tachycardia.4. Fluid intake is much greater than urinary out put

(positive balance).

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Corrective actions:-1. Decrease flow rate.2. Place the patient in semi-sitting position to

facilitate breathing.3. Notify supervisor immediately.4. Record observations & actions taken.

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Common complication of IVtherapy cont….

V . InfectionCauses:-1. Use of contaminated equipment.2. Poor aseptic technique.3. Contaminated site or IV equipment not

changed regularly.

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Signs & symptoms:-1. Redness, swelling & soreness around IV site.2. Sudden rise in temperature & pulse.3. Drainage from IV site.

Corrective actions:- 1.Notify supervisor immediately.

2. Discontinue IV & take culture of wound toidentify pathogens present.

3. Use strict aseptic technique when cleaning &dressing the wound.

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END LECTUREThank you

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