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Fluid Management: Joe Langton
Fluid Management: Joe Langton
Joe Langton
Learning outcomes
– So if trying to give 10 ml / hr
– This is 10 ml x 60 drops = 600 drops per hr
– Which is 600 drops per 60 minutes = 10 drops per minute
– So the IVI should be dropping 10 drops per minute
– This is 1 drop every 6 seconds
Severe dehydration
• Rapid IV rehydration with Ringer’s lactate or 0.9%
saline
First give 30ml/kg in: Then give 70ml/kg in:
< 12 months old 1 hour * 5 hours
≥ 12 months old 30 minutes* 2 ½ hours
* Repeat again if radial pulse is still very weak or not detectable
Dehydration
Severe dehydration
• Reassess every 15-30 minutes
• Hydration status not improving → give drip more rapidly
• As soon as the child can drink give ORS (~5 ml/kg/hr)
– Usually after 3 - 4 hours in infants or 1 - 2 hours in children
• If normally breastfed encourage the mother to continue
frequently
• Reassess
– Infant after 6 hours
– Child after 3 hours
• Then chose the appropriate management plan
– Severe / some / no dehydration
Dehydration
Some dehydration
• Give recommended amount of ORS over a 4 hour
period
Age < 4 months 4 – 12 months 12 – 2 years 2 – 5 years 5 – 15 years
Weight <5 kg 5 - 8 kg 8 - 11 kg 11 - 16 kg 16 - 50 kg
In ml 200 - 400 400 - 600 600 - 800 800 - 1200 1200 - 2000
Dehydration
Some dehydration
• Show the mother how to give the ORS
– < 2 years a teaspoonful every 1-2 minutes
– > 2 years frequent sips from a cup
• If the child vomits
– Wait 10 minutes, then resume ORS more slowly
• Advise breastfeeding mothers to continue
• Reassess after 4 hours, checking for signs of
dehydration
Dehydration
No dehydration
• Give extra fluid
• Breastfeed frequently and for longer at each feed
• If being exclusively breastfed, give ORS in addition
• In non-exclusively breastfed children give ORS / food based
fluids (soup, rice water, yoghurt drinks) / clean water
• Cold hands
• Capillary refill > 3 seconds
– Apply pressure to nail bed for 5 seconds
– Release and observe time for pink colour to return
• Weak pulse and tachycardia
= SHOCK
Managing shock
• Give oxygen
• Establish IV / IO access
• Give fluids
Managing shock WITHOUT malnutrition
20 ml / kg Ringer’s Lactate or 0.9% Saline as fast as possible
Reassess circulation No improvement
Marasmus
• Look at arms, legs, chest, buttocks
• Appears to be ‘skin and bone’
• Skin looks too large for body
• Head may appear large
Assessing for malnutrition
Kwashiorkor
• Oedema of both feet
– Press top of foot gently with thumb
– Look for a definite dent in tissues
Other signs
• Thin, sparse, depigmented hair
• Peeling skin rash (‘flaky paint’)
Managing shock WITH malnutrition
• General principles
• Weigh the child
• Monitor for hypoglycaemia
• Avoid IV fluid if possible
• Monitor closely for signs of cardiac failure/ increasing respiratory
distress/ worsening oedema
• Start oral fluids and F75 when able (10 ml /kg/hr for up to 10
hrs)
Managing shock WITH malnutrition
• If no improvement after first 15 ml/kg the child is
probably septic rather than dehydrated
• Start antibiotics
Neonates
Fluid management in neonates
• Encourage breastfeeding frequently to prevent hypoglycaemia
• If unable to feed give EBM via NGT
• Increase the amount of fluid given over the first 3-5 days
(total amount oral and IV)
– Day 1 60ml/kg/day
– Day 2 90ml/kg/day
– Day 3 120ml/kg/day
– Then increase to 150ml/kg/day
Scenario 1
• 30 kg girl presented with a history suggestive
of acute gastroenteritis
• On examination
– Lethargic
– Sunken eyed
– Skin turgor = 3 seconds
Scenario 1
• What type of dehydration?
– Severe dehydration
• How much fluid are you going to give and over what time
frame?
– 30ml x 30 kg = 900 ml over 30 minutes
• How much fluid are you going to give and over what time
frame?
– 15 ml x 6.5 kg = ~100 ml over 1 hr
Scenario 2
• After 1 hour you reassess
– The child is more awake
– The hands are warmer
– The CRT is 2 seconds
– The radial pulse is palpable
– RR 40, HR 150