Intravenous Fluid Management Guideline for Paediatric Patients, Lecture notes of Medical statistics

Download Intravenous Fluid Management Guideline for Paediatric Patients and more Lecture notes Medical statistics in PDF only on Docsity! Intravenous fluid management of paediatric patients Subject: Intravenous fluid management of paediatric patients Policy Number N/A Ratified By: Clinical Guidelines Committee Date Ratified: March 2008, reviewed March 2010, re- viewed with no change July 2014, reviewed with changes July 2016. Version: 3.0 Policy Executive Owner: Dr Neeta Patel Designation of Author: Dr Neeta Patel, Consultant Paediatrician and Clinical Director for Children and Young Persons ICSU Dr Sakaria Ali, Paediatric Registrar Name of Assurance Committee: As above Date re-issued: July 2016 Review Date: 3 years hence Target Audience: All staff involved in intravenous fluid admin- istration to paediatric patients (1 month – 16 years) Key Words: Intravenous fluids, hyponatraemia Version Control Sheet Version Date Author Status Comment 1.0 March 2008 Dr N Patel Off line New guideline approved at CGC 2.0 March 2010 As above Off line Reviewed with minor amendment 3.0 July 2014 As above Off line Reviewed as part of Paediatric speciality guideline review. No change required other than transposing into current template. 4.0 June 2016 Dr Sakaria Ali Dr Neeta Patel LIVE Reviewed and updated in line with current NICE guidance New chart for infants aged less than 3 months Page 5 Patient weight mls/day mls/hour 3 to 10kg 100 x wt 4 x wt 10 - 20kg 1000 plus 50 x (wt-10) 40 plus 2 x (wt-10) >20kg 1500 plus 20 x (wt-20) 60 plus 1 x (wt-20) 100mls/hour (2500mls/day) is the normal maximum amount B. In unwell children Maintenance fluid volumes may need to be adjusted in unwell children They may need less maintenance if:  Inactive (e.g. lying in a hospital bed )  There is excessive secretion of ADH (eg pneumonia, meningitis, bronchiolitis, head injury, post-operative ) They may need more maintenance if:  They have a persistent high fever  They are unable to concentrate urine (diabetes insipidus, sickle cell disease and some renal conditions) Page 6 Which maintenance fluid to use? If children need routine maintenance fluids use Isotonic solution such as 0.9% sodium chloride with 5% glucose +/- 20mmol KCL/1Litre bag • Measure plasma electrolytes when starting iv fluids for routine maintenance (except before most elective surgery), and at least every 24 hours thereafter. • Base any subsequent iv fluid prescriptions on the plasma electrolytes and blood glucose measurements. • Weigh before starting iv fluids and daily while continuing on iv fluids. • Document accurate fluid balance daily. • Stop fluids and check plasma electrolytes if clinical signs suggestive of hypo- natraemia develop. These features include nausea, vomiting, headache, irri- tability, altered level of consciousness, seizure and apnoea. Call for senior help Glucose replacement Maintenance fluids for children should include glucose. Less or no added glucose may be appropriate in children with high blood glucose levels which may occur with certain stresses e.g. severe infection, brain injury. The amount of glucose given in these circumstances must be guided by blood glu- cose levels. Potassium replacement Most infants and children on maintenance fluids will need potassium replacement. Generally 20mmol potassium chloride per 1L bag will be adequate (although this may have to be adjusted according to U&E results) Page 7 This is a single calculation /estimate of the amount of fluid lost before treatment has begun. (excluding any volume given to treat initial hypovolaemic shock) It can be calculated by making a clinical estimation of the degree of dehydration as expressed as a percentage of body weight: Example: Fluid deficit (L) = % dehydration X pre-illness weight (kg) /100 e.g: a 10kg child who is 5% dehydrated has a water deficit of 500mls Or based on pre illness and current weight if available: Example: Fluid deficit (L) = pre illness weight (kg) – current weight (kg) Note: Replacement may be rapid in most cases of gastroenteritis (although usually this is best achieved by oral or nasogastric fluids), but should be slower in diabetic ketoaci- dosis and meningitis, and much slower in states of hypernatraemia (aim to rehydrate over 48 hours, the serum sodium should not fall by >1mmol/litre/hour). ➢ Fluid deficit Which fluid to use to replace deficit? 0.9% sodium chloride +/- 5% glucose If both maintenance and deficit replacement is required use 0.9% sodium chlo- ride with 5% glucose + KCL aim to rehydrate over 48hours. Note: in surgical patients other isotonic solutions may be used e.g. Hartmann’s solution Page 10 Intravenous fluid guidelines for infants aged less than 3 months Assessment including hydration status plasma Na < 135 For newborns calculate routine iv maintenance fluids using the following formula: Day 1: 60ml/kg/day Day 2: 90ml/kg/day Day 3: 120ml/kg/day Day 4: 150ml/kg/day Maximum rate at 150ml/kg/day aiming to titrate it down gradually. • No sodium in the fluids until postnatal diuresis with weight loss; give 10% Dextrose bag using above rate • Base any subsequent iv fluid prescriptions on the plasma UEs and blood glucose measurements. • Discuss all babies with hyponatraemia with on call SpR • Consider causes (including non-osmotic antidiuretic hormone secretion) and hy- dration status • Seek immediate help if hyponatraemic symptoms seen - headache, vomiting, irritability, altered consciousness, sei- zure and apnoea plasma Na 135 - 145 plasma Na >145  Close monitoring of observations including daily weights  Keep feeding chart and maintain strict fluid balance  Monitor blood glucose level 12 hourly and urea electrolytes 4- 6 hourly for at least the initial 24 hours, then monitor according to treatment response  If hypoglycaemic ensure more frequent blood glucose level checks and changing iv fluids  If baby is not responding to iv fluids treatment consider reasons and discuss with the on call Paediatric Consultant  Regular review of the need for iv fluids and consider enteral feeding as soon as deemed appropriate 0.45% sodium chloride + 5% glucose + KCL 10mmol/500ml bag • Initial volume should be at 100ml/kg/day • If serum Na falls - restrict volume to 2/3 maintenance - replace the iv fluid with 0.9% sodium chloride with 5% glucose +/- KCL 0.45% sodium chloride + 5% glucose + KCL 10mmol/500ml bag • Initial volume should be at 100ml/kg/day • Consider enteral feeding and titrating down the amount of iv fluids being given 0.45% sodium chloride + 5% glucose + KCL 10mmol/500ml bag • Initial volume should be at 100ml/kg/day • If sodium rises or signs of de- hydration change the iv fluids to 0.9% sodium chloride +/- water deficit replacement over 48 hours. Page 11  Consultant paediatrician on call (via switch)  Children’s Acute Transport Service (CATS) Emergency referral/advice hotline 08000850003  Use of strong potassium solutions. Whittington Hospital Clinical Guideline September 2007  Intravenous fluid therapy in children and young people in hospital, NICE guideline, Dec 2015 https://www.nice.org.uk/guidance/ng29  Not enough salt in maintenance fluids! Powell CV. Arch Dis Child 2015; 100 (11):1013-5  National Patient Safety Agency, Patient Safety Alert 22 Reducing the risk of hyponatraemia when administering intravenous infusions to children  Royal Children’s Hospital, Melbourne, clinical practice guidelines 2010  APA Consensus Guideline on perioperative fluid management in children September 2007 ➢ References (evidence upon which the guideline is based) ➢ Further information