Fluid management in

Pediatrics
Presentor – Dr. Payal Nikose
Guide – Dr. Anju Ashokan

CONTENTS

• Objectives
• Fluids– physiology
• Basic principles of IV fluid therapy
• Composition of common IV fluids and uses
• Maintenance IV fluids management
• Fluids in dehydration
• Fluids in SAM
• Fluids in shock
• Fluids in special situations
• Take home message
 Objectives

• To learn basic physiology of iv fluids and total body water.

• To know composition of different IV fluids and uses.
• To know how to put iv fluids in maintenance doses.
• Iv fluids management in dehydration and in shock.
• Disadvantages and c/I of iv fluids
• Iv fluids in special situations
• Monitoring after iv fluids.

FLUIDS - PHYSIOLOGY
• In a fetus – TBW(total body water) – 75-90% total body weight
• At birth (term)- TBW – 70-80% of body wt

Falls as age advances

By 1 year – TBW – 60-65 % of body wt
• At puberty –males muscle mass (higher water) TBW 60%
• In female fat content (low water) TBW 50-55%
• In an obese child,TBW content is less than non obese child.

Fluid compartments
TBW in post infancy and adulthood
60-65% of total body wt

ICF ECF
Intracellular (30- Extracellular 20-25%
40%)

Interstitial Plasma 5%
15%
 Fluid intake

Lungs

ICF ECF
Skin

Intestine

Urine

Sources of water loss

• Urine – 60%
• Insensible water loss – 35 % (skin & lungs )
insensible water loss = 300 ml/m2 (body surface area
)/day
• Stools 5 %
FLUIDS - PHYSIOLOGY

ECF ICF
Major cation Sodium Potassium &
magnesium
Major anion Chloride & Phosphate , sulphate
bicarbonate & protein

Basic principles of Fluid therapy

• For proper fluid therapy,it is necessary to know :

a. Etiology of fluid deficit & type of electrolyte imbalance
b. Associated illness (DM,HTN,IHD,Renal or hepatic disorders)
c. Clinical status (hydration,vitals data,urine output ,etc )
COMPOSITION OF IV FLUIDS
dextrose Na K Cl acetate Ca lactate
5% 50 -- -- -- -- -- --
dextrose
0.9 % -- 154 -- 154 -- -- --
saline
D-5 45% 50 77 -- 77 -- -- --
saline
Dextrose 50 154 -- 154 -- -- --
normal
saline(DN
S)
Ringer -- 130 4 109 -- 3 28
lactate
Isolyte p 50 25 20 22 23 -- --

Commonly used IV fluids --

• 5%dextrose
• Isotonic saline (0.9%)
• Dextrose with half strength saline
• Dextrose saline
• Ringers lactate
• Isolyte p
5% dextrose

Indications Contraindications
1. Treatment of hypoglycemia. 1. Cerebral edema (worsened by
hypotonic fluid )
2. Pre & post operative fluid
replacement. 2. Acute ischemic stroke

3. IV administration of many drugs. 3. Hypovolemic shock

4. Treatment/prevention of ketosis in 4. Hyponatremia ,water intoxication

starvation,diarrhea and vomiting.
5. Uncontrolled
diabetes,hyperglycemia

6. Blood transfusion in same line.

Isotonic saline (0.9%)

Indications Contraindications
1. Water and salt depletion Use with caution in patients with
2. Treatment of hypovolemic ,hypertension,CCF
shock(bolus)
3. Treatment of hyponatremia
4. Vehicle for certain drugs
5. Fluid therapy in DKA
,hypercalcemia,fluid challenge in ARF
Dextrose with half strength saline

Indications Contraindications
1. Maintenance fluid therapy in 1. Hyponatremia
pediatric patients.
2. Treatment of hypernatremic
dehydration.

Dextrose saline

Indications Contraindications
1. Correction of salt depletion & 1. Anasarca in cardiac,liver or renal
hypovolemia with supply of energy diseases
2. Correction of vomiting and
nasogastric aspiration induced alkalosis
with supply of calories.
3. Fluid compatible with blood
transfusion.
Ringer lactate

Indications Contraindications
1. Correction of severe hypovolemia
2. Replacement fluid in post operative 1. In severe CCF,worsens lactic
patients acidosis.
3. Correction of severe dehydration 2. Along with blood transfusion

Isolyte p

Indications Contraindications
1. Preferred maintenance fluid in 1. Hyponatremia
infants & children. 2. Renal failure
2. Excessive water loss or inability to 3. Hypovolemic shock
concentrate urine (DI)
 Iv fluids maintenance :

Maintenance Fluids - rate

Weight Volume /24 hours Rate/hour

0-10 kg 100 ml/kg 4 ml /kg

11-20 kg 1000 ml + 50 ml /kg for 40 ml + 2 ml/kg for

each kg >10 kg each kg >10 kg

>20 kg 1500 + 20 ml /kg for 60 ml + 1 ml/kg for

each kg >20 kg each >20 kg

maximum 2400-3000 ml 100-120 ml

Neonatal fluid management

Day of life <1 kg 1 kg – 1.5 kg >1.5 kg

Day 1 100 ml/kg (D5) 80 ml/kg(D10) 60 ml/lg (D10)
Day 2 115 ml/kg (D5) 95 ml/kg(D10) 75 ml/kg(D10)
Day 3 130 ml/kg 110 ml/kg 90 ml/kg
Day 4 145 ml/kg 125 ml/kg 105 ml/kg
Day 5 160 ml/kg 140 ml/kg 120 ml/kg
Day 6 175 ml/kg 155 ml/kg 135 ml/kg
Day 7 190 ml/kg 170 ml/kg 150 ml/kg

Maintenance:
Pre - requisites
• Ideal body weight

• Note all losses

• Check electrolytes,sugar

• Knowledge about fluids

 Adjustments in maintenance water
Causes of increased water Causes of decreased water
needs needs
Skin • Fever ----
• Sweat
• Burns
• Warmer

Lungs • Tachypnea
• Tracheostomy

GIT • Diarrhea
• Emesis
• NG losses

renal polyuria Oliguria/anuria

Miscellaneous Surgical drain

Reduction in maintenance fluids

• Cardiac failure/myocardiac dysfunction – restrict iv fluids

• SIADH
• Acute Kidney Injury (AKI)
Fluids in dehydration

• Dehydration may be isotonic (commonest),hypotonic,hypertonic.

• Steps in correcting dehydration
1. Assessment of degree of dehydration
2. Rapid restoration of intravascular volume
3. Correction of total fluid deficit (rehydration therapy )
4. Replacement of ongoing losses and nutritional support
5. Provision of maintenance fluids and electrolytes
6. Monitoring to prevent resurfacing of fluid deficit an dyselectrolytemia.
 Assessment of dehydration

Parameters No dehydration Some dehydration Severe dehydration

Clinical/mental status Active /alert Irritable/restless Lethargic/comatose

Eyes Normal Sunken Very sunken,dry

tears + - -

Oral mucosa wet Dry Very dry

Thirst Not thirsty,drinks Thirsty,drinks eagerly Unable to drink

normally

Skin pinch Go back immediately Slowly (1-2 sec) Very slowly(>2 sec)

Assessment of degree of dehydration

Characteristics
Infants Mild 1-5 % Moderate 6-9% Severe >10%(>15% shock)
Children Mild 1-3 % Moderate 4-6 % Severe >7%(>9% shock)
Pulse Normal Tachycardia Tachycardia,weak pulse
Systolic BP Normal Normal-low Hypotension/shock
Urine output Decreased Decreased Oliguria/anuria
Buccal mucosa Slightly dry Dry Parched
Anterior fontanel Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Skin turgor /capillary refill Normal Decreased Markedly decreased
Skin (<12 months of age ) Normal Cool Cool,mottling +
 Management of dehydration

1. No dehydration – plan A (oral rehydration therapy )

<2 yr = 50-100 ml/loose stool
2-10 yr = 100-200 ml/loose stool
>10 yr = as much as wants
• Some dehydration – plan B (ORS)
Rehydration – 75 ml/kg over 4 hour- orally/NG tube
replace ongoing losses – 10 ml/kg/loose stool
Ensure normal maintenance fluids should be continued separately.
3. Severe dehydration – plan C (IV fluids )(RL In 5% dextrose/RL)

Plan c –
total 100 ml/kg

AGE 1st 30 ml/kg Next 70 ml/kg

<12 months Over 1 hour Over 5 hour

>12 months Over 30 min Over 2 ½ hours

1. Assessment of dehydration and estimation of
volume deficit
• A capillary refilling time of 2-3 sec corresponds to 50-100 ml/kg loss,3-4 sec
corresponds to 100-150 ml/kg and more than 4 sec to 150-200 ml/kg loss.

2. Rapid restoration of intravascular volume

• Rapid restoration of ECF volume can be achieved by infusing 20-40 ml/kg 0.9%
saline or ringer’solution over one hour period,followed by an additional 20-40
ml/kg if circulation is not fully restored.
 3. Correction of total fluid deficit
• Recommended fluid therapy for intravenous rehydration

Type of fluid therapy Solution

Maintenance 5 % dextrose with 0.45% NS with 20 mEq/l KCl over 24 hr

Isotonic dehydration 5 % glucose with 0.45% NS with 20 mEq/l KCl over 24 hr
Hypotonic dehydration 5 % glucose in 0.9% NS with 20 mEq/l KCl over 12 hr f/by 5
%dextrose in 0.45 % NS with 20 mEq/l KCl over next 24 hours

Hypernatremic dehydration 5 %dextrose in 0.45% NS containing 20 mEq/l KCl to be given

over no.of days necessary to lower Na concn by 10 mEq/day

Calculate fluid and electrolyte requirement of 1 yr old 10 kg infant having

severe dehydration (15%)?

• Deficit fluid 15 % dehydration

150 * 10 =1500 ml
• Daily maintenance 1000 ml
• Total requirement in 24 hours 2500 ml
• Administer one half (1300 ml ) of above amount in first 8 hours and remainder in next 16 hours.
• First hour 30 ml/kg 30*10 = 300 ml in one hour
(RL) 300/60 =5 ml/minute
• Next 7 hours 1300-300= 1000 ml in 7 hours
• Next 16 hours 1300 ml in 16 hours.
 Iv rehydration of 10 kg infant with
hyponatremic dehydration

Steps Time Volume Fluid

Step 1 0-1 hour 20 ml/kg 200 ml NS/RL
Step 2 1-9 hour ½ deficit +1/3 500 ml NS
maintenance 350 ml N/5 in D5W
Step 3 9-24 hour ½ deficit + 2/3 500 ml NS
maintenance+ 650 ml N/5 in D5W
ongoing losses

IV fluids in hypernatremic dehydration

Steps Condition Fluid
Step 1 Child in shock 20 ml/lg RL or NS IN 1st hour f/by 10
ml/kg/hour of N/2 saline in 5% dextrose
till child passes urine or dehydration is
corrected
Step 2 Slow rehydration (over 48 hours ) 60-75 ml/kg N/2 saline in 5% dextrose +
3/4th maintenance req. as n/2 saline in 5
% dextrose + ongoing losses
 Fluids in Severe Acute Malnutrition (SAM)

• It is difficult to assess severity of dehydration in patients of severe

acute malnutririon.
• Assume all the patients with watery diarrhea will have some
dehydration.
• Treatment of some & severe dehydration without shock in SAM will
be different from treatment of severe dehydration with shock in
SAM patients

Severe dehydration with shock in SAM

Ringer’s lactate 15 ml /kg/hour for first hour(ideal fluid is RL

with 5 % dextrose)

Continue monitoring during the infusion

Assess after one hour

No improvement/worsens Improvement seen

Consider septic shock and treat Consider severe dehydration with shock
accordingly #repeat ringer lactate 15 ml/kg over 1 hour

Clinically better /no evidence of shock

#give IV fluids 10 ml/kg/hour for next 8 hr and
substitute ORS for IV fluids when child accepts
orally (usually within 4-6 hr )

Fluids in shock
 Types of shock

Type of shock Pathophysiology

Hypovolemic Decreased preload sec to int/ext losses

Cardiogenic shock Cardiac pump failure sec to poor myocardial

function

Distributive shock Due to loss of arterial /venous capacitance

Septic shock Encompasses multiple forms of shock

Obstructive shock Decreased cardiac output sec to direct

impediment to rt/lt heart chambers

• Initial resuscitation of hypovolemic shock begins with infusion of

isotonic crystalloids or albumin with boluses upto 20 ml/kg over 5-
10 min. if not improved,maximum 60 ml/kg of boluses can be given
in septic shock.
• Ionotropes /afterload reducing agents in cardiogenic shock,boluses
are given cautiously here.
• Antibiotics in suspected septic shock
• Catecholamines,steroids,antihistamines in anaphylactic shock
• Blood replacement in hemorrhagic shock.
 Fluids in special situations

Fluids in Diabetic ketoacidosis

• Milwaukee regimen–
1. First give 20 ml/kg iv NS bolus over 1 hour
2. Then give remaining ½ NS over 23 hours by following formula
= 85 ml/kg + (maintenance fluid – fluid bolus ) given in 23 hours
 Q. A 20 kg weight 6 yrs old mch came to you having
features of severe DKA .how will you manage iv fluids?

1. 20 ml/kg iv NS bolus = 400 ml over 1 hour

2. Calculate maintenance iv fluids = 1500 ml
3. Subtract bolus fluid from maintenance fluid = 1500-400 = 1100 ml
4. Now,a/c to Milwaukee regimen 85 ml/kg
= 1700 ml + 1100 ml (maintenance) given over next 23 hours
= 2800 ml given in 23 hours
= 120 ml/hour for next 23 hours

Fluids in diabetic ketoacidosis

• All patients with DKA who are not shocked and are felt to require iv fluids
should receive 10 ml/kg 0.9% NS bolus over 1 hour.
• Shocked patients should receive a 20 ml/kg bolus of 0.9 % NS bolus over
15 minutes.
REQUIREMENT = DEFICIT + MAINTENANCE
1. Fluid deficit

Assume mild DKA – 5 % fluid deficit

moderate DKA – 7 % fluid deficit
severe DKA – 10% fluid deficit
• Always remember the volume of fluid which is given in form of resuscitation fluid
should never be subtracted from fluid deficit.
• Also in non shocked patients,10 % fluid bolus given is always subtracted from
fluid deficit

2. Maintenance fluid
• Holiday segar formula
1. 100 ml/kg /day for first 10 kg of body weight
2. 50 ml/kg/day for the next 10-20 kgs
3. 20 ml/kg/day for above 20 kgs

3.Fluid calculation

Hourly rate = ({deficit – initial bolus}/48 hr ) +

maintenance per hour
 Q. A 20 kg 6 yrs old mch who has ph of 7.15 (moderate DKA =7 %
dehydrated) came to you.How will you manage fluids ?

1. Firstly give 10 ml/kg NS bolus = 200 ml over 1 hour

2. Then calculate deficit fluid i.e. 7% = 7% of 20 kg = 1400 ml
3. Subtract initial bolus = 1400 – 200 =1200 ml over 48 hours =25 ml/hr
4. Maintenance fluid = 1500 ml over 24 hours = 62 ml/hr
5. Total fluid = 25 ml/hr (deficit fluid-bolus fluid) + 62 ml/hr (maintenance fluid )
= 87 ml /hr

Q. A 20 kg 6 yrs old mch who has ph of 6.9 (severe DKA =10 %

dehydrated) having shock came to you.How will you manage fluids ?

1. Manage shock first --- 20 ml/kg iv ns bolus = 400 ml over one hour
2. Deficit fluid – 10% of 20 kg = 2000 ml over 48 hours = 40 ml/hr
3. Maintenance fluid 20 kg = 1500 ml over 24 hours = 62 ml/hr
4. Total fluids – 40 ml /hr (deficit fluid ) + 62 ml/hr (maintenance fluid )
= 102 ml/hr
Fluids in Acute kidney injury (AKI)

• According to body surface area,we can restrict iv fluids in case of AKI

• Body surface area (BSA)=

• For 1 m sq 1500 ml/24 hrs (maintenance fluid )

• But in c/o oliguria or anuria ,40% restricted iv fluids will be given. Also ,replace urine
output ml/ ml with d5 ½ NS +_ kcl

Q. A child of 10 kg and 86 cm height .calculate fluid requirement a/c to

BSA ?

• BSA = 86 * 10 = 860 /3600 = 0.47 m2 bsa

• So fluid requirement = 1500 * 0.47 = 705 ml in 24 hours
• So total fluid will be 30 ml/hour for 24 hours.

If this patient is having oliguria/anuria—

• Fluid requirement = 400 *bsa = 400 *0.47 = 190 ml in 24 hours + urinary losses
• So total fluid will be 8 ml/hour (+ urinary losses )for 24 hours.
 Fluid in dengue

Dengue with warning signs

Normal saline (NS) or ringer lactate (RL) 7 ml/kg

No improvement
improvement

NS 10 ML/KG/HR(assess after 2
hrs) NS 5 ml/kg/hr

NS 15 ML/KG/HR
Further
improvement
Assessment after 3 hrs

NS 3 ml/kg/hr
No improvement
Colloids 10 mg/kg/hr Continue IV fluids till
stable for 24 hours

No improvement

Discharge when stable for

24-48 hrs
Look for anemia,acidosis
and treat accordingly

Severe dengue

Assessment of shock

Hypotension (DSS3) BP- non recordable

NS 10-20 ml/kg bolus and

NS 20 ml/kg 2-3 boluses f/by 20
then every hr
ml/kg/hr

assessment
 Improved Not improved

Gradually decrease NS infusion

with monitoring
PCV increased PCV decreased

Colloids 10 ml/kg Blood transfusion

assessment

No improvement

improved Look for blood loss,acidosis,treat it

Raised ICT

• Isotonic fluid preferably NS with KCL

• DNS if sugars not maintaining between 100-150
• Fluid restriction no longer recommended
Monitoring

• If patient is in shock,monitor vitals every half hourly for 2-4 hours

then every hourly for 24 hours.
• Watch for overhydration : can cause potential harm.
• Watch for I/O charting ,urine output.
• Watch for acid base imbalance and electrolyte disturbances.

Take home message

• Always calculate body weight/BSA for calculation of fluid requirement.

• Watch for electrolytes imbalance and overhydration.
• Prescribe IVF only when needed.
• Avoid hypotonic fluids as much as we can.
• Monitoring is very important.
References :

• Nelson textbook of pediatrics -21st edition

• Medical emergencies in children Meharban Singh – revised 5th edition
• www.bsped.org.uk/guidelines_dka
• PALS algorithm 2021 handbook

Thank you !!