CHANGING TRENDS:

PEDIATRIC MAINTENANCE IVF

DR. MAULIK SHAH MD(Ped)

Prescribe a maintenance IV fluid
 Age 2 years, wt. 10 kg admitted for pneumonia
With resonably stable vitals except mild tachypnea.
Answer :
1litre of IVF over 24 hrs.
IVF= ISOLYTE – P
 ISOLYTE – P : Dextrose 5% + 26 Na + + 20 K +
A Maulik Shah Presentation
 NPSA – Patient safety alert 22: Reducing the risk of hyponatraemia
when administering intravenous infusions to children (Alert 5 of 5)

Applies to all paediatric patients from 1 month to 16 years 28th March 2007

 Remove 0.18% NaCl / 4%Dextrose from general stock

 Produce and disseminate clinical guidelines for the fluid management of paediatric patients

 Adequate training and supervision of staff

 Reinforce safe practice

 Promote the recording and reporting of hospital acquired hyponatraemia

 Audit programme to ensure that the NPSA recommendations are being adhered to
A Maulik Shah Presentation
Recommendation -NPSA
 Oral fluids preferable to ivf
 Resuscitation Fluids –
bolus of 0.9% saline
 Deficit – calculated and replaced as
 0.9% saline or 0.9% saline with 5% dextrose
 Replace over 24 hours
 Maintenance – do not use 0.18% saline with 4% dextrose
0.45%saline with 5%dextrose(D5-½NS)
A Maulik Shah Presentation
What about other countries…?
 Royal children hospital, Melbourne.
 Which Fluid?

 0.18% NaCl with 4% glucose with KCl 20mmol/L is NOT the appropriate
initial fluid for unwell children.
 Three good fluid solutions for sick children include:

Fluid Alternative names

0.9 NaCl Normal Saline
0.9 NaCl with 5% Dextrose Normal saline with glucose
0.45 NaCl with 5% Dextrose ½Normal saline with glucose A Maulik Shah Presentation
 But Why do we require to change…
 Hoorn et al. Hoorn et al. Pediatrics 2004
“the most important factor contributing to hospital acquired
hyponatremia was administration of hypotonic fluid (case control) “

 Choong et al Choong et al. Arch Dis child 2006

”the use of hypotonic fluids increased the odds of developing
hyponatremia by 17 times when compared to isotonic
(systematic review).
A Maulik Shah Presentation
 Hazards of Hypotonic Fluids
Acute Hospital Acquired Hyponatraemia
 Acute Hyponatraemia
 Na < 136mmols/L occurring within 48 hours

 Severe hyponatraemia if Na < 130mmols/L

 Or any level of hyponatraemia associated with clinical signs

 Hyponatraemic encephalopathy

 50% of children with Na<125mmol/L

 8% mortality rate

 Children have a poorer outcome than adults for a given level of

hyponatraemia
A Maulik Shah Presentation
Acute Hospital Acquired Hyponatraemia – children at risk
child’s brain has a higher
brain /intracranial volume ratio
Common symptoms
 Headache
 Nausea & vomiting
 Weakness
Advanced signs
 Seizures
 Respiratory arrest
 Dilated pupils
 Decorticate posturing
Slide courtesy:
 Coma Heinrich Werner, M.D.
Pediatric Critical Care
 Pulmonary oedema University of Kentucky
 Hyponatremic encephlalopathy kills…!

Slide courtesy: A Maulik Shah Presentation

Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky
That means...
 Hypotonic fluids are not benign but potentially
dangerous.
 Isotonic fluids offer a safe alternative to hypotonic
fluids with no risk of hypernatraemia
 Fluid regimes should be tailored to the individual
 Appropriate monitoring
 Weight, baseline U&E’s

A Maulik Shah Presentation

 Hyponatremia
Most common cause of hyponatremia
Volume Status

in hospitalized patients
Hypovolemia Euvolemia Hypervolemia

Renal losses Extrarenal losses

“””””
“”””” “””””
“”””” “””””” SIADH “””””
“””””
“”””” “””””
Slide courtesy:
Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky
SIADH and Hyponatremia

Inappropriate AVP level Free water intake exceeds output

Typically done by
Symptomatic Hyponatremia
you and me !
Appropriate ADH Secretion Inappropriate ADH Secretion

Decreased Renal Water Secretion

Hypotonic Fluid

Hyponatremia
Osmolality : ADH level and Thirst

Osmolality is the prime

stimulus for ADH release or
suppression.

From:
Berl T, Robertson GL. Pathophysiology of Water
Metabolism. In: Brenner AM, ed. Brenner and Rector's
The Kidney. 6th ed. Philadelphia: W.B. Saunders;
2000:873. A Maulik Shah Presentation
Non Osmotic Stimuli for ADH Secretion
 Stress Drugs
 Pain  Morphine
 Post-operative period  NSAID’s
 Sepsis  SSRI’s
 Pyrexia  Barbiturates
 Nausea & vomiting  Carbamazepine
 Co-existing medical conditions  Clofibrate
 CNS infections
 Isoprenaline
 Respiratory disorders
 Metabolic & endocrine disorders
 Chlorpropamide
 Vincrisitine
A Maulik Shah Presentation
 Which hospitalized
child is not at risk
for SIADH ?
Slide courtesy:
Heinrich Werner, M.D. Pediatric Critical Care University of Kentucky A Maulik Shah Presentation
But why hypotonic fluid held responsible ?
IV SOLUTIONS Na(mEq/L) %EFW
5% Dextrose 0 100
ISOLYTE -P 26 84%
0.45% NS 77 50%
0.45 % NS in 5% Dextrose 77 50%
0.9 % NS in 5% Dextrose 154 0
Ringer Lactate 131 16%
0.9% NS 154 0

EFW = Electrolyte Free Water A Maulik Shah Presentation

 But what does EWF do ?

Sodium Principles
H2O
Sodium ions do
not cross cell H2O H 2O
membranes as H2O H O
2
quickly as water Na+
does Na+

A Maulik Shah Presentation

 So do we accept the change ?
Not fully – Why…?
 We live in tropics-hot climate –free water loss more.

 Our children are treated most often in non A/C ICU.

 Our indian data is in-sufficient for conclusion.

 BUT then summer and winter fluid has to be

different.!!!
A Maulik Shah Presentation
 So is “ISOLYTE- P” out ??
Not fully – Why…?
 Hypotonic solutions should be administered if the goal is to create a positive balance
for EFW:
1. To match daily loss of EFW in sweat in a patient with PNa > 138mM
2. PNa > 145
3. Ongoing free water losses (Renal, GI, skin) or a free water deficit
so use in
 NEONATES.
 Established third space overload : e.g. congestive heart failure,
nephrotic syndrome, cirrhosis A Maulik Shah Presentation
Let’s Share our views on this…

DR.MAULIK SHAH MD.(PED)

ASSOCIATE PROFESSOR
DEPARTMENT OF PEDIATRICS
M.P.S.M.C – JAMNAGAR(GUJARAT-INDIA)
maulikdr@gmail.com
http://matrutvanikediae.blogspot.com/