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PEDIATRIC FLUID THERAPY 
DR. VIJAY DIHORA
Body Fluid Compartments 
TOTAL BODY WATER (60%) 
EXTRACELLULAR FLUID 
(1/3 TBW) 
INTRACELLULAR FLUID 
(2/3 TBW) 
INTERSTITIAL FLUID 
(3/4 ECF) 
PLASMA 
(1/4 ECF) 
TRANSCELLULAR 
FLUID 
Accurate for children 6 months of age and older
Body Fluid Compartments 
90 
80 
70 
60 
50 
40 
30 
20 
10 
0 
Preterm Term 6 
months 
1 year Adult 
Total Body Water 
Muscle Mass 
Fat 
B 
o 
d 
y 
C 
o 
m 
p 
o 
s 
i 
t 
i 
o 
n 
(%)
Body Fluid Compartments 
• ICF – 2/3 TBW 
• The proportion of ECF is much greater to that 
of the ICF in the preterm infants. 
• Upon birth, there is gradual shift from the ECF 
to the ICF
Neonatal Fluid Management 
• At birth: ECF is greater than ICF 
• A few days after birth: 
ECF contraction and wt loss due to ANP induced diuresis 2° 
to ↑ pulmonary blood flow & stretch of left atrial receptors 
• This is followed by ↑ water and Na requirements to match 
those of the growing infant 
Implication: Fluids should be restricted until the postnatal weight 
loss has occurred.
Neonatal Fluid Management 
• If a baby requires IV fluids from birth, they shld be given 10% 
dextrose in the following volumes 
Day 1 60 ml/kg/day Day 4 110 
Day 2 80 Day 5 120 
Day 3 100 
• Na+ 3 mmol/kg/day & K+ 2 mmol/kg/day shld be added after 
the postnatal diuresis or if Na+ drops 
• A premature neonate may require an additional 30 ml/kg/day 
and additional Na+
Neonatal Fluid Management 
• Fluid requirements are titrated to the: 
patient’s changing weight 
urine output 
serum sodium
Evaluation of Intravascular Volume 
• Physical Examination 
• Laboratory Exam 
• Hemodynamic Measurements
Clinical and laboratory assessment of the severity of 
dehydration in children 
Signs and 
Symptoms 
Mild 
Dehydration 
Moderate 
Dehydration 
Severe 
Dehydration 
Wt loss (%) 5 10 15 
Fluid deficit 
(ml/kg) 
50 100 150 
Vital Signs 
Pulse Normal ↑, weak greatly ↑, feeble 
BP Normal Normal to low ↓, orthostatic 
Respiration Normal Deep Deep & rapid
Clinical and laboratory assessment of the 
severity of dehydration in children 
Signs and 
Symptoms 
Mild 
Dehydration 
Moderate 
Dehydration 
Severe 
Dehydration 
Behavior Normal Irritable Hyperirritable 
to lethargic 
Thirst Slight Moderate Intense 
Skin turgor Normal Decreased Greatly ↓ 
Ant. fontanelle Normal Sunken Markedly 
depressed 
Urine flow 
(ml/kg/hr) 
<2 <1 <0.5 
Urine SG 1.020 1.020 – 1.030 >1.030
Choice of fluids 
• Crystalloids 
• Colloids 
• Blood products 
– Whole blood 
– pRBC 
– FFP 
– Platelets
Crystalloids 
• sterile aqueous solutions which may contain 
glucose, various electrolytes, organic salts and 
nonionic compounds 
• rapidly equilibrates with ECF
Composition of Crystalloids 
Fluid Osmolarity pH Na K Cl Glucose 
0.9% 
NaCl 
308 6.0 154 0 154 0 
LR 273 6.5 130 4 156 0 
D5W 252 4.5 0 0 0 50 
D5LR 525 5.0 130 4 156 50 
D5NR 547 5.2 140 5 0
Crystalloid Solutions 
• 2 ways of classification 
a. based on use 
b. based on tonicity
Types 
• Saline e.g. 0.9% saline, Hartmann’s solution 
0.18% saline in 4% glucose. 
• Glucose : e.g. 5% glucose, 10% glucose, 20% 
glucose. 
• Postassium chloride 
• Sodium bicarbonate : e.g. 1.26%, 8.4%.
Crystalloid Solutions: Based on Use 
• Maintenance-type solutions 
– water loss 
– hypotonic solutions 
• Replacement-type solutions 
– water and electrolyte losses 
– isotonic electrolyte solutions
Type of IV solution 
based on tonicity 
Type of IV solution 
Isotonic Hypotonic Hypertonic
Isotonic solution 
 A solution that has the same salt 
concentration as the normal cells of the body 
and the blood. 
 Ex: 
1- 0.9% NaCl . 
2- Ringer Lactate . 
3- Blood Component . 
4- D5W.
Hypertonic solution: 
 A solution with a higher salts concentration 
than in normal cells of the body and the blood. 
 Ex: 
1- D5W in normal 
Saline solution . 
2-D5W in half normal 
Saline . 
3- D10W.
Hypotonic solution 
 A solution with a lower salts concentration 
than in normal cells of the body and the 
blood. 
 EX: 
1-0.45% NaCl . 
2- 0.33% NaCl .
Crystalloid Solutions: Based on Tonicity 
• Balanced salt solutions 
– electrolyte composition similar to ECF 
– Hypotonic with respect to Na 
Fluid Osm pH Na K Other 
LR 273 6.5 130 4 Lactate = 28 
Normosol 295 7.4 140 5 Mg =3, acetate = 27, 
gluconate = 23 
Plasmalyte 298.5 5.5 140 5 HCO3 = 50
Crystalloid Solutions: Based on Tonicity 
• Normal Saline 
– isotonic (6.0) and isoosmotic (308) 
– contains no buffers or electrolytes 
– large volume: 
dilutional hyperchloremic acidosis
Crystalloid Solutions: Based on Tonicity 
• Hypertonic Salt Solutions 
– Na concn range from 250 – 1200 meq/L 
– Rapid volume expansion after infusion of small 
amounts (e.g. 250 mL) 
– t½: similar to isotonic saline 
– may cause hemolysis at point of injection
Glucose containing solutions 
• Glucose—given intravenously—is rapidly 
metabolized, leaving free water behind 
• distributes across all compartments rapidly
Sodium Bicarbonate 
Type 
• Isotonic sodium bicarbonate 1.26% 
• Hypertonic sodium bicarbonate (1mmol/ml) 8.4% 
Uses 
• Correction of metabolic acidosis 
• Alkalinisation of urine 
Routes 
• IV 
25
Ion content of sodium bacarbonate (mmol/L) 
Na+ K+ HCO3 C1 Ca2 
1.26% sodium 150 150 
Bacarbonate 
8.4% sodium 1000 1000 
bacarbonate 
26
Crystalloids 
• Advantages 
– Inexpensive 
– Very low incidence of adverse reactions 
• Disadvantages 
– Short lived hemodynamic improvement 
(intravascular t½: 20 – 30 mins.) 
– Peripheral/pulmonary edema
Crystalloids 
• Best crystalloid 
Isotonic crystalloids are preferred over 
hypotonic crystalloids
Do we have to routinely give glucose containing 
solutions? 
• Routine dextrose administration is no longer advised. 
• There is a growing consensus to selectively administer 
intraoperative dextrose only in pts at greatest risk for 
hypoglycemia and in such situations to consider the 
use of fluids with dextrose concentrations
Colloids 
– contains high MW substances - proteins, large 
glucose polymers 
– maintain plasma oncotic pressure 
– intravascular t½: 3 – 6 hrs.
Colloids 
Types 
• Albumin: e.g. 5%, 20 % , human albumin solution 
31 
• Dextran: e.g. 6% Dextran 
• Gelatin: e.g. 3.5% polygeline (Haemaccel), 4% 
succinylated gelatin (Gelofusion) 
• Hydroxyethyl starch: e.g. 6% hetastarch
Colloids: Classification 
• Natural Protein Colloid 
– Albumin or Plasma Protein fraction 
• Synthetic Protein Colloids 
– Hetastarch 
– Dextrans 
– Gelatins
Albumin 
• Colloid “gold standard” 
• Derived from human pool plasma → heated to 60 C for 10 hrs 
→ ultrafiltration 
• MW: 69 kDa 
• Available as: 5% and 20% 
• Albumin 5% osmotically equivalent to an equal volume of 
plasma
Albumin 
• Use with caution in patients with 
increased intravascular permeability 
(e.g. critically ill, sepsis, trauma, burn)
Albumin: Side Effect 
• Rare 
• Might still have weak anticoagulation effects through 
platelet aggregation inhibition or heparin-like effects 
on antithrombin III 
• These effects are thought to be clinically insignificant 
if volume replacement with albumin is kept below 
25% of the patient’s blood volume.
Hetastarch 
• modified natural polysaccharides 
Amylopectin Hetastarch
Hetastarch 
Described in terms of: 
1. Concentration 
2. Average mean MW 
3. Molar substitution 
4. C2:C6 ratio
Hetastarch: Concentration 
• Definition – grams in 100 ml 
• Available as: 6%
Hetastarch: average mean MW 
1. Low - <70 kDa 
2. Medium - 130 – 270 kDa 
3. High - >450 kDa 
higher MW ⇒ longer volume effect 
⇒ greater side effect
Hetastarch: Molar Substitution 
Definition: CH3CH2OH : glucose units 
• Low (0.4 – 0.5) 
• High (0.62 – 0.7) 
higher MS ⇒ longer volume effect 
⇒ greater side effect
Hetastarch: C2:C6 ratio 
• Hydroxyethyl group attached at C2 hinder 
breakdown 
• Higher ratio of C2:C6 ⇒ in slower enzymatic 
degradation and prolonged action without 
increasing side effects.
HES Solutions Properties and Availability 
HES HES HES 
Trade Name Hespan Hextend Voluven 
Concn 6 g 6 g 6 g 
Volume effect (h) 5 – 6 5 – 6 2 – 3 
MW 450 670 130 
C2:C6 ratio 4:1 4:1 9:1
HES: Unwanted Side Effects 
• Hypocoagulable effect 
- seems to interfere with the function of vWF, factor VIII 
and platelets 
• Renal toxicity 
- induce renal tubular cell swelling & create hyperviscous 
urine 
• Pruritus 
- accumulation on HES molecules under the skin
Gelatins 
• polypeptides produced by degradation of 
bovine collagen 
• ave MW: 30,000 – 35,000 kDa 
• requires repeated infusions 
• no dose limitation
Gelofusine: Pharmaceuticals Characteristics 
Concentration 4% 
Na 154 
Cl 120 
pH 7.4 
Volume effect 100% 
Duration of vol expansion 4 hrs
Gelofusine 
• It has less anaphylactoid and coagulation 
effect in comparison to HES. 
• The data supporting use of gelatin in children 
are limited.
Colloids 
• Advantages 
– Smaller infused volume 
– Prolonged increase in 
plasma volume 
– Minimal peripheral 
edema 
• Disadvantages 
– Expensive 
– Coagulopathy 
– Pulmonary edema 
– Anaphylactoid reactions
Blood Product Transfusion 
• What? 
• When? 
• How much?
Transfusion: pRBC 
Indications: 
As replacement fluid in acute blood loss. 
As replacement in chronic anemia with a 
hemoglobin level between 6 – 10 gm % considering 
the following factors: 
- The patient symptoms and signs (Tachycardia, 
Tchypnea) 
- Anemia.
Transfusion: FFP 
• Indication: 
replacement factor deficiencies, 
replacement of factor in bleeding induced by warfarin 
therapy, 
coagulopathy asociated with liver disese 
• Initial therapeutic dose: 10–15 mL/kg 
• Goal: 30% of the normal coagulation factor 
concentration
Transfusion: Platelets 
• Indication: 
pts with thrombocytopenia or dysfunctional 
platelets in the presence of bleeding

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Fluid therapy

  • 1. PEDIATRIC FLUID THERAPY DR. VIJAY DIHORA
  • 2. Body Fluid Compartments TOTAL BODY WATER (60%) EXTRACELLULAR FLUID (1/3 TBW) INTRACELLULAR FLUID (2/3 TBW) INTERSTITIAL FLUID (3/4 ECF) PLASMA (1/4 ECF) TRANSCELLULAR FLUID Accurate for children 6 months of age and older
  • 3. Body Fluid Compartments 90 80 70 60 50 40 30 20 10 0 Preterm Term 6 months 1 year Adult Total Body Water Muscle Mass Fat B o d y C o m p o s i t i o n (%)
  • 4. Body Fluid Compartments • ICF – 2/3 TBW • The proportion of ECF is much greater to that of the ICF in the preterm infants. • Upon birth, there is gradual shift from the ECF to the ICF
  • 5. Neonatal Fluid Management • At birth: ECF is greater than ICF • A few days after birth: ECF contraction and wt loss due to ANP induced diuresis 2° to ↑ pulmonary blood flow & stretch of left atrial receptors • This is followed by ↑ water and Na requirements to match those of the growing infant Implication: Fluids should be restricted until the postnatal weight loss has occurred.
  • 6. Neonatal Fluid Management • If a baby requires IV fluids from birth, they shld be given 10% dextrose in the following volumes Day 1 60 ml/kg/day Day 4 110 Day 2 80 Day 5 120 Day 3 100 • Na+ 3 mmol/kg/day & K+ 2 mmol/kg/day shld be added after the postnatal diuresis or if Na+ drops • A premature neonate may require an additional 30 ml/kg/day and additional Na+
  • 7. Neonatal Fluid Management • Fluid requirements are titrated to the: patient’s changing weight urine output serum sodium
  • 8. Evaluation of Intravascular Volume • Physical Examination • Laboratory Exam • Hemodynamic Measurements
  • 9. Clinical and laboratory assessment of the severity of dehydration in children Signs and Symptoms Mild Dehydration Moderate Dehydration Severe Dehydration Wt loss (%) 5 10 15 Fluid deficit (ml/kg) 50 100 150 Vital Signs Pulse Normal ↑, weak greatly ↑, feeble BP Normal Normal to low ↓, orthostatic Respiration Normal Deep Deep & rapid
  • 10. Clinical and laboratory assessment of the severity of dehydration in children Signs and Symptoms Mild Dehydration Moderate Dehydration Severe Dehydration Behavior Normal Irritable Hyperirritable to lethargic Thirst Slight Moderate Intense Skin turgor Normal Decreased Greatly ↓ Ant. fontanelle Normal Sunken Markedly depressed Urine flow (ml/kg/hr) <2 <1 <0.5 Urine SG 1.020 1.020 – 1.030 >1.030
  • 11. Choice of fluids • Crystalloids • Colloids • Blood products – Whole blood – pRBC – FFP – Platelets
  • 12. Crystalloids • sterile aqueous solutions which may contain glucose, various electrolytes, organic salts and nonionic compounds • rapidly equilibrates with ECF
  • 13. Composition of Crystalloids Fluid Osmolarity pH Na K Cl Glucose 0.9% NaCl 308 6.0 154 0 154 0 LR 273 6.5 130 4 156 0 D5W 252 4.5 0 0 0 50 D5LR 525 5.0 130 4 156 50 D5NR 547 5.2 140 5 0
  • 14. Crystalloid Solutions • 2 ways of classification a. based on use b. based on tonicity
  • 15. Types • Saline e.g. 0.9% saline, Hartmann’s solution 0.18% saline in 4% glucose. • Glucose : e.g. 5% glucose, 10% glucose, 20% glucose. • Postassium chloride • Sodium bicarbonate : e.g. 1.26%, 8.4%.
  • 16. Crystalloid Solutions: Based on Use • Maintenance-type solutions – water loss – hypotonic solutions • Replacement-type solutions – water and electrolyte losses – isotonic electrolyte solutions
  • 17. Type of IV solution based on tonicity Type of IV solution Isotonic Hypotonic Hypertonic
  • 18. Isotonic solution  A solution that has the same salt concentration as the normal cells of the body and the blood.  Ex: 1- 0.9% NaCl . 2- Ringer Lactate . 3- Blood Component . 4- D5W.
  • 19. Hypertonic solution:  A solution with a higher salts concentration than in normal cells of the body and the blood.  Ex: 1- D5W in normal Saline solution . 2-D5W in half normal Saline . 3- D10W.
  • 20. Hypotonic solution  A solution with a lower salts concentration than in normal cells of the body and the blood.  EX: 1-0.45% NaCl . 2- 0.33% NaCl .
  • 21. Crystalloid Solutions: Based on Tonicity • Balanced salt solutions – electrolyte composition similar to ECF – Hypotonic with respect to Na Fluid Osm pH Na K Other LR 273 6.5 130 4 Lactate = 28 Normosol 295 7.4 140 5 Mg =3, acetate = 27, gluconate = 23 Plasmalyte 298.5 5.5 140 5 HCO3 = 50
  • 22. Crystalloid Solutions: Based on Tonicity • Normal Saline – isotonic (6.0) and isoosmotic (308) – contains no buffers or electrolytes – large volume: dilutional hyperchloremic acidosis
  • 23. Crystalloid Solutions: Based on Tonicity • Hypertonic Salt Solutions – Na concn range from 250 – 1200 meq/L – Rapid volume expansion after infusion of small amounts (e.g. 250 mL) – t½: similar to isotonic saline – may cause hemolysis at point of injection
  • 24. Glucose containing solutions • Glucose—given intravenously—is rapidly metabolized, leaving free water behind • distributes across all compartments rapidly
  • 25. Sodium Bicarbonate Type • Isotonic sodium bicarbonate 1.26% • Hypertonic sodium bicarbonate (1mmol/ml) 8.4% Uses • Correction of metabolic acidosis • Alkalinisation of urine Routes • IV 25
  • 26. Ion content of sodium bacarbonate (mmol/L) Na+ K+ HCO3 C1 Ca2 1.26% sodium 150 150 Bacarbonate 8.4% sodium 1000 1000 bacarbonate 26
  • 27. Crystalloids • Advantages – Inexpensive – Very low incidence of adverse reactions • Disadvantages – Short lived hemodynamic improvement (intravascular t½: 20 – 30 mins.) – Peripheral/pulmonary edema
  • 28. Crystalloids • Best crystalloid Isotonic crystalloids are preferred over hypotonic crystalloids
  • 29. Do we have to routinely give glucose containing solutions? • Routine dextrose administration is no longer advised. • There is a growing consensus to selectively administer intraoperative dextrose only in pts at greatest risk for hypoglycemia and in such situations to consider the use of fluids with dextrose concentrations
  • 30. Colloids – contains high MW substances - proteins, large glucose polymers – maintain plasma oncotic pressure – intravascular t½: 3 – 6 hrs.
  • 31. Colloids Types • Albumin: e.g. 5%, 20 % , human albumin solution 31 • Dextran: e.g. 6% Dextran • Gelatin: e.g. 3.5% polygeline (Haemaccel), 4% succinylated gelatin (Gelofusion) • Hydroxyethyl starch: e.g. 6% hetastarch
  • 32. Colloids: Classification • Natural Protein Colloid – Albumin or Plasma Protein fraction • Synthetic Protein Colloids – Hetastarch – Dextrans – Gelatins
  • 33. Albumin • Colloid “gold standard” • Derived from human pool plasma → heated to 60 C for 10 hrs → ultrafiltration • MW: 69 kDa • Available as: 5% and 20% • Albumin 5% osmotically equivalent to an equal volume of plasma
  • 34. Albumin • Use with caution in patients with increased intravascular permeability (e.g. critically ill, sepsis, trauma, burn)
  • 35. Albumin: Side Effect • Rare • Might still have weak anticoagulation effects through platelet aggregation inhibition or heparin-like effects on antithrombin III • These effects are thought to be clinically insignificant if volume replacement with albumin is kept below 25% of the patient’s blood volume.
  • 36. Hetastarch • modified natural polysaccharides Amylopectin Hetastarch
  • 37. Hetastarch Described in terms of: 1. Concentration 2. Average mean MW 3. Molar substitution 4. C2:C6 ratio
  • 38. Hetastarch: Concentration • Definition – grams in 100 ml • Available as: 6%
  • 39. Hetastarch: average mean MW 1. Low - <70 kDa 2. Medium - 130 – 270 kDa 3. High - >450 kDa higher MW ⇒ longer volume effect ⇒ greater side effect
  • 40. Hetastarch: Molar Substitution Definition: CH3CH2OH : glucose units • Low (0.4 – 0.5) • High (0.62 – 0.7) higher MS ⇒ longer volume effect ⇒ greater side effect
  • 41. Hetastarch: C2:C6 ratio • Hydroxyethyl group attached at C2 hinder breakdown • Higher ratio of C2:C6 ⇒ in slower enzymatic degradation and prolonged action without increasing side effects.
  • 42. HES Solutions Properties and Availability HES HES HES Trade Name Hespan Hextend Voluven Concn 6 g 6 g 6 g Volume effect (h) 5 – 6 5 – 6 2 – 3 MW 450 670 130 C2:C6 ratio 4:1 4:1 9:1
  • 43. HES: Unwanted Side Effects • Hypocoagulable effect - seems to interfere with the function of vWF, factor VIII and platelets • Renal toxicity - induce renal tubular cell swelling & create hyperviscous urine • Pruritus - accumulation on HES molecules under the skin
  • 44. Gelatins • polypeptides produced by degradation of bovine collagen • ave MW: 30,000 – 35,000 kDa • requires repeated infusions • no dose limitation
  • 45. Gelofusine: Pharmaceuticals Characteristics Concentration 4% Na 154 Cl 120 pH 7.4 Volume effect 100% Duration of vol expansion 4 hrs
  • 46. Gelofusine • It has less anaphylactoid and coagulation effect in comparison to HES. • The data supporting use of gelatin in children are limited.
  • 47. Colloids • Advantages – Smaller infused volume – Prolonged increase in plasma volume – Minimal peripheral edema • Disadvantages – Expensive – Coagulopathy – Pulmonary edema – Anaphylactoid reactions
  • 48. Blood Product Transfusion • What? • When? • How much?
  • 49. Transfusion: pRBC Indications: As replacement fluid in acute blood loss. As replacement in chronic anemia with a hemoglobin level between 6 – 10 gm % considering the following factors: - The patient symptoms and signs (Tachycardia, Tchypnea) - Anemia.
  • 50. Transfusion: FFP • Indication: replacement factor deficiencies, replacement of factor in bleeding induced by warfarin therapy, coagulopathy asociated with liver disese • Initial therapeutic dose: 10–15 mL/kg • Goal: 30% of the normal coagulation factor concentration
  • 51. Transfusion: Platelets • Indication: pts with thrombocytopenia or dysfunctional platelets in the presence of bleeding