小儿补液英文修.ppt

Fluid Therapy,The first affiliated hospital SUN YAT-SEN university Prof. Wang Huishen 王慧深,Last lesson Emphasis,Etiology (in/ex/no),Pathogenesis (4+ex/b/v/no),Clinical manifestation,Diagnosis,Differential Diagnosis (p/d/n),Treatment,Predisposing (4),Diagnosis,Not difficult According to clinical manifestation, laboratory tests and character of stool.,+,+,Infectious Or Noninfectious,Dehydration Degree and quality,Electrolyte disturbances And Disturbance of acid-base balance,Severity clinical signs of dehydration,Dehydration,Dehydration,Same proportion loss,P,IF,C,P,IF,C,Electrolyte loss more,P hypotonic, IF+C hypertonic,Cell expansion Severe Easy to shock,P: plasma, IF: interstitial fluid, C: cell,Isotonic,P,IF,C,Water loss more,P hypertonic IF+C hypotonic,Cell hydration Mild Thirsty,Acute diarrhea after vomiting greatly,Hypotonic,Hypertonic,Na+ :130150mmol/L,Na+: 130mmol/L,Na+: 150mmol/L,Electrolyte disturbance,Diarrhea complicated,hyponatremia & hypernatremia hypokalemia hypocalcemia hypomagnesemia,K+ (potassium)3.5mmol/L (normal: 3.55.5 mmol/L) causes： Excessive losses: vomit, diarrhea. Inadequate intake. Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia.,Clinical manifestation: electrolyte disorder Hypokalemia,depressed Tension of skeletal muscle ，tendon reflex， even respiratory muscle weakness Tension of smooth muscl , abdominal extension, intestinal sound or disappear Myocardium excitability , arrhythmia, ECG: T-wave is low or inversion, U-wave occurs, prolonged P-R interval and Q-T interval, ST section descending. Baseosis,hypokalemia K+ (potassium)3.5mmol/L (normal: 3.55.5 mmol/L),Clinical manifestation: nerve and muscular excitability,Ca2+1.75mmol/L (7mg/dl) ; Mg2+0.6mmol/L (1.5mg/dl). Symptoms usually occur after dehydration and acidosis resolved, or fluid replacement. Clinical manifestation: thrill, tetany, convulsion. If convulsion hasnt relieved after supplement calcium, pay attention to hypomagnesemia.,hypocalcemia & hypomagnesemia,Case example,An 8 month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150/min, weight loss was 10%, blood pressure 65/40mmHg, skin color showed grey and skin turgor looked like tents. Mucous membranes were very dry; eye ball was sunken greatly, anterior fontanel depressed greatly. Abdomen distended, bowel sound diminished. Questions: 1.What is the diagnosis? 2.How to administer the fluid therapy?,Answer 1 (diagnosis),Acute diarrhea severe dehydration hypokalemia,Fluid Therapy,Neonate. 80% Older children65% Adult60%,features of body fluid balance in children,The younger,The larger proportion of body water,Total body water (by body mass),-amount of body fluid,features of body fluid balance in children,The younger,The larger proportion of extracellular water,Intracellular,Body fluid,Extracellular,Interstitial fluid Plasma Lymph fluid Secretory juice,-distribution of body fluid,P 6%,IF 37%,IC 35%,IF 20%,IF 10% 15%,IF 25%,IC 40%,P 5%,P 5%,P 5%,IC 40%,IC 40%45%,Neonate 78%,1y 70%,2y14y 65%,Adult 55%60%,features of body fluid balance in children,P: plasma IF: interstitial fluid IC: intracellular,-distribution of body fluid in different ages (by BW),features of body fluid balance in children,-water requirement,Requiring more water Regulating function poorly Easy water metabolism disturbance,Due to grow quickly, need 0.5%3% water for growth. Insensible water loss : 2 times more than adult. Fluid exchange of digestive tract quicker. Water metabolism higher: infant 1/2 by total fluid adult 1/7 by total fluid. Regulating function of water metabolism poorly: kidney, lung.,features of body fluid balance in children,-water requirement,Similar with adult,Extracellular: Na+, Cl-, Hco3-,Intracellular: K+, Mg, Hpo4=, protein,Features of neonate (Several days after birth) :,Composition of body fluid,Particularly in preterm infant,K+, Cl-, P, lactic acid,Na+, Ca+, Hco3-,Function of excluding H+,Acidosis,Acid-base balance and adjust -two concept,Acid-base balance Acidity and alkalinity Anion-cation balance Anion and cation,Compensation of adjust has limit,Acid-base balance and adjust -body liquid,Buffer system lung ：exhale of store CO2 (respiratory) kidney: exclude H+ and store Na+ (metabolic),NaHCO3/H2CO3 Na2HPO4/NaH2PO4 Buffer system of plasma protein,Adjust HCO3-,NaHCO3/H2CO3=20:1,PH：7.4 (7.357.45) PaCO2：40 (3445) mmHg SB：24 (2227) mmol/L BE：-3 +3 mmol/L CO2CP：22 (1827) mmol/L,Acid-base index,Blood gas analysis（normal ）,Compensation & decompensation,Acid-base balance disorder,respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis,Dispirited, dysphoria, drowsiness, coma Hypernea (Kussmauls breathing)，exhalation cool Expiratory gas smells ketone Cherry lips Nausea, vomit,Metabolic acidosis-clinical manifestation,Mild: breath frequency slightly Severe: occur:,To cure water and electrolyte disturbance,Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte,Normal physiological function,Fluid therapy Purpose,oral,intravenous,Fluid therapy Method,prevention dehydration: Rice soup add salt solute（1/3） Mild dehydration: ORS。 Mild/moderate dehydration : ORS mild: ORS： 5080ml/kg moderate: ORS：80100ml/kg Severe dehydration or vomiting and diarrhea intravenous,NaCl：3.5g NaHCO3 (Sodium citrate)：2.5g (2.9g) KCl：1.5g GS：20g,oral rehydration salts （ORS）,Na+ 90mmol，+20mmol， Cl80mmol，HCO3 30mmol Add water to 1000ml 2 / 3 isotonic , Total osmotic pressure: 220mmol Can be diluted in Children,口服补液盐 Oral rehydration salt (ORS),WHO2002年推荐的低渗透压ORS配方 成分 含量 (克) NaCl 2.6 枸橼酸钠 2.9 KCl 1.5 葡萄糖 13.5 水 1000ml 该配方中各种电解质浓度为：Na+ 75mmol/L， K+ 20 mmol/L，C1- 65 mmol/L，枸橼酸根 10mmol/L，葡萄糖75m mol/L。总渗透压为245 mOsm/L,sodium citrate could instead by NaHCO3,Na + - GS transport in Small intestine,Na+GS carrier,enterocyte Brush border,intracellularintercellularblood,Na+ GS,Na+ GS,transport,promote,Na+、H2O absorb,Na+(pump) intercellular space(Cl- )OP H2O into blood,Mechanisms of ORS,Characteristics of ORS -Advantages,Osmotic pressure similar with plasma(2/3 tonicity) Correct losses by proper concentration of Na+ 、K+ 、Cl- Children easily accept the tastes Correct metabolic acidosis by sodium citrate Promote Na+ and H2O absorption by 2% GS,Characteristics of ORS -disadvantages,Liquid tonicity higher (2 / 3) Can not be used as the maintenance media Na+ concentration is relatively higher to neonates and infants (proper diluted) .,ORS： Rice soup 500ml+ salt 1.75g Fried rice noodles 25g + salt 1.75g + water 500ml (Cooking 23min) GNS: White sugar 10g + salt 1.75g + water 500ml (boil),Simple preparation at home,Severe dehydration,intravenous,Osmotic pressure of plasma (OPP) OPP= (crystal + colloid) osmotic pressure,Na+ 142 Cation: K+ 5 (mmol) Ca+ 2.5 Mg+ 1.5,HCO3- 27 Anion: Cl- 103 (mmol) HPO4= 1 SO4= 0.5 Organo-anion 19.5,151 mmol/L,151 mmol/L,OPP range：280320mOsm/L,Concentration of electrolyte and calculation,Osmotic pressure, osmol（OSM） Dissolve 1mmol solute into 100ml water: 1mOsm.,100ml water,1mmol,1mOsm,Concentration of electrolyte and calculation,To non electrolyte,1mmol GS,1mOsm,2mOsm,1mmol Nacl,To electrolyte,1mmol Cacl2,3mOsm,Concentration of electrolyte and calculation,Na:Cl=3:2 （in plasma）,Fluid isotonic,Isotonic liquid: osmotic pressure similar with plasma Sodium isotonic:,Isotonic: 150mmol sodium in 1000ml tonicity: 75mmol sodium in 1000ml 2/3 tonicity: 100mmol sodium in 1000ml 1/3 tonicity: 50mmol sodium in 1000ml,Liquid solution commonly used,5%GS 10%GS,0.9%NaCl 10%NaCl Ringer 5% NaHCO3 11.2% NaL 10%KCl Mixture,nonelectrolyte solution,electrolyte solution,glucose enter the body by oxidation change into water and CO2 for energy and water without tension,Percentage concentration: 5%GS、10%NaCl Molar (mol, gram molecular weight) , mmol 1 mol NaCl=23+35.5=58.5g Molarity (mol/L) calculation：,mol/L=,e.g. 0.9%NaCl=,=0.154mol/L,Concentration of electrolyte and calculation,Percentage concentration of solute（%）10,Molecular weight (atomic weight),0.910,58.5,=154mmol/L,10%NaCl： 1ml=1.7mmol 5%NaHCO3：1ml=0.6mmol 11.2%NaL： 1ml=1mmol 10%KCl： 1ml=1.34mmol,Calculation,The element and simple dispensing in the commonly mixed solution,Solution composition ratio dispensing (ml) NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl 2:1 isotonic solution . 2 1 500 30 47 1:1 solution (1/2 tonicity) 1 1 500 20 2:3:1 solution (1/2tonicity)2 3 1 500 15 24 4:3:2 solution (2/3tonicity)4 3 2 500 20 33 1:2 solution (1/3 tonicity)1 2 500 15 1:4 solution (1/5 tonicity) 1 4 500 9 daily requirement (1/3tonic) 1 4 500 9 7.5,常用溶液成分 溶 液 每100ml含 NaCl 电解质渗透压 血 浆 （142：103）3 ：2 300mmol/L 0.9%氯化钠 0.9g 11 等张 5%或10%葡萄糖 5或10g 5%碳酸氢钠 5g 3.5张 1.4%碳酸氢钠 1.4g 等张 10%氯化钾 10g 8.9张,溶 液 每100ml含 NaCl 电解质 11含钠液 50ml,50ml 11 1/2张 12含钠液 35ml,65ml 11 1/3张 14含钠液 20ml,80ml 11 1/5张 21含钠液 65ml,35ml 32 等张 231含钠液 33ml,50ml 17ml 32 1/2张 432含钠液 45ml,33ml 32 2/3张 22ml,续 表,Water supplement & correct acidosis,Accumulative losses -losses from onset to pre-treatment ongoing losses -continuing losses during treatment daily requirement -to maintain basically physiological function,Amount , composition and time,The first day fluid infusion ：,Dehydration Fluid replacement=losses (Accumulation + ongoing + daily ) Accumulation ongoing daily total amount (ml/Kg) mild 50 1030 6080 90120 moderate 50100 1030 6080 120150 Severe 100120 1030 6080 150180,Accumulation: accumulation losses Ongoing: Ongoing losses daily: Physiological requirement,Severity clinical signs of dehydration,Dehydration,Accumulation losses,amount,mild： 50ml/kg moderate: 50100ml/kg severe： 100120ml/kg,Water supplement-1: accumulation losses,Amount , composition and speed: - according to the degree and quality of dehydration,composition,isotonic ： 1/2 tonicity(1:1) hypotonic：2/3 tonicity(4:3:1) Hypertonic:1/31/5 tonicity (1/3 tonicity),speed,Principle: fast slow severe：bolus of isotonic fluid 2:1 isotonic : 20ml/kg(300ml) in 301h(rapidly expand) others： 812h (810ml/（kgh） iv,Water supplement-1: accumulation losses,Accumulation losses,Dehydration :,Ongoing losses,amount,1/21/3 tonicity(1:1),speed,1216h after stage-1 In 24h, steady speed 5ml/（kgh）,1040ml/kg.d,composition,Water supplement-2: ongoing losses,daily requirement,amount,1/31/5 tonicity (Physical main medium),speed,In 24h, steady speed Accompany with stage-2,6080ml/kg.d （including oral）,composition,Water supplement-3: daily requirement,To master three principles,The volum of rehydration- Amount Deficit fluid =(percentage of dehydration)(body weight in Kg) The type of fluid- Composition Isotonic dehydration1/2 tonicity solution Hypotonic dehydration2/3 tonicity solution Hypertonic dehydration1/3 tonicity solution The speed of liquid-Time：four steps,four steps (for fluid and electrolyte deficits),Step 1. Expanding volume: restoration of circulation emergency, within 30 min to 1 hour 20ml/kg, 2:1 (isotonic )sodium solution Step 2. supplement lost body liquid: first 810 hours 810ml/h half of total loss volume 2:3:1 solution(1/2 tonicity),Step 3. maintenance rehydration: - another half loss - next 16 hours 5ml/(kg.h) physical demand : 6080ml/kg 4:1 solution(1/31/2 tonicity) Step 4. repair of potassium deficit,four steps,mild：correct etiological factor Moderat & severe： Alkaline solution requirement (mmol) (40 CO2CP Vol%) 2.2 = (22 - CO2CP mmol/L) 0.7 kg = BE 0.3 kg,0.7 kg,Usually use the dose halved first and than according to blood gas analyses,Correct acidosis,=,Emergency : Per-elevate 5mmol HCO3- 5mmol/L(10% CO2-CP) need alkaline solution: 3mmol/kg 5%NaHco3 5ml/kg or 1.4% NaHco320ml/kg,Correct acidosis,Supplement potassium: 10%KCL,mild hypokalemia：200300mg/（kgd） 23ml/（kgd）oral sever hypokalemia：300450mg/（kgd） 34.5ml/kg.d 10% KCl ivdrip,Supplement after urine or urination before coming diagnoses Intravenous concentration68h/d（intravenous） Time：keep 46 day interdiction：directly intravenous， because heart stop！,Supplement potassium principle：,Supplement Calcium and Magnesium,Convulsion emerged ： 10% Calcium Gluconate 10ml+25% Glucose 10ml IV If convulsion hasnt relieved after supplement calcium, give 25% Mg.Sulfas 0.20.4ml/kg deeply IM Q6h be careful （Calcium ）: HR80 time /minute ，stop！ Dont leak out vessel Interval of the Digitalis Dont injection with subcutaneous and intramuscular,first fast then slow,Principles of Therapy,first thick then thin,supplement potassium when having urine,adjust any time and monitor,Ongoing losses and daily requirement daily requirement 6080ml/kg (1/31/5 tonicity) Ongoing losses follow the how much of the lost in the any time ( 1/21/3 tonicity) 1224H equal the speed iv drip To continue the supplement potassium and correct acidosis,The second day fluid infusion ：,Neonate: to reduce the liquid and electrolytes properly. Severe malnutrition：to reduce the water amount properly, with low speed, 2/31/2 tonic supplement 10% GS and / or plasma,Notes,operation day 2 ml/kg/h the first day* 4 ml/kg/h (the first 10kg) 4 ml/kg/h (the second 10kg) 2 ml/kg/h *heart failure / breathing machine utilization: 3ml/kg/h put to open warm casing, the volume 10%,Fluid requirement at post operation or heart failure,heart failure or heart post operation,Control the solution by intravascular injection Volume include : maintenance fluid in vascular； medicine and dilution； rinse solution for the vascular tubule； gastric tube or food-intake。,Fluid requirement at post operation,Include potassium glucose and sodium 1/41/5 tension 10% GS 500ml 10%NaCl 10ml 10% KCl 15ml ( 9.5%GS、0.19%NaCl、0.29%KCl ),An 8 month boy had diarrhea and vomit