Fluid Therapy NS = 154 mEqL Na 3% NaCl

							                                       Fluid Therapy

NS = 154 mEq/L Na
3% NaCl = 513 mEq/L Na
D5W= 5 gm dextrose/100 ml

                             Maintenance fluid requirements:

• Use D5 ½ NS + 20 meq KCl/L (D10 ¼ NS if <6mos, D5 1/4NS if <10 kg).
100 cc/kg/day for 1st 10 kg body weight
50 cc/kg/day for next 10 kg
20 cc/kg/day for each kg above 20 kg
• Rate (ml/kg/hr): First 10 kg: 4; Second 10 kg: 2; Each additional kg: 1

                                        Dehydration

   Weight Change      Mild (5%)      Mod (5-10%)       Severe (>10%)
   Urine Output       Normal - ↓     Oliguria          Anuria
   HR                 Normal         ↑HR               ↑↑HR
   BP                 Normal         Orthostatic       ↓BP
   Perfusion          Normal         ≥ 2 sec           > 3 sec
   Membranes          Moist          Dry               Parched
   Skin turgor        Normal         Tenting           None
   Tears              Present        Reduced           None
   Fontanelle         Flat           Soft              Sunken

                                   Rehydration therapy

• NS 20 cc/kg IV bolus as needed to restore BP and perfusion.
• IVF = Maintenance + deficit fluid volume – bolus fluids given
• Isotonic & Hyponatremic: Give half of replacement therapy in addition to maintenance needs
over the first 8 hr and the second half over the next 16 hr.
• Hypernatremic: Losses should be measured and may require replacement every 6-8 hr.
Deficit and maintenance should be evenly replaced over 48 hrs. Avoid dropping serum Na > 15
mEq/L per 24 hrs, follow Na levels Q 4 hrs.
                                           Electrolytes

Electrolyte Deficit: mEq required = (CD –CP) x fD x wt
CD = Concentration desired (mEq/L) i.e. Na 135
CP = Concentration present (mEq/L) i.e. Na 126
fD = distribution factor as fraction of body weight (L/kg) (Na: 0.6-0.7) (Cl: 0.2-0.3) (HCO3: 0.4-
0.5)
wt = baseline weight before illness (kg)

 Hyponatremia             Seizures caused by hyponatremia 10-12 mL/kg 3% NaCl over 60
                          min
 Hypernatremia            Always with dehydration. Replace half of free water and all of the
                          solute deficit over 24 hrs, avoid dropping serum Na > 12 mEq/L
                          per 24 hrs to minimize cerebral edema. Free water needed to
                          decrease serum Na by 1 mEq/L is 4 mL/kg for Na < 170. Correct
                          over 48 hrs, check Na Q 4 hr. Goal is change of <0.5 mosm/L/hr.
 Hypokalemia              KCl 0.5-1 meq/kg/dose IV over 2hrs. (max 20 mEq in IV bolus).
                          Use 0.5 if renal or cardiac disease.
 Hyperkalemia             K = 6 –7: Eliminate K from diet and IVF. Cardiac monitor, Consider
                          Kayexalate 1-2g/kg PO/PR Q6hr.
                          K > 7: Above plus Ca Gluconate (10%) 100 mg/kg/dose over 305
                          min (may repeat in 10 min, will normalize membrane NOT lower K
                          concentration); NaHCO3 1-2 mEq/kg IV over 5-10 min; Insulin 0.1
                          U/kg IV with D25W 2cc/kg over 30 min (repeat 30-60 min, monitor
                          glucose Q1hr); consider albuterol; consider dialysis if
                          unsuccessful.
 Hypomagnesemia           MgSO4 25-50 mg/kg/dose IV q4-6hr x 3 doses (max single dose 2
                          gm)
 Hypocalcemia             Ca Gluconate 10% 50 mg/kg IV
 Hypercalcemia            Hydrate to inc UOP and Ca excretion. If GFR & BP are stable, NS
                          with maintenance K at 2 -3 x maintenance rate until Ca
                          normalized; diuresis with lasix; hemodilaysis for severe/refractory
                          cases.
 Hypophosphatemia         NaPhos or Kphos 5-10 mg/kg/dose IV over 6hr
 Hyperphosphatemia        Restrict dietrary phosphate; phosphate binders (calcium
                          carbonate, aluminum hydroxide(Amphojel)).
                                      Gastroenterology

Stress Ulcer Prophylaxis
• Famotidine (Pepcid) 0.5 mg/kg/dose PO/IV Q 12hr
• Ranitidine (Zantac) 1-2 mg/kg/dose PO Q 12 hr or 2-4 mg/kg/day ÷ IV Q 6-8hr

Motility Agents
• Metoclopramide (Reglan) 0.1-0.2 mg/kg/dose PO/IV/IM Q 6hr

Constipation
• Mineral Oil 5-15 ml/24 hr ÷ PO QD-TID (NOT < 1 year old, risk of aspiration)
• Lactulose 7.5ml/24 hr PO QAM. Titrate to effect
• Docusate (Colace) 10 mg/year age/dose ÷ PO QD-QID (max 500 mg/dose)
• Bisacodyl (Dulcolax) 0.3mg/kg/24 hr PO; <2yrs 5mg, >2yrs 10mg PR prn.

Emesis
• Always use Phenergan, Compazine, Reglan, or Droperidol with Benadryl to prevent dystonic
reactions
• Chemotherapy: Kytril (Granisetron) (10-20 mcg/kg IV 30 min prior to chemo). Can add
compazine, reglan, or droperidol.
• Postanesthesia: Zofran (Ondansetron) 0.15 mg/kg/dose IV Q4hr or Reglan 1-2 mg/kg/dose
Q 2-6hr
• Benadryl (Diphenhydramine) 1 mg/kg/dose Q 6hr PO/IV/IM
• Droperidol 0.03-0.07 mg/kg/dose IV/IM Q 4-6hr
• Compazine (Prochlorperazine) 0.1 mg/kg/dose PO/PR Q 6hr
• Promethazine (Phenergan) 0.25-1 mg/kg/dose IV/IM/PO/PR Q 4-6hr
                                             Renal

Oligura or Anuria
• Flush foley, make certain foley is patent.
• Decide if prerenal, renal or postrenal.
• Labs: lytes, BUN, Cr, uric acid, PO4, Urine Analysis, Specific Gravity, Urine lytes, Urine Cr
• Adjust all meds to renal dosing.

                    BUN/Cr      S.G.         UNa      Uosm         FENa
    Prerenal        >20         >1.020       <20      >500         <1%
    Renal           <10         <1.020       >40      <350         >3%

FENa = [UNa (PCr)/PNa(UCr)] * 100

UTI Prophylaxis
• Keflex: 25mg/kg PO QD
• Bactrim: 2-4 mg/kg PO QD
• Nitrofurantoin: 1-2 mg/kg PO QHS
                                          Endocrinology
Diabetic Ketoacidosis

PICU Admission:
• Arterial pH < 7.3 or venous pH < 7.25
• Bicarb or CO2 < 15
• Altered mental stus
• Severe vomiting/dehydration
• Glucose > 600

Management:
 First hour           • NPO; Large bore IV; Accucheck Q 1 hr; Neuro check Q 30-60
                      min; VBG Q 2-4 hrs; Lytes Q 4 hrs; RUA Q 8 hrs
                      • Labs: BMP, Ca, Mg, Phos, CBC, VBG, RUA, Insulin level (new
                      onset only)
                      • NS 20 cc/kg fluid bolus over 30-60 min
                      • Insulin drip
 Second hour          • Accucheck
                      • Rehydration at 1 ½ x maintenance
                      • Insulin drip
                      • Correct Electrolyte abnormalities
 Fluids               NS + 20 mEq/L KCl + 20 mEq/L K phos
                      If serum K ≥ 5, decrease total K in fluids to 20 mEq/L
                      If serum K ≥ 5.5, omit K from fluids
 Fluid rate           1 ½ x maintenance for 24 hrs or until acidosis is resolved
 Insulin              0.1 Units/kg/hr, DO NOT BOLUS!!
 Dextrose             Add dextrose when serum glucose < 300, accuchecks Q 1 hr,
                      titrate dextrose to maintain accuchecks 100-200

                                   Insulin Preparations
      Insulin                 Onset (hr)   Peak (hr)    Duration (hr)
      Rapid-Acting
      Lispro (Humalog)        5-15 min        30-90 min   5
      Insulin, regular        0.5-1           2-3         5-8
      Intermediate-Acting
      Insulin (NPH)           2-4             4-10        10-16
      Insulin (Lente)         2-4             4-12        12-18
      Long-Acting
      Ultralente              6-10            10-16       18-24