Fluid Maintenance in Pediatric Patients

C. Hammond RN, MN

Volume is Important
Needed for all metabolic processes Imbalance results in negative health consequences Delicate requirements of pediatric patients

Delicate Balance in Pediatrics

Greater proportion of body fluids, higher metabolisms, more fluid output, small size Need relatively more fluids to maintain balance

 Those with the greatest proportion of body water are most sensitive to changes and imbalances We have to ensure we are providing an adequate amount of fluid to maintain optimal body functioning (oral, IV, feeding tubes) This is a particularly delicate balance for children and infants because they have a greater proportion of body fluids, high metabolisms with more fluid output relative to size, and small sizes which puts them at greater risk for developing fluid imbalances, particularly dehydration, than adolescents and adults. So, they require relatively more fluids to maintain balance. Many hospitalized children demonstrate or can develop fluid imbalances during their stay. Therefore, as nurses, we need to develop an understanding of the fluid requirements of children in order to prevent problems, or take appropriate action to deal with problems.

Assessing Fluid Balance

Vital signs Monitor I & O Daily weights Mucous membranes Skin turgor Capillary Refill Fontanels Lungs Level of consciousness

Signs of Over Hydration

Edema Shortness of breath Crackles Cough Increased weight Increased BP Bulging fontanels Altered urine output

Conditions that May Limit Fluid Requirements

CHF Increased ICP SIADH Post op Renal failure

Signs of Dehydration (vary with severity)

Tachycardia Fever Thirst Decreased cap refill Sunken eyes No tears Dry skin and membranes Decreased weight Decreased urine output Late signs= dizziness, lethargy, altered mental status, low BP

Conditions Requiring Increased Fluids

Fever Vomiting Diarrhea Burns Diabetes insepidus Tachypnea Shock Renal failure

So what is the right amount?

WEIGHT, WEIGHT, WEIGHT!!! Maintenance fluid is the amount of fluid the body needs to replace usual daily losses from the respiratory tract, the skin, and the urinary and GI tracts. This can be through drinking, IV fluids, or feeding tubes. If a child takes in significantly less than maintenance requirements, he or she will gradually become dehydrated.

The 4-2-1 Rule

4 ml/kg/hr for the first 10 kg 2 ml/kg/hr for the second 10 kg 1 ml/kg/hr for the remaining weight

Lets Practice!
1) 7 year old Jane is 23 kg. What is the minimum amount of uid she should drink? 2) 4 day old Ben has an IV. If he is 3.2 kg, what is the hourly rate the IV should be infusing at to maintain his uid requirements?

Answers
23kg 4 ml x 10kg = 40 2 x 10 = 20 1 x 3 = 3 40+ 20 + 3= 63ml/hr or 1512ml/day (1.5L)

3.2kg 4 x 3.2 = 12.8ml/hr or 307.2ml/day

Jack is 17 kg. 1. Calculate the hourly fluid maintenance requirement.

2. Convert this into his requirements for a 24hr period.

Management of Pediatric Dehydration

Normal Saline bolus of 20ml/kg (can be repeated twice if needed) Replace decit and ongoing losses Provide maintenance uids

What goes in must come out!

Urine output in the pediatric population:
Infants- 2ml/kg/hr Children- 1ml/kg/hr Adolescents- 0.5ml/kg/hr Oliguria= <0.5ml/kg/hr Anuria= 0 Polyuria= >3ml/kg/hr

Calculating urine output

Urine output divided by paYent weight divided by # hours since previous output 1) 10kg Joe was last changed at 1400. It is now 1800 and his wet diaper weighs 84mg (dry diaper weight has already been subtracted). Is this an adequate output?

Summary
Our bodies rely on maintaining adequate fluid volume Pediatric patients are more sensitive to changes in volume We can use the 4-2-1 Rule to calculate basic fluid maintenance requirements in uncomplicated pediatric cases All of our metabolic processes and body functions rely on maintaining the appropriate volume and composition of fluid in our bodies Adults and children differ significantly in their fluid requirements Because of their higher metabolic rate, greater proportion of body fluid, and small sizes, children require relatively more fluid to maintain their requirements Ensuring adequate fluid intake is an essential for pediatric patients