Magical Salty Water: An Overview of Pediatric Fluid Resuscitation

11.5 hours into a night shift…  2 week old male 5kg  911 for tachypnea and decreased level of consciousness  Eyes to voice, withdraws from pain, weak cry  HR – 205, BP 80 sys, RR-60

Objectives  Pediatric assessment  Fluid resus – indications  Fluid resus – contra-indications

Compensated Shock  Tachycardia  Cool & pale distal extremities  Prolonged (>2 seconds) capillary refill  Weak peripheral pulses compared to central pulses  Normal systolic blood pressure Circulation.Circulation Nov 2;122(18 Suppl 3):S doi: /CIRCULATIONAHA

Decompensated Shock  Decreased mental status  Decreased urine output  Tachypnea  Weak central pulses  Deterioration in colour Circulation.Circulation Nov 2;122(18 Suppl 3):S doi: /CIRCULATIONAHA

What does normal mean? AgeHeart Rate (Beats/min)  Infant  Toddler  Preschooler  School-age  Adolescent AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.40

They told me not to worry about the BP  Neonates (0-28days): <60mmHg systolic  Infants (1-12 monthes): <70mmHg  Children (1-10 y/o): < 70mmHg (+ 2 x age)  Children (>10y/o): <90mmHg Circulation.Circulation Nov 2;122(18 Suppl 3):S doi: /CIRCULATIONAHA

Because I feel like it… Resuscitation vs. rehydration (Treatment vs. diagnostic) Quick & Dirty Assessment  Heart Rate  Skin colour/condition  Level Of Consciousness

The magic of the salty water  NRP Guidelines Under 28 days 10cc/kg over 20 minutes  PALS Guidelines 20cc/kg NS as a resus bolus: 60cc/hr then dopamine  Sepsis – Crystalloid (NS or RL) :Class IIa LOE C  Hypovolemia – Crystalloid (NS or RL): Class I LOE A Circulation.Circulation Nov 2;122(18 Suppl 3):S doi: /CIRCULATIONAHA

She got legs… Do you know how to use them?  Proximal Humerus  Proximal Tibia  Distal Tibia  Distal Femur  Consider Lidocaine

Special Considerations: Diabetic Ketoacidosis:  What does DKA Look like?  Why not give fluid?  What should I do? Cardiac Anomalies:  What do cardiac problems look like?  Why not give fluid?  What do I do?

No, actually, I haven’t dipped the urine…  History of polyuria, polydipsia, weight loss, nausea and vomiting  Signs of Dehydration  Breath with fruity odor  Abdominal pain  Tachypnea  Lethargy AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.188

Oops, I didn’t know that would happen… Cerebral edema  Frequency 1%  Most important cause of mortality  Presents with headache and/or altered level of consciousness AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.189 Cerebral herniation/ICP  Obtundation  Papilledema  Pupillary dilation  Anisocoria  BP variability  Bradycardia  Apnea

But you said he was dehydrated? What do I do?  Minimally dehydrated?  Oral rehydration  No vascular decompensation? (clinically dehydrated, vomiting)  7cc/kg 0.9% NaCl over the first hour; then 3.5-5cc/kg/hr  Vascular Decompensation? (Hypotension, +/- coma)  10cc/kg 0.9% NaCl over the first hour, then 5cc/kg/hr The hospital for Sick Children handbook of pediatrics/editors, Anne I. Dipchand … (et. Al.) – 11 th edition (2009) Toronto

I am calling about your ducts…  High Index of Suspicion!  BP  Pre-Ductal  Post-Ductal  Sp02  Pre-Ductal  Post-Ductal  Hypoxia without dyspnea

So what? I sweat when I eat too..  Who is at risk of CHF?  What is exertional dyspnea  Hepatomegaly vs pulmonary edema

Cardiac Anomalies  NS 5-10cc/kg  Consider Lasix  Consider Dopamine

Back to the night shift…  3 week old male 5kg  911 for tachypnea and decreased level of consciousness  Eyes to voice, withdraws from pain, weak cry  HR – 205, BP 80 sys, RR-60

Summary  Big picture assessment!  Don’t be scared of the IO  Treatment vs. diagnostic  20cc/kg NS or LR (give more!!! Kids need fluid)  5-10cc/kg NS or LR (Careful of cardiac & DKA)

Questions Jonathan