1. Nadin Abdel Razeq, PhD

2. Objectives To gain awareness of the proper procedure of peripheral IV access in pediatrics To review types of IV fluids used in children To review basics of maintenance and deficit fluid and electrolyte requirements To gain awareness of the proper procedure of IV- formula preparation and administration in pediatrics To review basics of IV medications administration in children!

3. Proper Procedure of Peripheral IV Access in Children Let us watch a Video First … Then Let us Focus on Some Important Concepts All procedures at a treatment room Scalp Site and Arterial insertion To Get Better IV access you can… Number of IV access Attempts…

4. Basic Concept :- Osmotic Pressure

5. Basic Concept :- Osmolality of the blood Isotonicity of Blood = 275-295 mOsm/L Solutions having the same osmotic pressure as that of blood are said to be isotonic with blood. Solutions with a higher osmotic pressure than body fluids are called hypertonic Solutions with a lower osmotic pressure are called hypotonic.

7. Types of IV fluids in children 5% glucose in water 0.9% NaCl (Normal Saline)

8. Types of IV fluids in children 25% or 50% glucose in water Never as an infusion Only used in NICU and at low vol eg. 1-2mls/hr via central line 10% glucose in water -------------------------- 15% or 20% glucose in water Give only via a central line as a 1-2ml/kg bolus for hypoglycaemia. Monitor blood glucose

9. Types of IV fluids in children 0.9% NaCl with 5% dextrose (Normal saline with glucose) Osmolarity: 560

10. Types of IV fluids in children 0.18% NaCl and 4% dextrose (4% and 1/5th normal saline) 0.45% NaCl with 5% dextrose (1/2 Normal saline with glucose and no potassium

11. Types of IV fluids in children Ringer Lactate : 0-10 gram glucose/100cc Na 130 mEq/L NaHCO3 28 mEq/L as lactate K 4 mEq/L 273 mOsm/L Water for injection

12. Maintenance Electrolyte Requirements Maintenance K Requirements: IV: 1-2 mEq/100ml of water/day OR 1-2mEq/kg/day Indications : Administration: Added only once the urine output is established. Strength: Calculate : Side effect: ECG monitoring Frequent testing \

14. Maintenance Electrolyte Requirements Maintenance Ca Requirements: IV: 60 to 100 mg/kg/day Indications : Administration: Strength: Calculate : Side effect:

16. IV formulas – Practice 100ml 0.9% NaCl + 20 ml 10% G/W + 5 mEq KCL / 8 hrs Microdropper

18. Calculation of Maintenance Fluid Requirements…the Holliday-Segar Method Class activity: A 30-kg child would require??? Kathleen Asas, MD.MPH

19. Calculation of Maintenance Fluid Requirements… A 30-kg child would require (100 × 10) + (50 × 10) + (20 × 10) = 1,700 cc/day or (4 × 10) + (2 × 10) + (1 × 10) = 70 cc/h. Kathleen Asas, MD.MPH

21. Oral Rehydration: Key Concepts Mild to moderate dehydration may be managed successfully with oral rehydration in the majority of cases. Oral rehydration solutions should contain glucose and sodium in a ratio not to exceed 2:1 Amount of rehydration solution to be given is based on the estimated percentage of dehydration by weight. Kathleen Asas, MD.MPH

22. Oral Rehydration Patient vomiting – 5-10mL Q 5-10 minutes and increase as tolerated Mild Dehydration – Deficit replacement: 50 mL/kg over 4 hours Moderate Dehydration – Deficit replacement: 100 mL/kg over 4 hours Kathleen Asas, MD.MPH

23. Phase I: Resuscitation using Isotonic Fluids (NS/LR) at 20ml/kg. Re-evaluation until urine output and dehydration signs improved Phase II: Calculate maintenance & deficit fluid Determine if Isotonic, Hypotonic or Hypertonic Dehydration Hypotonic Na <130 Isotonic 130< Na <150 Hypertonic Na >150 Replace fluids over 48hrs** Kathleen Asas, MD.MPH

24. Resuscitation phase Goal: Restore circulation, re-perfuse brain, kidneys Mild-Moderate  20 mL/kg bolus given over 30 – 60 minutes Severe  May repeat bolus as needed (ideally up to 60ml/kg) Fluids – something isotonic such as NS or lactated ringers (LR) Kathleen Asas, MD.MPH

25. Replacement Phase Stabilization Phase (For Isotonic/Hypotonic Dehydration) Goal: Replace deficit of fluids and electrolytes Replacement Phase 1 st 8 hrs Stabilization Phase Next 16 hrs MIVF and Maint Na 1/32/3 Deficit Fluid & Deficit Na 1/2 Kathleen Asas, MD.MPH

26. IV Medications

27. IV Medications - basic Concepts Correct :  Patient  Drug  Dose  Rout,  IV or Oral ----- check IV site,  Time, Time of Other Medications  Documentation

28. IV Medications - basic Concepts Administration :  Micro-dropper for each Med  Minimum dilution of drugs  What to Do with the extra fluids  Type of solution and computability  Meds Never with blood product  Duration of administration – Time of Other Medication