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NICE guideline on IV fluid Therapy in Children and young People in Hospital.

This will be of interest anyone who uses IVF in kids.  I’ve picked out the bits I think are relevant to EM.  The guideline does not cover pre term infants so if you’re interested in that look elsewhere.

Whether IV fluid therapy is needed for fluid resuscitation, routine maintenance, replacement or redistribution, it is vital that the correct composition, volume and timing of IV fluid therapy is used. Errors in prescribing or administering IV fluids can result in inadequate or excessive provision, leading to hypovolaemia and poor organ perfusion, or hypervolaemia, oedema and heart failure Failing to deliver correct fluids can therefore have a significant impact on morbidity and mortality.

This guidance represents a major opportunity to improve patient safety for children and young people having IV fluid therapy in hospital.

When assessing a child for IVF in ED you need to consider and document the following. There is a more exhaustive list in the guideline but I think these are what we’re likely to do in ED.

  • Actual or estimated daily body weight: if using an estimate the actual weight should be recorded as soon as possible.
  • An assessment of fluid status.
  • The results of any tests, including Point Of Care tests.  The guideline specifically mentions measuring blood glucose before starting IVF and then recommends measuring it daily
  • Details of ongoing losses.
  • Detail of how you’ve calculated the fluid you’re prescribing.

The table below is how NICE recommends we discriminate between the hydrated, dehydrated and shocked child.  I think taking this in the context of the child in front of you is vital!

 

Severity of dehydration
No clinically detectable dehydration Clinical dehydration Clinical shock
Symptoms (remote and face-to-face assessments) Appears well Red flag Appears to be unwell or deteriorating
Alert and responsive Red flag Altered responsiveness (for example, irritable, lethargic) Decreased level of consciousness
Normal urine output Decreased urine output
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Signs (face-to-face assessments) Alert and responsive Red flag Altered responsiveness (for example, irritable, lethargic) Decreased level of consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Eyes not sunken Red flag Sunken eyes
Moist mucous membranes (except after a drink) Dry mucous membranes (except for ‘mouth breather’)
Normal heart rate Red flag Tachycardia Tachycardia
Normal breathing pattern Red flag Tachypnoea Tachypnoea
Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses
Normal capillary refill time Normal capillary refill time Prolonged capillary refill time
Normal skin turgor Red flag Reduced skin turgor
Normal blood pressure Normal blood pressure Hypotension (decompensated shock)

 

Resuscitation fluid should be a glucose free crystalloid at 20mls/kg over less than 10mins: Give some consideration to what and how you‘re going to give it.

Do not use tetrastarch for fluid resuscitation. The nail surely is in the coffin now of this sticky wet stuff as a resuscitation fluid?!

You must then reassess to decide if they need more.

Maintenance fluid should be calculated using the Holliday–Segar formula (100 ml/kg/day for the first 10 kg of weight, 50 ml/kg/day for the next 10 kg and 20 ml/kg/day for the weight over 20 kg).  For this fluid you should be using isotonic fluid with a Sodium in range 131-154mmol i.e. normal saline or Hartman’s.

 

References:

 

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