Pediatric Shock Part 8 Fluid therapy

Fluid Resuscitation Goals

·         Restore circulating fluid volume

·         Restore oxygen-carrying capacity

·         Reducing oxygen demand

·         Correct metabolic imbalances secondary to fluid depletion

Note:  Early resuscitation of circulating blood is important in halting the progression of shock to cardiac arrest

Fluid Resuscitation

• Give isotonic crystalloids 20ml/kg over 5-20 minutes
• Repeat 20ml/kg boluses to restore BP and tissue perfusion
• Frequently reassess the child to determine response to therapy

Fluid Replacement

·         Crystalloid

·         Colliods

·         Blood products

Crystalloids-

·         Normal Saline, Ringers lactate

·         Inexpensive, readily available,

·         Expand the interstitial space

·         Do not remain in the intravascular spaces

·         Usually large volumes are required

·         20ml/kg bolus over 5-20 minutes

·         5-10ml/kg if myocardial dysfunction is present

Note:  When signs and symptoms of shock are detected, rapidly administer a fluid bolus and assess the patient’s response. Provide additional boluses until systemic perfusion improves and signs of shock are corrected

Colloids

·         5% albumin, fresh frozen plasma, hetastarch

·         More efficient volume expanders

·         Remain in vascular space longer

·         May cause sensitivity reactions

Blood Products

·         Not first choice for volume expansion

·         Used to replace blood loss not responsive fluid boluses

·         Correct coagulapathies

·         10-15ml/kg of PRBCs

Blood Products

Fully crossmatched

Unmatched type specific

Type O (O-negative for females)

Blood Product Complications

·         Hypothermia

·         Myocardial dysfunction

·         Ionized hypocalcemia

·         Consider risk of blood-borne infections

Rate and Volume of Fluid Administration

·         Isotonic crystalloids  20ml/kg over 5-20 minutes

·         Repeat boluses of 20ml/kg as needed

·         Give 5-10ml/kg over 10-20 minutes with myocardial dysfunction

Fluid Delivery

·         Use as large an IV catheter as possible

·         Place an in-line 3 way stopcock in the IV line

·         Deliver boluses using a 30-60ml syringe to push the fluids

Reassessment

·         Observe for signs of physiologic improvement after each fluid bolus

·         Evaluate need for further fluid boluses

·         Assess for signs and symptoms of fluid overload.

Maintenance fluid

·         < 10kg                           4ml/kg

·         10-20kg                        40ml/hr + 2ml/kg per hour for every kg between 10-20kg

·         >20kg                            60ml/hr + 1ml/kg for every kg over 20kg


Source:

Pediatric Advanced Life Support Provider Manual by Leon, M.D. Chameides, Ricardo A., M.D. Samson, Stephen M., M.D. Schexnayder and Mary Fran, RN Hazinski (Oct 12, 2011)

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