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DOMICILIARY INTRAVENOUSFLUID THERAPY IN CHILDREN

Pankaj K Mehta, Reena Mehta

Family Physicians, Kalachowki, Mumbai 400 033.

Intravenous fluid therapy in children is considered as taboo by most family physicians, probably because it involves taking extra risk, facing certain problems and difficulties.

Common problems are:

A. Difficulty in first catching a tini-mini vein of a struggling child and later maintaining needle or IV canula inside the vein by various splints.

B. Selection and calculation of the fluid amount.

C. Calculation and regulation of the drip rate.

D. Constant monitoring of various parameters and untoward reactions.

Friends, it sounds depressing but in practice it is not so. Though risk benefit ratio may be narrow, it is definitely very self satisfying and highly rewarding in long run.

Domiciliary IV therapy can be given either at patient’s home where patient is more comfortable with his family and familiar surrounding or at the clinic, if extra cot is available where doctor is more comfortable because he can monitor the progress as well as he can attend to other patients too. After three to four hours of observation in clinic, depending upon the condition, patient may be shifted to home, hospital or IV can be discontinued.

We shall try and give you very simplified approach which may not be scientifically foolproof, but at the same time not irrational or unscientific and works reasonably well in our day to day practice.

INDICATIONS

1. Acute Gastroenteritis with second degree dehydration with persistent vomiting, where a trial of conventional antiemetic has failed, ORS was tried properly and failed. After excluding other sinister causes of vomiting, one may start IV drip. It gives rest to the g.i. tract, corrects fluid and electrolyte imbalance to some extent and within couple of hours, child usually starts accepting fluids and ORS by mouth and acute problem gets solved in many instances.

2. Infective Hepatitis : Usually it is type ‘A’ in children and most of them recover. During prodromal period, before jaundice appears clinically, many children vomit incessantly. SGPT is very high and if prothrombin time and index are normal, one may give IV fluids at home for a day or two and acute problem is resolved.

3. Fever with marked vomiting : Certain infective conditions especially enteric group of fevers, measles, mumps etc. associated with marked vomiting one needs to exclude intracranial infections.

What fluid to give?

Of the various fluids available in the market one third saline in 5% dextrose, popularly known as Isolyte-M is very useful for most occasions as far as we are concerned. For under one year of age Isolyte-P should be used. For rapid correction in severe dehydration, Ringer lactate may be used.

 

Common IV fluid available in the market
  
Name
Dextrose
Na
K
Cl
Bicarbonate
Cal
Other
1.
5% Dextrose
5%
—
—
—
—
—
   
2.
10% Dextrose
10%
—
—
—
—
—
    
3.
25% Dextrose
25%
—
—
—
—
—
    
4.
DNS
5%
154
—
154
—
—
    
5.
DNS 0.2%
5%
34
—
34
—
—
     
6.
DNS 0.33%
5%
57
—
57
—
—
     
7.
DNS 0.45%
5%
77
—
77
—
—
     
8.
Normal Saline
—
154
—
154
—
—
    
9.
Ringer Lactate
—
131
5
111
29
4
    
10.
Isolyte-P
5%
26
21
21
—
—
    
11.
Isolyte-M
5%
39
35
36
—
—
     
12.
Isolyte-G
5%
65
17
149
—
—
     
13.
Isolyte-E
—
142
10
—
—
5
       
14.
IV Metro. (100 ml)
    
    
     
   
   
    
Metro. = 500 mg
15.
IV Metro. (500 ml)
    
   
  
    
    
    
Metro. = 1000 mg
16.
IV Ciplox
    
    
   
   
    
    
Ciproflo. = 200 mg

 

IV fluids useful in paediatric IV Therapy in GP
 
Name
Dextrose
Na
K
Cl
Bicarbonate
Cal
1.
Isolyte-M
5%
39
35
36
—
—
2.
Ringer Lactate
—
131
5
111
29
4
3.
Isolyte-P
5%
26
21
21
—
—

How much fluid to infuse?

Fluid therapy can be considered under three headings.

A. Maintenance therapy - Normal daily requirements.

B. Deficit therapy - Replacement of abnormal losses that have occurred.

C. Supplemental therapy - Replacement of abnormal ongoing losses (it is usually met with ORS and diet).

Hence for calculating fluid amount, maintenance therapy and deficit therapy are taken into consideration.

Maintenance therapy : It varies with age.

For simplification it is 75 to 100 ml/kg body weight, between 2 and 10 years of age.

Maintenance fluid requirements
Age
ml/kg/day
1-3 years
100
3-5 years
90
5-7 years
75
> 7 years
60

Deficit therapy

Mild dehydration - 50 ml/kg

Moderate dehydration - 100 ml/kg

Severe dehydration - 150 ml/kg

To give you an example of a 4 year old child weighing 16 kg. with second degree dehydration.

Maintenance therapy is 16 x 90 = 1440 ml

Deficit therapy is 16 x 100 = 1600 ml

i.e. Total fluid required is approximately 3000 ml in 24 hours. Of this 50% i.e. 1500 ml is given in first 8 hours and remaining 50% in remaining 16 hours.

If vomiting is too much, more chlorides are lost, Isolyte - G is useful here. If diarrhoea is severe more bicarbonates are lost, where Ringer lactate is useful.

While understanding deficit therapy, it is best to remember that the body has a lot of reserves to combat deficits of fluid and electrolytes and has very little reserves to combat the excess of either one. Thus it is always best to undercorrect.

If child is brought in severe dehydration, and while arranging for hospitalisation, one can give 30 ml/kg of Ringer lactate in first hour and this is like golden hour project and has considerable influence in final outcome.

How to regulate the drip rate?

It is important to regulate the drip rate in children because the amount of fluid required must be given uniformly over a definite period of time. In commonly used IV set one ml is equal to 15 drops while in microdrip IV set, one ml is equal to 60 drops. Therefore by simple mathematical calculation one may determine the drip rate. For example if one wants to administer 500 ml in four hours that comes to 125 ml in 60 min. i.e. 2 ml in one minute, i.e. 30 drops per minute.

How to set up iv drip?

Keep a tray containing.

1. IV solutions : Sterile and clear.

Shake the bottles and look for suspended particles; fluids that are discoloured, cloudy in appearance or that contain suspended particles should not be used.

2. IV Set

Make sure that the drip set is sterile and in good working order, keep extra sets ready.

3. Sterile scalp vein or IV canula

In children, number 22, 23 or 24 scalp vein or number 22 and 24 IV canula serve the purpose.

4. Tourniquet or BP cuff

Keep pressure between systolic and diastolic for distending veins.

5. Adhesive plaster with scissors.

6. Spirit, cotton swab.

7. Covered arm splints.

Either readymade plastic splints with velcro strapes or suitable wooden plank with adhesive plaster may be used.

8. Kidney tray.

9. IV pole or any other suitable arrangement to hang the bottle. Keep cotton string handy.

PROCEDURE

Follow strict aseptic technique thoughout the procedure. Carefully remove the bottle seal, clean the top with spirit swab. Holding the bottle upright, insert the drip set.

Close the screw clamp.

Hang the bottle.

Connect the scalp vein to the IV tube and remove the protective covering.

Open the clamp and flush the IV fluid through the tube and scalp vein needle into the kidney tray until all air is removed. Clamp the tube and reapply the protective cap over the needle. Prepare few strips of adhesive tapes and keep ready for use. Prepare the venepuncture site : Avoid veins near joints.

The most commonly used veins in order of preference are :

1. Veins of the forearm (basilic and cephalic veins)

2. Veins in the antecubital fossa (median cubital, cephalic and basilic vein).

3. Veins in the radial area (radial vein)

4. Veins on dorsum of hand (dorsal metacarpal veins)

5. Veins in the foot and leg are better avoided as these veins may be needed as bypass vascular graft at later age.

6. Veins in the thigh (femoral and saphenous veins)

7. Veins in the scalp for infants.

The limb must be properly immobilised, following the general principles of immobilisation, i.e. one joint above and one joint below.

Apply a tourniquet firmly proximal to the venepuncture site. It should obstruct the venous flow but peripheral arterial pulsations should be palpable.

Clean the area with a spirit swab.

While doing venepuncture, the needle should be introduced for a short distance into the subcutaneous space before entering the vein. The skin should be tightly stretched during the procedure.

When backflow of blood occurs into the needle tube, insert the needle further up by about 1 cm. Release the tourniquet and open the clamp to allow the fluid to run in. Secure the scalp vein needle either by the ‘H’ method or by the ‘criss cross’ method. The adhesive plaster should be used liberally rather than miserly.

Secure the scalp vein tube and IV tube to the skin.

If the flow of fluid is slowed or stopped, find out the cause. One of the following reasons may be found.

A. Spasm of the vein : Stroking the vein gently above the needle relieves it.

B. Displacement of the needle, characterised by local swelling. The flow must be stopped and restarted elsewhere.

C. Kinking or external pressure on the IV tube.

D. The bevel of the needle may be pressed against the wall of the vein. Slight lifting of the needle mount by placing a cotton ball under the needle or wings of scalp vein or changing the position of the arm will restore the flow.

E. Low pressure within the IV fluid bottle : Elevate the height of the fluid bottle and/or insert a 20 bore needle in the top portion of plastic fluid bottle containing air, taking care not to touch iv fluid.

Never allow the bottle to get empty completely to prevent the entry of air into the tissues. Change the iv bottle or discontinue the iv infusion when a small amount of solution is in the neck of the bottle and before the drip chamber is empty.

Usually same iv set can be used for the same patient upto 24 to 48 hours. Scalp vein may be used for 2 to 3 days while iv canulae may be used upto 6 to 7 days. For short duration IV therapy scalp veins are convenient, economical and freely available. To keep them patent one may flush them at the end with Heparin solution i.e. one drop of heparin in 10 ml of saline.

What parameters to observe?

Most important are general condition and urine output. One is reassured if general condition is improving and child passes urine freely.

Other parameters to observe are:

Pulse

Temperature

Blood pressure

Abdominal distension

Number and amount of vomit and/or loose mo tions.

Later if condition permits and child accepts and retains, one must encourage ORS and other fluids by mouth while IV is going on, as it is physiological and will shorten the duration and amount of iv therapy.

Look for early signs and symptoms of overhydration and heart failure. They are cough, breathlessness, grunting or any distress and basal pulmonary creps. Later puffiness of eyelids develop while tender hepatomegaly and oedema feet are very late features, not worth waiting.

If appropriate, teach the family members to observe and report if-

1. The fluid chamber is not dripping.

2. The fluid bottle nearly empty.

3. Backflow of blood into the tube.

4. Needle or connections in the tube is disconnected.

5. Increasing pain and discomfort at the needle site or along the vein.

6. Local swelling at the needle insertion site.

7. Any unusual symptoms such as chills, restlessness etc.

When we should not institute IV therapy?

* Child with severe dehydration i.e. child in shock or severe oliguria or anuria.

* Septicaemic or toxic looking child.

* Child with associated major problems like severe malnutrition, heart disease etc.

* Child with abdominal distention.

* Child with altered sensorium or convulsions.

* Child less than two years for technical difficulties.

In due course, if child does not seem to be improving or is deteriorating one should not hesitate to seek paediatritician’s opinion or transfer to a hospital.

COMPLICATIONS

1. Circulatory overload. It occurs by too rapid or too much of fluid.

2. Dislodgement i.e. needle going out of vein.

3. Haematoma : Usually due to careless introduction of needle causing damage to walls of blood vessel. Apply firm pressure for few minutes and later cold compresses.

4. Thrombophlebitis : It is caused by mechanical trauma to the vein or chemical irritation or infection. There is burning pain, redness, swelling and increased skin temperature over the course of the vein.

5. Pyrogenic reactions : Symptoms generally appear within 30 minutes of starting iv infusion. There is temperature elevation, chills, headache, nausea and vomiting. It is caused by pyrogens (usually the fungus) present in the iv fluid or due to contaminated iv tube and needles. Stop the iv infusion and administer anti allergic drugs. Change the iv fluid and iv tube.

6. Air embolism : To prevent this complication, make sure to expel air completely from the tube and the needle.

Lastly as long as renal function is maintained, profound electrolyte and pH disturbances do not occur.

Friends, it is important to remember that these guidelines are not hard and fast rules and need modifications in a given individual case and therefore the quotation.

"The baby is your best guide and his kidney your best friend"



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