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Hello, everyone and welcome to the next installment in uh me education. And we're really delighted to have doctor Ali with us today, who's a consultant, pediatrician at mercy University Hospital in County Cork in Ireland. And he's going to be talking to us about intravenous fluids in particularly in the pediatric patient. Um We're really excited to have Dr Ali share with us today and it was a really great opportunity to learn everything you need to know about pediatric food management. So please pop any questions you have in the chat on the right hand side and we'll have a little bit of time for questions uh towards the end. And we would uh we really love to, to, to make this as interactive as possible. So please do pop your questions in there and we will pass them across to Doctor Ali towards the end. Um We'd love to know where you're joining from today. Please pop it in the chat and, and let us know Doctor Ally. I'm going to hand straight over to you for an awesome session on intravenous fluid management. Hello everyone and thank you very much, Phil for the introduction and thank you everyone for tuning in and joining. And, uh, today we are going to speak about the intravenous fluids and, and actually choose this topic because it's, um, it's, it's, it's a, you know, the majority of patients and lot of patients has been admitted to, uh, pediatrics. Uh, they will require intravenous fluids at some stage of their, of their, of their, of their, of their admission whether or not is, uh, they are, you know, they have problems with uh drinking or they have calcium or if they are dehydrated or have sepsis with infection, they go in for the surgery and they're fastening. There's lots of indications for the uh intravenous fluid administration. And uh for that it's becoming uh every day, um sort of an activity every day, a sort of prescription that's, we are, uh, we are, we are uh taking it um, to some extent, a little bit casually, you know, you're sitting in the ward there, we see, you know, you're doing stuff and nurse comes over to you and ask you to write some fluids and we just, you know, write the fluids close 5% with uh normal align and you calculate the fluid requirement. And without, without thinking, you know, and um, honestly, I, I, I'll be looking and, and, and asking about kind of the composition of the everyday uh fluids like the normal IGN and lots of doctors and, and see doctors and nurses, they don't know um what's, what's, what's actually, how much is it and you know, what's, what's going to do when you're giving in normal to, and, and put it in the, in, in the patient. Uh So I, I think, I think it will be kind of logic and wise uh to try to understand, you know, the basics, it's just going to the, to the basics. So this is uh this is why the um uh intravenous fluids. Now, uh so today we are going to talk about uh fluids and electrolytes. Uh heis uh we will try to answer the question, what fluids should we use in resuscitation and maintenance fluids and how much should we uh should we use? Um And then we think a little bit about the kidneys protecting the kidneys uh um which, which can be at, at at risk in times of dehydration and you know, anything that's affecting the kid, the kidney is causing a K. So uh before we start in the talk, I will have some general principles and some general concepts. I think that we need to be um that we need to highlight it. Um And so that will be a touch over the, the talk. And uh just to highlight important points, the fair principle, which I think it makes sense whenever possible, the enteral rule should be used. So uh every time that we are prescribing intravenous fluids for a child, we have to ask ourselves, is it really required to prescribe the intravenous fluids. Can we use the enteral route and then in the loss of Children, it's, uh, the enteral route, uh, could be, you know, better and it's, uh, it's, it's easier, uh, it's cheaper and it's, if there is no contraindication, uh, and if the child is tolerating intravenous, uh, oral fluids in terms of, you know, um, diet or semi solids or any sort of drinks, you know, that should, you should consider that. So just not to automatically write intravenous fluids because someone is in having whatever is a gastro or is not drinking well, or, you know, it's not by itself an indication to write intravenous fluid, in fact, as well. Uh lots of sick Children, very, very sick Children who are kind of unwell and they are intubated and ventilated and, you know, stabilized. Uh you know, you should thinking of starting in intravenous fluids and putting them in, on, on oral fluids. Um And by that, you know, it's a better heis and, you know, um and um you are not going to do better than the body if, if there is no contraindications, you know, to sort out the fluids. So that's the first process, second principle it does in most situations, the preferred fluid type is sodium chloride, what 9% with sterols, 5% plus or minus potassium for maintenance fluids. So, and this is the, the the usual uh type of intravenous fluid that we use. We use, uh, no, I, with dextrose you can add in potassium. Um, and that's for, for the men. Now, it is the preferred, however, might not be the most appropriate. Uh, and we'll talk about that. What's, you know, why is it, the preferred preferred, I think, because it's, uh, it's, it's readily available. It's easy. It's cheap and, um, it's used all the time. We should know it in and out. Um, And, but it probably is not the most appropriate because it's a little bit, you know, um you know, it's affect a little bit and we say it in sometimes in a negative way. Uh another most six Children will retain water and require less than full maintenance fluids. So, uh that's another concept that we, we need to consider six Children. Um For example, if they have respiratory problems, they have respiration. Um uh if they have asthma, severe asthma, um those uh you know, they tend to have a syndrome of an appropriate, an uh antidiuretic hormone secret. Uh So they probably require less than the full maintenance fluids. Uh Another example is, you know, a child with meningitis, we see it as insult, you know, uh putting full maintenance fluid for this, for these Children can overload them. So usually we, you know, start with 80% 2 3rd maintenance and then titrate it up and down. Um It depends on the, on the, on the of the response and this is kind of, uh, you know, in the past, I think it's a survival mechanism like in the past when someone is in a stress condition, uh you know, lost in the desert. No. Um, access to fluids and water. Fish makes sense that they conserve the amount of water that they have rather than just getting rid of it all um, by pass urine. So that's one of the principles. Another principle is that cereal wight measurements are the best measure for acute changes in fluid surface. And we return to that while it's very easy while it's very, you know, available and um and it's it's accurate. So for example, you have a child who is having, you know, in intravenous fluids who is kind of dehydrated. You, uh you weigh the child today, his weight is, for example, is 12.3 kg and you weigh the same child tomorrow while he is still having more vomiting, more fluid loss and his weight is 30 kg. So this 300 g most likely, you know, you know, if the, if the we mechanism is accurate, most likely this 300 will represent uh 300 g as he lost, will represent uh that he he is in a negative of fluids. So on the other hand, the child was the full maintenance fluids for um is having asthma in the warts and no drinking. And then if you weigh today and the weight is 16 kg and weigh and tomorrow the weight is 16.5 kg, then this is extra half, half is probably half a liter of fluids that's uh probably was uh supposed to be restricted. So, you know, we should be uh uh whenever it is possible doing everyday weight for Children who are continued to, you know, to um require uh intravenous intravenous fluids. Um Another flu uh principle that fluids with a similar electrolyte concentration to plasma are the most appropriate. And if you remember, you know, here the f is one of the principles that in most situations, the preferred fluid type is sodium chloride. Uh But here the fluids with similar electrolyte concentration to plasma are the most appropriate. And here then by definition, sodium chloride is not the most appropriate because sodium chloride does not contain the same similar electrolyte concentration to plasma. Uh because sodium chloride contains um 154 millimoles of uh of sodium and 154 millimoles of chloride in uh in, in, in, in the, in the liter. While uh in like in the plasma, it's in the serum, the normal um sodium content is around 175 to 145. Well, and the normal chloride is around 100 is between 95 to 100 and five. I think it 100 or 102 is the is, is the is kind of the, the, the m know the average. So you are given a content of 100 and 45 to um uh a content of uh sorry, I'll come back later. So sorry for that. So you are given a chloride content of 100 and 45 to uh a serum content. Um you know that is supposed to be 100. So there is a very large load of chloride. Uh It's the same for the sodium sodium is if you are given 145 is uh 154 the normal sodium is 145 around 100 100 and 40 between 175 150. So you're giving more sodium. So that's definitely is going to upset the, you know, kind of the heta and um like someone can ask the question, why is it 145 you know, sodium 145 chloride. And the answer is that because in all the solution to be kind of stable, they have to have the normal amounts of cations and the normal amount of of alliance. So the sodium has to be equal to the chloride for the solution to be stable. So they cannot put sodium chloride at 145 to 100 and uh with, with uh with 100 as well if you calculate the total number of the. So units you're going to get the for the sodium chloride, you're going to get around uh 300 something 310 and that will give you the osmolality. And so the total solutes in the, in the fluids and all the fluids that we are given, uh, should be isotonic. We shouldn't be given hypotonic uh, fluids to, to, to, to patients. Um, and for that reason, the, it has to be, the osmo has to be like that. So it's not, it's not the most appropriate, but, you know, the, so be uh most benefit and we'll talk about what's the most appropriate one to give. Uh the last concept which will make sense. I think the safe use of intravenous fluids and you require careful prescribing unmonitored. OK. Uh Then we have to check the compatibility of intravenous fluids with any IV drugs that been administered. And um an example of that is uh cefotaxime with um uh with um ring lactate because la contain calcium and, and they have there is incompatibility between the two. So you need to give Ceta. Uh then we'll talk a small bit about body fluids composition. So total body water is around huge number in the in ingredients. You like 90% in uh premature infants between 75 to 80% and the total body water decreases radically to 70% in 10 new born and to around 60%. Uh by the age of one year, a little bit more in males than females, 60 to 55%. And if you have a look here. So there is an um there is uh the composition of the two third is intracellular and one third is extra third cellular. And out of that, the extra uh cellular, the blood volume is 1.5 liter and four and 4.5 liters for the extracellular fluids. So, the majority of the fluids are intracellular and uh one third of the fluids are in the uh extra, some of it's in the intersession and some of it in the blood volume. And this is just another uh presented, say uh the the the decline in the change in the body water uh with. So it gets, it's gets less uh percentage. Uh So the solu composition of the body water. So these are classified as we know into electrolytes and to non electrolytes. So sodium is the major C and chloride is the major in the extracellular fluids. So, sodium and chloride, these are the major component of the extra uh fluids. While potassium and phosphate are the major um components of intra. So the potassium is the major C and phosphate is the major uh an uh So for that reason, when we measure the serum electrolytes, they do not always reflect the total body content because we know now that the potassium and the phosphate are more insular. So when you are measuring, you're measuring just the extracellular, uh you are not measuring the insular potassium insular phosph. So pos phosphate level is not, is not going to reflect for you the total amount of potassium and phosphate in the body as well as these. Uh two of these are, you know, there is uh concentration gradients and electrolytes moves between intra and excess. So this is we have to um add just to just to check that, you know, uh an example of that is if someone who has a normal potassium, but the total body or normal potassium or phosphate of the total body could be depleted because in is is is less. Uh you know, an example of that is uh you know, anor has a high risk, they have a total depleted pota level. So when you are giving them, you know, uh carbohydrates is going to give you more insulin, insulin production and that will get the phosphate inside the cells and you will end up with severe hyperphosphatemia. So, uh it's, you have, you have to consider these facts. Uh um So a little bit of talk about hypernatremia or hyperosmolality which indicates a relative deficiency of water to solutes in the excess of the fluids. So the free water is corrected slowly to prevent seizure and edema. Um and the pat pathogenesis of the common disorder season to hyperosmotic hypernatremia either due to water depre an example of uh that is in um a TN in osmotic diuresis in uh in central diabetes inhibitors or gen diabetes inhibitors or there is non uh renal free water loss like in gastroenteritis, uh low water intake. Uh So you'll have more solute or if you are administering a, a high solute uh excess uh in like in sodium chloride, uh supplementation, intravenous fluids or hyperalimentation. Uh So, on the other hand, hyponatremia or hypo osmolarity is an indicator for relative relative excess of water to solu in the extracellular fluid. So here we try to avoid rapid correction of hyponatremia because it will cause an osmotic shift of water. Uh And that lead to central pro time myo it's mostly um seen in uh those who are uh chronically hyponatremic, like in elderly patients who are chronically hyponatremic. That's the, you know, when, when, when they get uh you know, rapid correction of their hyponatremia, uh they get a shift of water from inside the cells outside and that will lead to uh pro time myo. Um So, some of the causes of the hyponatremia if we have solute depletion, as in if you are given diuretics, uh if you have non renal loss uh in, in brain and in blood loss and uh in cases of solute dilution and the most important cause of syndrome. If a prop secret of an hormone, we should touch base a little bit about it. So, uh this is, this is just for uh you know, to remind you about the sodium homeostasis, that's an extra fluid volume. Uh If it's decreased, we stimulate the dexa appre will lead to renin angiotensin activation, angiotensin one to angiotensin to and um and then the is the opposite effect of the same. So you can re um retain to that read a little bit more about the. So faial mon. So if you have a patient uh for his hyponatremia, what should we do? We usually check the serum osmolality. So, uh a hyponatremia is usually associated with a low serum osmolality. That's, that's the, that's, that's usually if there is a normal serum personality with hyponatremia, then it has to be either uh there is uh you know, uh pseudo hyponatremia and hyperlipidemia or hyper proteinemia or if the low sodium is associated with the high osmolality, maybe the this OS comes coming from something else like in hyperglycemia in case patients of DK A and in Melatonin infusion, but usually when there is hyponatremia, there is low osmolality. So when there is low, what we look for, we look for the true OK. Uh uh there is a true hyponatremia and we look at the s modality uh and that's uh what you would be expect if you expect if you have a low serum o oral, low sodium, you expect to have a low urine os. And uh then there is AAA primary polydipsia here. So, and this is common in Children who are habitual drinking too much, you know, polydipsia. So they, they, they, they drink a lot, they get um you know, hyponatremia due to, to um and the urine will be dilute. But if there is hyponatremia, hyposmolality and still and you find the osmolality, yours is concentrated. Then there is an impaired free water execution. Then you look at the serum sodium, serum sodium. If it's low, it's possibly due to uh congestive heart, heart failure. If the urine is mo is high, then this is the situation of uh most likely syndrome if you. Um and now uh the main part of our talk here is um when you are seeing a patient and they are dehydrated, especially if they are, they needed resuscitation, we need to answer uh this question, which fluid uh are we going to give and how much of these fluids we will we give. So uh the there is a statement in the uh New England uh about resuscitation fluids and it says the ideal resuscitation fluid should be the one that's produced, predictable and sustain increasing intravascular volume. So you give it and you expect that, you know, your fluid status is going to improve by how much. And so this is number one, number two has a chemical composition as close as possible to the fluid. And remember earlier on when you were speaking about the sodium chloride, sodium chloride is not close to the extra Ayar fluids because sodium chloride has a high sodium content and has a a very, very high chloride content compared to the extra fluid. This uh should be metabolized and completely excreted. Without accumulation in the tissue, uh does not produce adverse metabolic or systemic effect. Um And uh and it's cost effective in terms of improving the uh the patient outcomes. So, uh currently, there is no such fluid available for clinical use that will fulfill all of these criteria. So that's what why we said sodium chloride is the with the prefer, but it's not the most appropriate, the most appropriate is the fluid that has a similar constituents. So let's try to see what's our options. OK. So we can give steroids which like the sodium chloride, like the react and the um plasma light, we can give it uh like the plasma, we can give blood products what they have given. We do not give hypotonic for this to Children, sick Children or um not sick if they require fluids, these fluids has to be isotonic unless unless if there is a clinical indication, it could be, you know, at this stage guided by, you know, ICU or guided by, you know, uh endocrinology to give hypotonic fluids if there is severe hypernatremia, for example, or you know, not correcting with um with, with, with, with, with, with normal saline. Um So um so at that stage, you give hypotonic fluids but you have to titrate it very, very um you know, carefully cause in generally, this is uh a general rule that we do not give on the fluids. And I say that because I know that adults, sometimes they just put in on, on dexter fluids without any electrolytes. Um uh So, um so what are the choices? Uh our choice is 0.9% sodium chloride for resuscitation. Our choice is Homan solution for resuscitation. And we have a choice of al other are plasma light and hes hydroxy star and we can give uh blood products. So, if we uh have is the same as the ringer ringer lactate. So, 0.9% is the is is the most common fluid that we use for for resuscitation. However, the most recent recommendations with the is to use the one solution which is the ringer lactate. So if a patients, a pediatric patient coming in with sepsis with dehydration with shock and we need resuscitation fluids. We will use the ringer lactate uh or the man solution and the advantage of the heart one solution to the sodium chloride. That's the constituent components of this uh uh of the heart. One solution are closer uh to the extrasolar fluids compared to the sodium chloride. It does not produce um a kind of a a bad metabolic effect compared to the to the normal sali. So um here is um just show showing uh I'm not sure if you see my uh my care site, but it's just showing uh sort of the fluids. Uh this is the the left side, there is the normal extra uh the normal extra fluids or the normal serum. Uh, and then we have the albumin, we have the hydroxy hydroxy are rarely and very seldom. Uh, is, is used. It's very expensive and it's not available. I mean, uh, even in big centers, if you are looking for hydroxy, it's not going to find it, uh, hand. Uh, at the same time, it's kind of associated the use of hydroxy starch with, uh, an increased, uh, requirement for renal replacement therapy in sick patients who are associated with hydroxy. So it's is it actually is not um it's not usually a very good option. Um Then we have this align, we have the crystalloids align and uh sodium lactate and uh the plasma plasma light. So if we look at the composition here, so I I'm I'm just getting the three main types of fluids that we use the nor align, the ring and lactate in the middle and the plasma light. So, nor align is the most read readily uh found is the most, it's a preferred one to be used because it's available, it's easy. And um and um but the as I said, the recent recommendation that if you have it to hand, if it's not very expensive, um you use the lactate the lactate and then we have the plasma plasma light at the end. Uh So we'll talk about nor a little bit more again. So nor I is 154 as we mentioned earlier on of uh sodium in a liter and 100 and 54 of chloride. So it's just a, a very lazy solution. It's just sodium and chloride. The same amount to give you a similarity of 308 which if you put 154 plus 154 is uh 308. Uh but that will give you, if you look at the end, I give you a ph of 5.5. So why is that? Why is sodium chloride is very, it's actually an acid, it's an acid solution. And I tell you the majority of um of doctors who prescribe the normal IGN every day, they don't know or don't realize that the ps of the normal is 5.5. And once every one of you, after we finish, just to look at the normal itself and see they always, they're going to write the phe. So just, you know, you believe that I'm saying the truth, I'm not just make um then if you compare that to the ringer lactase solution, uh ringer lactate, the sodium is 100 thirties. So much less sodium compared to the normal. There is some potassium there four, there is some calcium three, there is a chloride which is reduced 109 but is still a higher chloride. There is some lac tape which is 28 and the osmolarity is 275. So osmolarity is kind of equal to the total of these solutes, all of them together and the BH is 6.75. So the PH is a little bit better, you know, could lose it to normal PH of 7.34 but it is still an acid. So normal is very acid ringer lac ta acidic. If you compare that to the plasma light ph of 7.4 normal ph of plasma light, OK. Try to answer course. Why, why is that? And this is a full topic by itself. I don't want to get myself into it. However, the idea is behind the high chloride content uh that there has to be an eli an equi between the ions and the cats in, in the solution. And that's why they put the lactate of 28 in the so solution with the sodium of 30 130 the chloride of 109 because if you calculate the cations 1 30 plus four plus three, it will be more than the chloride than the AM. And I said earlier on, there has to be an electrical neutrality in the solution. So what should they do to bring the ring ate into an electrical neutrality state? They put the lactate of 28 and the lactate is, you know, the name of the lactate came from the ringer, you know, ringer lactate came from the adjectives which is the lactate. So you think that there is a high lactate content as well in the ringer lactate and you have to be careful if there is primary kind of liver problem. So the body cannot uh metabolize the lactate. Then um then you are going to overload the patient with the lactate. So that's one of the contraindications. At the same time as I mentioned earlier, oner lactate will be, you know, incompatible when you are given uh zone or the caffeine. So, and it's a, it's a, it's a common combination. A child in six sepsis, dehydrated shocks get uh a bolus of uh fluids. And if you are, if they recommended is ring lactate, and then at the same time, the most common antic you give is this combination, they don't work together. So now the recent recommendation is for resus patients to give rather than RCA, which is compatible with the lactate. But this is not our talk today. Sorry. Uh If you want more information about why is normal is very acidic thing that like it is a little bit acidic. You can refer to something called the steward approach or uh for the acid base balance or the uh quantitative approach for the acid base. But, but we just know now that it's because of the very high chloride content in the, in the normal IGN uh 100 there is hyper metabolic acidosis. Um why if you compare that to the plasma lights, I spent uh uh you know more time in this slide because it's important if we look at the plasma, light, plasma light is similar to the uh body condition. So his sodium is 140 potassium is five, magnesium is three, chloride is 98. Um So, and here uh so it's the same, it's the same as, as uh so it's, this is the one which is the most appropriate to be given. However, it's not usually available, it's very difficult to find. And um and it's very expensive. So if we calculate the cations here, 104 plus five, and the Magne with the magna three, then we have a gap of anion. And we mentioned earlier about kind of elliptical neutrality. You then how do they make their plasma light stable by putting gluconate and acetate? So there is a gluconate and acetate compared to the r lactate where there is um lactate there. All of these, the gluconate, the ace and that is going to be metabolized in the liver, in the liver. Sorry. So uh Nosal I is very readily available. It's easy, it's cheap. Um it can cause metabolic acidosis for patients. It causes hyperchloremia, but you know, the body is going to collect that uh if the kidneys are normal, if the kidneys are functioning plas is the most appropriate. However, it's not available, it's very expensive. Um So it's uh the choice is uh usually ring, get lac it if it's available. Otherwise you go for the chloride. Uh this is here, some of these just studies, as I just would like to mention, there is a study comparing uh album iun oral fluid resuscitation intensive care unit. And there is better, that's the safest study. And uh in those with severe sepsis, there is a trend towards an improvement when they are receiving uh albumin as a resuscitation. Uh Another um important one study is s the base deficit hyperchloremia acidosis following 0.9% align uh fluid resuscitation. And it's basically tells us that if you give too much courses of normal lin, you're going to end up with a hyperchloremia with a acidosis. And uh then we have the nice guidelines for intravenous fluid therapy in Children and young people in hospital. So what the nice guideline says nice guideline says if child, young people needs intravenous fluid resuscitation, use a glucose free cholesterol. So we don't give the with Deos it has to be glucose free containing sodium in the range of 151 to 100 and 54 with a bolus of either 10 to 20 ML per kilogram or less than 10 minutes. Uh and take into account preexisting condition, for example, cardiac disease or kidney disease as a small of fluids may be needed. Uh And then for the new 10 units, it's more or less the same, same, same recommendation. So what's, what's this uh nice guideline says, you know, either you give 10 to 20 mls immediately or over 20 minutes. So basically nice guideline says, um, give, you know, don't give too little, don't give too much, uh don't give it too fast and don't give it too slow. So it's up to you to, to decide. Um, and that's asking you as well to take into account the general condition of the patient. So it's not, it's not actually very useful and why it's not very useful because there is no strong evidence behind all of these. However, the most recent A PS guidelines, it says about giving um the policies in 10 MS uh allocate. So we give 10, 10, 10 rather than previously, we used to give 2020. Um So another, another um study here in s in 2018, hypertensive resuscitation was blocked. The most appropriate approach in hemorrhagic shock makes sense. You know, you have hemorrhage bleeding, you give blocked uh antic shock. Uh Conservative approach seems to be appropriate with preference given to colon steroids or albumin as an alternative uh core review in 2018. Um liberal versus conservative. Conservative fluids in sepsis says that it needs more sodium. Um And uh but there are two studies says that liberal regime increased mortality. And here is the very famous study uh probably most of you have heard about it. Uh So it's the FISA study in 2011 in six centers in Africa. I think it's Tanzania, Kenya and Uganda. Probably I think so. This is was investigating the fluids for and it says that fluid policies significantly increase 48 hours mortality and critically ill Children with impaired perfusion in these resource limited ses in Africa. So basically this is study, the bottom line is that they've got um their target was approximately, I think was 3600 patients. They wanted three recruit, 3600 patients. They recruited 3000 patients. These patients were dehydrated, were shocked, they have poor perfusion um and they have evidence of sepsis. And what they've done is that they given some of them an 20 MLS and some they given um they were 20 mils per kg and they repeated the PO us and the other um they given normal to and 20 emails per kg and they repeated the po us and the first uh patients, they were not given resuscitation, fluids policies. So we just put in mental i to fluids and they found that there is a significant increase in mortality in patients who receive policies by albumin or by um Norcos. And compared to those who have not received any policies uh now, so they were, you know, all they were, you know, they, they say that significant increase for mortality. However, uh is uh the, this study, I if you look at the cohort of the patients, these are patients who are, you know, kind of managed in low resources. Uh No ICU or intensive care uh access. They were given a huge amount of uh fluid policies. Half of these pop of the population, they have malaria. Half of the population were severely anemic and they were not given blood transfusion. So it's, it's someone who's septic, who is sick, who is probably have malaria, who is anemic and you're giving too much fluid, what's going to happen? They were going to develop the pulmonary edema and they will die. It's, you know, it's, they were, you know, so the study, uh if you want to apply this study to you, you cannot generalize it to, you know, all of your patients who are kind of sick and dehydrated. And uh so uh I know you need to because everything is management. So that's, you know, we need to look at the study and what's what's sort of the situation of the study. Uh However, the for this study, the, the results were very strong to the extent that the study was halted when they reached around 3000 patients. Um the target 3600 because it was ethically uh not, not OK to continue the study while they have, you know, kind of a very, you know, convincing results. So anyway, what we do, we need to do, we need to take into account volume status, the ongoing loss and the maintenance requirement. Uh this um most of the pediatrician, they know this uh formula, it's a formula 100 M per kg. Per day. This is the maintenance for the fairest 10 kgs of the weight, 50 MS for the next 10 kgs of the weight and 20 MS for uh a weight over 20 ki for example, if I have a patient who is 18 kg, then for the fairest 10 kg, you need 100 mils per kg and that's one liter for the next 10, you need 50 ML. So that's 500 MLS and then for the rest which are three kg, you need 20 mils per kg. Uh So this is our 60 ML. So uh uh 1560 divide that over 24 hours. So it's going to give you hours, they need over an hour. And when we want to add in fluid deficits, we calculate uh the percentage of dehydration multiply that by the weight multiply that by the 10 and we add it to the uh maintenance fluids over other 24 or 48 hours according to the um condition. So here we said that we take into account the fluid status and the ongoing loss. So the most important part probably and the message from this from this talk and the assessment I'm monitoring. So what would you need to assess? We said, and we mentioned already, we need to assess the body weight. Those are who are having intravenous fluid, they should be having the weight uh measured um uh regularly uh every day or every two days or, you know, depends on the situation. If, if it's possible we have, sorry, we have to check the fluid input output and balance over the previous 24 hours. So the input, how much she's getting, what sort of type of fluids is getting? What's uh what's the root? Uh We check the output and the most important one, the output is the urine output and the urine output, we want it more than one ml per kg. There, uh there are uh at least usually we want it between 2 to 4 MS per kg per hour. Um And then the whole um fluid balance is is negative, is it positive or it's neutral? And you do a clinical assessment for the fluid status and the clinical assessment of the fluid status is by looking at uh the starting from the BP, heart rate and all of these, checking the child, looking at the skin tea and looking at the time, uh looking at evidence of puffiness in the face or in other areas. Um So uh whether he kind of constipation is either U volume or uh volume depleted or uh overload. Um then you check the details of all ongoing losses and at the end, you might need to do a laboratory and end of point care assessment. So, uh um uh I expect that kind of a patient who is more than 24 hours on IV fluids, you need to check the electrolytes, you need to check the sodium, you need to check the potassium and see if you need to add in more potassium or, or not. Um If you're not planning then more than 24 hours, you know, then probably you might not need to check the poly on a daily basis. Uh But the general rule is at least 24 hours and sometimes you might need to do, you know, every 12 hours, you need to do electrolyte. If the sodium is off, if the potassium is off, if you are giving supplementation to correct the electrolytes, then you, you probably need to do it more frequent. And another point of uh care assessment is that is done if it's available, that you do a blood gas as well to see if you are given sodium chloride. Are you going is your patient getting acidotic and checking of the glucose as well? So, uh the last part of our talk is about getting think uh about the kidneys. And here is this a study uh it's called uh it's in ne general medicine. 2018, the history of childhood kidney disease and risk of adult end stage renal disease. So they are looking at thinking of these are uh insult to the kidney when, when someone is a child. And uh what's the risk of them developing chronic renal failure? So this was a nationwide population past for the whole country. OK. That was in Israel historical cohort study of around 1.5 million Israel ADOS who were examined before compulsory me service in 1967 throughout the 19 9. So what they do the Israel, everyone is coming into the military, compulsory military service. They get kind of a demographic and bi chemical and lab data and they follow them up and they check the full, the full history and then they try to get um uh kind of an information from, from, from this. So they uh uh outcome of that for the whole population, it there's a history of clinical evident kidney disease in childhood, even if renal function was apparently normal in adolescent, was associated with a significant increased risk of endstage renal disease, which suggests as the kidneys, the kidney injury or sexual abnormality in the childhood has long term consequence. Bottom line for that. If your kidneys are, you know, getting an insult when, when you are a child by dehydration, by only the urea by whatever you know, severe pyelonephritis, all of these, this will increase your risk of developing chronic kidney failure. Even if you, you know your and creatinine were normal at the time when you uh when, when, when at that time. So we have to think about the kidneys, we have to prevent, you know damage to the kidneys. We have to think that even if the urine electrolytes are normal, uh that's uh putting stress on the kidneys. If the kidneys are under stress, you know, that will increase the risk of the kidneys being affected. So, the British Association of Pediatric Nephrology, they have an A K I Management recommendation. They have a website, it's called th kidneys. And you can look, you know, all visit that's website and has like very good resources for the management of A K I and everything. Uh but uh this is kind of um you know, the, the the this is just an overview of the risk assessment for, for A K I. So they uh uh try to prevent. And the, so what what we do is that we classify the patients who are at risk for uh A K I into 21 is a high risk group and high risk sna so high risk group who are, what's the type of patient that they think they might develop any problem in the the kidneys and high risk scenarios? What sort of situation that's can affect the kidneys? So who are the high risk groups are ne nephro neurology, patients, cardiology, patients, liver disease, all of these. And that makes sense if they have malignancy, bone marrow transplant, if they are dependent on other for access to fluids. And this is very important. So by definition, all babies, all toddlers who are dependent or babies who are breastfeeding or if they are less than one year, they cannot go and you know, grab a drink and drink from it. They need someone else to give them fluids are at risk uh as well. Patients who have complex neuro disability, who they cannot approach the fluids and bleed by themselves or they have a big tube they use for administration of fluids they cannot take orally. All of these are at high risk of AKI and then those who are on medications like nonsteroidal uh diuretics, aminoglycoside calci inhibitors. This is like that tacrolimus uh which is a an inhibitor. So these, these are the types of uh of group and, and, and it's not uncommon to find a child who is being admitted with high temperature dehydrated, not drinking well. And because of the temperature, they are non steroidal that should not have happened, you know, uh I come every day and look and see if the child is um kind of dehydrated, require resuscitation of fluids if there is a baby that his mother is saying that he has dry mouth, this is not possible urine for the last 24 hours. And they shouldn't be a nonsteroidal because that's basically that's you are increasing the risk of them developing a AKI. So you need to, you know, cross over the cross the, the ibuprofen or whatever they're given as a nonsteroidal because uh you know, temperature and fever does not kill the child. However, AKI will kill the child, you know, um another, the, the the other group is the high risk scenario. So if they have this history of reduced urine output. There. Some likes of uh babies who are no sick and the mother says that he's not passing urine, his are dry. Uh if there is sepsis, if there is hyperperfusion, nephrotoxic drugs, um and major surgery, all of these. So how to prevent we have monitor, maintain and minimize. We monitor the fluid hydration, fluid color, daily weight u analysis the same as I said, and we monitor the serum creatinine and electrolytes. We maintain the circulation circulation by treating hypoperfusion. We minimize further insult by reviewing drugs and medication monitoring and adjusting medication. If someone is an ace, there has to be, you know, thinking of, can we stop this ava if they are aminoglycoside, can we stop the aminoglycoside? If they are, if you cannot stop the aminoglycoside, we have to adjust the dose according to the GFR. So uh then they have just a little bit of memo how to recognize an A K I and A K I is a serum creatinine more than 1.5 reference creatinine uh or if they have a previous baseline of no. So this is the stage or um and the second stage if it's, you know, 2 to 3 times the difference. And the third stage, if it's more than three times uh the difference or the urine output, if it's less than 0.5 mils per kilogram per hour for the last eight hours, now 0.5 mils per kilogram per hour less than that. Then this is only to urea, you know, or Anura and to some extent aura uh but you know, 0.5 ML per kilogram per hour, this is, you know, at this stage, if less than 0.5 mils per ki gram, then this is an A K I now, however, you need your own output to be more than one ML per kilogram per hour, especially on those who are less than 12 years, more than 12 years, you can live to some extent with uh as a little bit reduced. Um you know, urine output between 0.5 MS to, to one ML five g per hour. But uh in the, in, in general, in general, you need your renal output to be more than one ML per hour. If it's less than 0.5 MS M gram per hour, then this is an A K I and we said the same. So monitor Children should have their creatinine checked and repeat it. Uh fluid panels including urine output weight urinalysis, uh PS score should be recorded. Uh And then any signs of sepsis should be aly investigated and treated. Uh We maintain uh the fluid status hyperperfusion, we minimize further risk uh and an injury, uh intravenous control should be avoided. Uh So I have uh I'm not sure if you can put this in a poll. I have um a question is uh which of the following? Please describe uh the standing eli hydrotic pressure is created by dexa glomerular apparatus. In the kidney, increased orthotic pressure results in fluids leaving the intravascular space. Patients with congestive heart failure have cardiac dysfunction that lead to increased intravascular volume, increased hydrotic pressure and resulting in increased interstitial volume. And the last statement is patient with nephrotic drawn. Do they, can you have any increase oncotic pressure resulting in from hypo aia? So which one of these you would think A or P or C or D is the correct answer? It's only one correct answer. Uh I'm not sure you can put that in on. Yeah, we've just launched that pool. Doctor Ali. Um I, I don't see, I can't see the results. So what's the result? Uh I will let you know. So we've got uh one person who's responded at the moment. So if everyone can answer the pool, that would be great. Oh, yeah, I can see that. So some, the 50% 50% between A and C but there are only two. Ok. I'm really sorry. I'm bringing him back to the medical school. But you know, this is a little bit of me was, oh, what's the, is he a player in Aston via or Spa? Anyway. Uh ok. Uh Only eight responses. So we're coming in, we've got nine. We're creeping up. How many do we have in the lobby? We've currently got 49 people here tonight. So, yeah, so a bit more so tender responses. OK. So the she, some are saying a 10%. Um what's the a, the A is hydrotic pressure is uh caused created by the art. I don't think the art has to do anything with the hydro pressure in the kidneys. So this is not the correct answer. Uh And b uh some they are getting b which is increase aquatic pressure results in fluids leaving the intravascular space which is not correct because increase a cortic pressure will not lead to the fluids leaving the intravascular space. So, opposite, uh the majority are getting ce patient with congestive heart failure have cardiac dysfunction that leads to increased intravascular volume, increased hyperstatic pressure and result in increased interstitial volume, which is the correct answer. So that's the correct answer. The patients with Nephro Ron typically have increased oncotic pressure resulting from hyaline. No. So this is not this opposite, the Nephro, they have uh decreased oncotic pressure resulting from. So what's the eli if you remember the four fours, the hydrotic pressure um and uh on, on the oncotic pressure at the arterial ends, the fluids leaving the arterial end and then going in to the venu end from the artery to the vein. So when the fluids are going from the uh uh in the arterial end, there will be a hydrostatic pressure higher than the oncotic pressure. So that will force the fluid out from inside the ves into the interstitial. Uh and then there will be a gradient after that at the ve end, because there will be a less hydrostatic uh pressure, the oncotic pressure will be more. So we draw the fluids back from the intersession into the uh the the the arterial end uh into the manar end, sorry back to the back to the veins. So from the arterio end to the vee end hydrotic pressure initially higher than the oncotic uh pressure forcing the fluids out from inside the intravascular to the intercision and then drawing it back by the forces of the oncotic pressure which draw the fluids in while the hydrotic pressure is getting less and that's kind of the circulation. So in patients with congestive heart failure, they have um the dysfunction that will increase, increase intravascular volume. If you increase intravascular volume, you increase the hydrostatic pressure and then you upset this equilibrium because they need to be forces, need to be equal. So the amount of fluids going out should be equal to the amount of fluids coming back in, in equi. So that's why they get uh they get uh you know, in cons heart failure, they get uh edema. Uh a patient with uh nephrotic syndrome, they have hyperpnea, they have reduced uh inco pressure inside uh the uh inside the vis. So that will cause uh the uh the the the hydrotic pressure to be more than what the pressure for and the fluids, fluids out. And thank you very much and if there is any question, I'm happy uh, to write to answer. Thank you so much, Doctor Ali. What a great, um, tour of pediatric, uh, fluid management. We're really grateful. Um, if anyone has any questions, uh, please pop them in the chat and we don't have any at the moment. Um, but if there is a question, we've got a minute or two to answer questions. And, uh, and if not, then, uh, then it just leaves me to say thank you, Doctor Ellie for a really great teaching session. And um and I knew it will have been so valuable to all of us joining here today. So we're really grateful for your, no, no problem. I am happy to do later on if there is any way that we can make this a little bit interactive, not to be just one I thought at times I'm talking to myself, you know, uh because they need to ask her questions, you know, gets interaction, gets, you know, so sure, so make it like we, we're uh we're really grateful. So thank, thank you.