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Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Short Title: Fluid Management in Patients with Known Renal Disorders Full Title: Date of production/Last revision: Guideline for Management of Fluids in Children and Young People with Known Renal Disorders June 2008 Explicit definition of patient group to which it applies: This guideline applies to all children and young people under the age of 19 years. Name of contact author Dr Farida Hussain, Consultant Paediatric Nephrologist Ext: June 2011 Revision Date This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Contents Page Introduction 2 Summary of organization 3 Patients with chronic kidney disease: Oligo-anuria Polyuria 4 Tubulopathies 5 Nephrogenic diabetes insipidus 6 Acute renal impairment 7 Appendix Composition of fluids Chronic kidney disease categories Normal ‘maintenance’ fluid requirements 8 Farida Hussain Page 1 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Introduction The aim of this guideline is to provide guidance in management of intravenous fluids in patients with known renal disease who are nil by mouth (for whatever reason). This includes patients with chronic renal impairment, acute renal failure and tubulopathies. The commonest situation where this arises is in the peri-operative time period, but is also applicable if the patient is nil by mouth for other reasons e.g. unable to tolerate oral fluids due to severe gastroenteritis. For ALL patients undergoing surgery, good liaison with the surgeons and anaesthetists is imperative. Discussion with the surgeons may limit the length of time that the patient requires to be nil by mouth (for fluids +/- medicines) which will help with the overall management of these patients. Co-ordinate to place the child first on the operating list if possible. Wherever possible (e.g. routine surgery) the problem should be anticipated and fluids calculated before the patient is admitted for surgery. This is especially important in certain groups of patients (e.g. patients with cystinosis) where preparation of the i.v. fluids need to be checked by pharmacy and can cause delays. The following is intended to be used as a guideline only. All cases should be discussed with the consultant paediatric nephrologist on-call. For all patients, on-going assessment of their clinical state and regular review of weight, along with regular blood tests are imperative (the frequency of which should be discussed with the consultant on-call) as this may alter the fluid regime that needs to be prescribed. Farida Hussain Page 2 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Summary of Organisation Planning for elective procedures Referral letter from Paediatric nephrology to surgical team (with a copy in the notes). The surgical team should ensure the relevant anaesthetist is also sent a copy of the letter. The letter should include: Current weight Height BP Estimated 24 hour urine output Current recommended fluid intake (restriction / target) Current medication Current electrolyte results For all procedures: Pre-op assessment (by surgical team): 24 hour urine output estimation current fluid intake (restriction or target) current medications (inc. mineral supplements) recent U&E results liaison w surgeons & anaesthetists (&PICU if necessary) prescribe fluids if requires pharmacy input At time of operation: confirm above details examine patient paying particular attention to: o State of hydration o Weight – compare with previous weights o Height o Blood pressure Prescribe fluids if not already done Post-op monitoring of patient: (frequency to be agreed) Clinical status Strict fluid input / output charts Weight U&E’s - (should include full renal profile: includes HCO3-, Ca and PO4 frequency decided by consultant An immediate post-op sample should be sent on all patients Liaise with surgeons re: when can restart oral / gastrostomy feeds +/- medications Farida Hussain Page 3 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Patients with Chronic Kidney Disease The management pre, peri, and post-operatively, of ALL of these patients should be discussed with the paediatric nephrologists on-call, even if the patient is admitted under a different team (e.g. surgical team). Depending on the patient’s diagnosis, and current CKD staging (See appendix), their management will be different, and an up-to-date knowledge of their current estimated 24 hour urine output, current fluid requirements and current medications (as outlined in the planning stage) allows a decision as to which of the following categories to place the patient. a) Oligo-anuric These patients usually have severe chronic renal insufficiency (typically GFR < 15mls/min/1.73m2) Pre-renal transplant This is a very specific clinical situation, as the patients need to be well hydrated pre-op. Please refer to separate renal transplant guidelines Other situations If the patient has a set fluid restriction at home (provided that they are not either dehydrated or fluid overloaded), this can be set as a 24 hour fluid requirement. Fluid prescription – this will depend on recent blood results, but in general 5% dextrose 0.45% saline is used. For most oligo/anuric patients, potassium should NOT be added to i.v fluids Regular monitoring of both clinical and biochemical status is required and fluids adjusted accordingly. (typically this involves blood test monitoring 12 hourly initially) If no fluid limits have been set, the patient can be managed safely with a regime of insensible losses + urine output Insensible losses are calculated as: 400mls/m2/day). Body Surface Area calculated using the equation: √ (ht in cm x wt in kg / 3600). b) Polyuric patients These patients may produce large volumes of urine, and are also typically salt-losers, and are therefore at high risk of dehydration without adequate fluid replacement. Pre- renal transplant This is a very specific clinical situation, as the patients need to be well hydrated pre-op Please refer to separate renal transplant guidelines Other situations Pre-operative calculate current daily fluid intake Review recent U&E’s blood results Calculate current sodium intake (if on supplements) Check urinary sodium Farida Hussain Page 4 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Tubulopathies Fanconi syndrome (e.g. cystinosis) Cystinosis is an autosomal recessive disorder characterized by defective lysosomal cystine transport, leading to excessive intracellular cystine accumulation. This affects predominantly the proximal tubule, leading to a severe Fanconi’s syndrome (hypophosphataemia, aminoaciduria, glycosuria and acidosis). They also have a high fluid requirement due to polyuria. Pre-op Calculate the current fluid intake that the patient requires Calculate daily sodium, potassium and bicarbonate requirements from medications. Choose appropriate fluid, and calculate how much potassium chloride and sodium bicarbonate need to be added to each bag. o Please note that these patients often have very high potassium requirements. Addition of potassium to i.v fluid bags is restricted to certain wards and therefore it may be necessary for the fluids to be made up in pharmacy – these should be written up in advance to avoid any delays all calculations should be checked with responsible nurse Example: A 15kg child with cystinosis usually takes 1.5 litres/day. He is on 5mmol tds of potassium acid phosphate and 5mls tds of polycitra LC (1mmol /ml K+, 1mmol/ml Na+, 2mmol/ml of bicarbonate) Each day, he therefore requires: 1500mls fluid total of 30mmol of K+ total of 30 mmol of bicarbonate total of 45 mmol of Na+ (30mmol = ‘maintenance’ :(2mmol/kg) + 15 mmol supplements). It would be appropriate to prescribe 4% Dex/ 0.18% Saline with 10mmol K+, 10mmol Bicarbonate – added to each 500 ml bag, to run at 65mls/hr (Rounded up from 62.5mls/hr). Fluids should be commenced as soon as the patient is nil by mouth, and not wait until the patient is in theatre – as there is a risk of dehydration in this time. Post-op Fluids continued with regular clinical review (including repeating patient weight if necessary) regular blood monitoring ((U&E should be a full renal profile - includes HCO3-, Ca and PO4 and is typically 8 hourly) with adjustment to fluids (rate +/- composition) if necessary. Liaise with surgeons about re-starting medications and using NG tube or gastrostomy (if patient has one) as soon as possible, as this will aid management. Farida Hussain Page 5 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Nephrogenic Diabetes Insipidus (NDI) NDI is the inability of the kidney to concentrate urine in response to arginine vasopressin, leading to polyuria and polydipsia. In contrast to the conditions mentioned already, these patients produce very dilute urine and ‘hold on’ to sodium. Patients are normally able to ‘selfregulate’ their sodium concentration, provided they have access to free water and are able to tolerate this. If they are kept nil by mouth, their clinical status can change rapidly and this is reflected in the level of monitoring suggested for them post-operatively. Admission to PICU / HDU electively should be considered for all NDI patients who require to be kept NBM post-operatively Discussion with the surgeons as to when the earliest time water can be given orally or via gastrostomy should occur, as this will ease management. Pre-op Knowledge of current total daily fluid intake – allows calculation of hourly fluid requirement. Fluids should be commenced as soon as the patient is nil by mouth Calculate the ‘normal’ maintenance volume for 24 hours the patient would receive for their weight. This volume should be given as 4% dextrose / 0.18% Saline Then calculate what ‘extra’ fluid they normally take per day. This volume should be given as 5% dextrose. The 2 fluids should be run simultaneously (i.e. 2 iVAC pumps will be required) Example A 10 kg child with NDI who normally takes 3 litres / day ‘maintenance’ = 100mls/kg = 1 litre (41mls/hr of 4% dextrose / 0.18% saline) ‘extra’ = 2 litres (83mls/hr of 5% dextrose) As these patients run the risk of hypernatraemic dehydration, close monitoring is required including: Hourly input/ output (weighing nappies is usually sufficient) Regular weights (up to 6 hourly if NBM) Regular biochemistry monitoring including BM’s (6 hourly initially – as long as initial post-op bloods satisfactory) Bloods samples should be requested as urgent, and results should be chased up and entered onto a results flow sheet) If there is any evidence of worsening hypernatraemia, weight loss or negative fluid balance discuss with consultant. The ratio of fluids being given may need to change and the rate of administration may need to be altered (if the rate requires changing, it will usually involve increasing the rate of 5% dextrose alone) If there is evidence of hypokalaemia, potassium should be added –to the ‘maintenance’ (4% dex/0.18% Saline) fluids. If there is evidence of hyperglycaemia, this should be controlled, as this may drive the urine output further – discuss with consultant if rising BM or BM>15 or glycosuria. Farida Hussain Page 6 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders As soon as the patient can tolerate enteral fluids (discuss with surgeon if post-op, to see if clear fluids allowed as soon as possible) allow them to take water orally / via NG / via gastrostomy, and reduce the iv fluid rate accordingly (as long as clinically stable) A decision as to which fluid rate to reduce will depend on factors including: current sodium and glucose levels. Patients with Acute Renal Failure +/- Acute Glomerulonephritis These patients usually present with oliguria or anuric. ALL of these patients should be referred to paediatric nephrology Many patients will be given a set fluid restriction by the consultant paediatric nephrologists on-call Fluid prescription – this will depend on recent blood results, but in general 5% dextrose 0.45% saline is used. For most oligo/anuric patients, potassium should NOT be added to i.v fluids Regular monitoring of both clinical and biochemical status is required and fluids adjusted accordingly. (typically this involves blood test monitoring 8 –12 hourly) If no fluid limits have been set, the patient can be managed safely with a regime of insensible losses + urine output Insensible losses are calculated as: 400mls/m 2/day. Body Surface Area calculated using the equation: √ (ht in cm x wt in kg / 3600). Farida Hussain Page 7 of 8 June 2008 Paediatric Guideline Renal 6.6 Fluids Management in Patients with Known Renal Disorders Appendix Composition of Commonly Used Intravenous Fluids: 0.9% Saline 0.9% Saline + 5% dextrose 0.45% saline + 5% dextrose 0.18% saline + 4% dextrose 5% dextrose Na+ (mmol/l) 156 156 78 30 - Cl(mmol/l) 156 156 78 30 - K+ (mmol/l) - Glucose (g/100ml) 5 5 4 5 Note: 0.45% solution alone is a hypotonic solution and its use is severely restricted. Chronic Kidney Disease Categories CKD stage 1 2 3 4 5 Description Kidney damage with Normal or ↑ GFR Kidney damage with Mild ↓ GFR Moderate ↓ GFR Severe ↓ GFR Kidney failure GFR (ml/min/1.73m2) ≥90 60 – 89 30 – 59 15 – 29 < 15 (or dialysis) “Normal’ Maintenance Fluid requirements per 24 hours 100mls/kg– for the 1st 10kg 50mls/kg– for the 2nd 10kg 20mls/kg thereafter Insensible Losses These are estimated on the basis of body surface area as 400mls/m 2/day. Body Surface Area is estimated using the equation: √ (height [cm] x wt [kg] / 3600) Farida Hussain Page 8 of 8 June 2008