6.6 fluid management patients with renal disorders

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Paediatric GuidelineRenal 6.6Fluids Management in Patients with Known Renal Disorders

Farida Hussain of 8 June 2008

Short Title: Fluid Management in Patients with Known Renal Disorders

Full Title: Guideline for Management of Fluids in Children and Young People withKnown Renal Disorders

Date of production/Last revision: June 2008Explicit definition of patient groupto which it applies:

This guideline applies to all children and young people under the age of 19years.

Name of contact author Dr Farida Hussain, Consultant Paediatric NephrologistExt:

Revision Date June 2011

This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretationand application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact asenior colleague or expert. Caution is advised when using guidelines after the review date.

ContentsPage

Introduction 2

Summary of organization 3

Patients with chronic kidney disease: 4Oligo-anuriaPolyuria

Tubulopathies 5

Nephrogenic diabetes insipidus 6

Acute renal impairment 7

Appendix 8Composition of fluidsChronic kidney disease categoriesNormal ‘maintenance’ fluid requirements





Summ ary of Organisat ion

Planning for elective procedures

Referral letter from Paediatric nephrology to surgical team (with a copy in the notes). Thesurgical team should ensure the relevant anaesthetist is also sent a copy of the letter. Theletter 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 hydrationo Weight – compare with previous weightso Heighto 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





Patients with Chronic Kidney Disease

The management pre, peri, and post-operatively, of ALL of these patients should bediscussed with the paediatric nephrologists on-call, even if the patient is admitted under adifferent team (e.g. surgical team).

Depending on the patient’s diagnosis, and current CKD staging (See appendix), theirmanagement will be different, and an up-to-date knowledge of their current estimated 24 hoururine output, current fluid requirements and current medications (as outlined in the planningstage) 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 t ransplantThis is a very specific clinical situation, as the patients need to be well hydrated pre-op.Please refer to separate renal transplant guidelines

Other s i tuat ions 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 fluidsadjusted 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 ofinsensible losses + urine output

Insensible losses are calculated as: 400mls/m2/day).

Body Surface Area calculated us ing 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 aretherefore at high risk of dehydration without adequate fluid replacement.

Pre- renal t ransp lantThis is a very specific clinical situation, as the patients need to be well hydrated pre-opPlease refer to separate renal transplant guidelines

Other s i tuat ions Pre-operative calculate current daily fluid intake Review recent U&E’s bloodresults Calculate current sodium intake (if on supplements) Check urinary sodium





Tubulopathies

Fanconi syndrome (e.g. cystinosis)

Cystinosis is an autosomal recessive disorder characterized by defective lysosomal cystinetransport, leading to excessive intracellular cystine accumulation. This affects predominantlythe proximal tubule, leading to a severe Fanconi’s syndrome (hypophosphataemia,aminoaciduria, glycosuria and acidosis). They also have a high fluid requirement due topolyuria.

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 pat ien t s of ten h ave very h igh potass ium

requi rements .

Addition of potassium to i.v fluid bags is restricted to certain wardsand therefore it may be necessary for the fluids to be made up inpharmacy – these should be written up in advance to avoid anydelays

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+, 10mmolBicarbonate – 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 thepatient is in theatre – as there is a risk of dehydration in this time.

Pos t -opFluids 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 (ifpatient has one) as soon as possible, as this will aid management.

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, thesepatients produce very dilute urine and ‘hold on’ to sodium. Patients are normally able to ‘self -regulate’ their sodium concentration, provided they have access to free water and are able totolerate this.

If they are kept nil by mouth, their clinical status can change rapidly and this is reflected in thelevel of monitoring suggested for them post-operatively.

Admission to PICU / HDU electively should be considered for all NDI patients whorequire to be kept NBM post-operatively

Discussion with the surgeons as to when the earliest time water can be given orally orvia gastrostomy should occur, as this will ease management.

Pre-op

Knowledge of current total daily fluid intake – allows calculation of hourly fluidrequirement.

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 fortheir 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 begiven 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 requiredincluding:

Hourly input/ output (weighing nappies is usually sufficient) Regular weights (up to 6 hourly if NBM) Regular biochemistry m onitoring 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 fluidbalance discuss with consultant. The ratio of fluids being given may need to change andthe rate of administration may need to be altered (if the rate requires changing, it will usuallyinvolve 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 urineoutput further – discuss with consultant if rising BM or BM>15 or glycosuria.





Appendix

Composition of Commonly Used Intravenous Fluids:

Na+(mmol/l)

Cl-(mmol/l)

K+(mmol/l)

Glucose(g/100ml)

0.9% Saline 156 156 - -0.9% Saline + 5% dextrose 156 156 50.45% saline + 5% dextrose 78 78 - 50.18% saline + 4% dextrose 30 30 - 45% dextrose - - - 5

Note: 0 .45% solu t ion a lone i s a hypo tonic so lu t ion and i t s use i s severely res t r i c ted .

Chronic Kidney Disease CategoriesCKD stage Description GFR (ml/min/1.73m2)

1 Kidney damage withNormal or ↑ GFR

≥90

2 Kidney damage withMild ↓ GFR

60 – 89

3 Moderate ↓ GFR 30 – 594 Severe ↓ GFR 15 – 295 Kidney failure < 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/m2

/day.

Body Surface Area is estimated using the equation: √ (height [cm]x wt [kg] / 3600)

6.6 fluid management patients with renal disorders

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