I respect your great effort. I wish you to clarify some points: **Regardless to the type of dehydration, what's the maximum rate of IV fluids to avoid over volume heart failure ? **IV re hydration with special situation: ^Ongoing losses of urine output more than 3 ml/kg/hour (e.g. in DKA ) ^Fever ^Burn ^Increase intracranial pressure ^If the child can tolerate some oral fluids (e.g. 75 ml after 8 hours from starting IV fluids) this amount must be subtracted from the total ?
Respected Sir, yours is an excellent presentation, infact my students, PG residents also liked it very much. Sir no confrontation at all. Please don’t misunderstand me. Just thinking, giving HYPOTONIC ( more specific as hypo-osmolar) N HYPONITREMIC FLUID as maintenance in Isotonic and Hyponitremic dehydration , will exacerbate the dehydration as Fluid Will shift from ECF to ICF , making exacerbation of Hypovolemia in intravascular compartment. Hence it would be logical also to give iso- osmolar Fluid ie D5NS as maintenance? Please opine sir. Be a friend of mine. Mine ABG PPT is highest read in the world, may send you on your email. Thanks n best wishes 🙏.
Dear Dr. Buche, It is my pleasure to be your friend, I am sorry when you were sending all the comments I was overseas and traveling with limited access. Please email me the ABG PPT. Osamanaga@yahoo.com Thank you. Osama
Kindly check recent edition of Harriet lane, they have recommended, I stress, D5NS for isometric and hyponatremic denydration and D5 1/2 N.S. for hyperntremic dehydration, please go through now
Dear Sir.Thank you very much for those valuable videos.I want to 1/ understand how to calculate the ongoing losses by using bicarbonates if there is severe acidosis. 2/ there is overlap in rapid calculation of the rate in isonatremic dehydration : you said the rate is 1.5 or double or 2.5- 3 times the maintenance according to the severity OK. then at 32.19 you mention the maintenance plus the deficit volumes can be infused over 24 hours. please give another clinic case scenario with complete RAPID calculation of isonatremic dehydration.
For the calculations, does anyone actually calculation for the first 8-hr and then the next 16-hrs? Or in practice people generally only use a 24-hr period?
Many thanks my prof Dr Naga for your most appreciated effort I just want to clarify apoint For example in hyponatremic dehydration We use D5/half NS It means If we are preparing 100cm fluid it will be formed of 50cm glucose 5%+25cm distelled water and 25cm saline 0.9% Am I right or wrong?
We hope to fulfill all subjects and continue infectious diseases then solve MCQ and demonstrate cases as seen in clinic (including videos, heart sounds, adventitious respiratory sounds and syndromes) ( updating ) نريد مجموعة محاضرات( د/أسامة نجا ) مرجعية عالميه مع عمل (guidelines )بإستمرار على حسب ال
I think there is a very minor error at 18:00... in the example, deficit of Na is 84mEq and not 84mEq/L because the 1L deficit of fluid was already counted... same for K, deficit is equal to 60mEq and not 60mEq/L
Thank you so much for the comment, this is what I meant. Na deficit for every 100ml lost is 8.4mEq means for each 1000ml is 84mEq. Same with K. Approximately 60% of acute fluid and electrolyte losses come from the extracellular space, with about 40% of fluid and electrolyte shifts coming from the intracellular space. Sodium in the extracellular space (content of about 140 mEq/L [140 mmol/L]) and potassium in the intracellular space (content of 150 mEq/L [150 mmol/L]) are the major electrolyte components that are lost. For every 100 mL of water lost, 8.4 mEq (8.4 mmol) of sodium {(140 mEq/L [140 mmol/L] × 0.60) ÷ 10} and 6 mEq (6 mmol) of potassium {(150 mEq/L [150 mmol/L] × 0.40) ÷ 10} are lost. Source. Pediatrics in Review. Please correct me if I am wrong. Thanks again.
i totally agree with you. I just want to comment the fact that at 18:00 Na deficit for 1000mL is just 8.4 x 100 = 84 mEq and not 84mEq/L ... you are counting the Na deficit in mEq and therefore mEq/L is not absolutely correct as only mEq is. Having said this, I have also to say that my comment is just my opinion and it is not an important comment at all, so forgive me and thank you again for the wonderful and precious videos you make. Regards.
Okay. Now I understand your point. Thank you very much for the clarification. Will make sure to clarify this point in the next updated videos. Thanks again.
Also there's minor error in calculating example of hypernatremic dehydration you forgot to subtract free fluid deficit 3000 ( 2000+980) you made it 3500 then 3300
salam alikom first of all thank you for this effort i would like to ask about the source of the lecture?! and i would like to ask you to revise the calculation of case scenario regarding hypernatremic dehydration as there is a mistake
Thank you, the lecture and cases from an article in Pediatrics in Review AAP, including the cases calculations, I used the exact same examples, please specify the mistake and give the correct calculation. Thanks again.
Sir in case of hypernatremic dehydration patient will remain nill per oral till 48 hours while on IV fluids as taking orally will disturb our calculations which we would do for 48 hours and might decrease sodium rapidly
This is true, LR may be superior to NS in trauma and hemorrhagic shock. But we do not use routinely in pediatric patients with dehydration. " Lactated Ringer solution should not be used routinely because it is relatively hypotonic (130 mEq/L [130 mmol/L]) of sodium and could adversely lower the patient’s serum sodium. In addition, it contains 4 mEq/L (4 mmol/L) of potassium that could contribute to hyperkalemia. Finally, children with significant emesis may have a contraction alkalosis (increase in blood pH) as a result of fluid losses that could be worsened by the lactate content of the fluid being converted to bicarbonate."
RL is not recommended in the case of vomiting because the pt. already has alkalosis because the loss of HCL and lactate turns into bicarbonate when enters the body soooo for vomiting N/S is superior
+shauna harvey All patients presents with dehydrations, who are stable, alert, and able to drink, should be encouraged for PO intake all the time e.g. regular diet, formula or breast feeding as tolerated, and IV fluids can be discontinued once they are hydrated and their electrolytes are normalized and no more acidosis.. PO always is the best. On the other hand you can not correct hypernatremic dehydration with PO fluids, at the same time we do not place them NPO. Encourage PO intake even with a syringe or dropper even during IV hydration, e.g. cases of herpangina, because this is the ultimate goal. ORS or Pedialyte are the best fluids, breast milk or formula for infants even better.
Sandra Milan Friend, yes u can correct Hypernitremic dehydration in 24 hrs maximum correction upto 10 meq/ L provided change in Sr Na is 10 or less than 10.
I think a doctor who practice internal medicine will be able to help you with adults fluids and electrolytes, I have no idea about adult medicine, thanks.
In hypernatremic dehydration: logically, the more Na concentration the more free fluid deficit so, why we calculate free fluid deficit as 3 ml/kg (instead of eg. 5 ml/kg) if Na is more than 170 mEq/l
This formula is to calculate the fluid containing electrolytes (IV fluid), in order to avoid fast correction. In this case we will use less Na in the IV fluids if the serum Na is 170 or more, and slightly more Na if the level is more than 145 and less than 170. Try one example with serum Na 150 and another example with serum Na 170.
if you give hypotonic saline( as per your video) to correct isonitremic and hyponitrmic dehydration, will it not push child in to more dehydration, as it will push fliud in to ICF?????????
Thanks. Its the percentage of fluid loss from the extracellular space in a child ill 3 days or more "of course the fluid in ECF containing Na". I explained this in the beginning in two slides in this video, please go back to the video one more time. Thanks.
Hello Dr Restrepo. Thank you so much for your comment. The most common cause of seizure in cases of hypernatremic dehydration is rapid infusion of hypotonic solution and rapid drop in serum Na in a short time > cerebral edema > seizure > herniation of brain stem and even death. The best way is to correct that by giving the Na back acutely > giving hypertonic Na 3 %. Actually in this case you are treating the rapid and inappropriate drop in serum high Na level and cerebral edema not hypernatremia. This is the idea. Please let me know if you have any question. Thanks again. The source of that is Pediatrics in Review by AAP. "The calculation ordinarily equates to 0.2% NS. Potassium should be added once the infant is voiding and is clearly without intrinsic renal disease. Thus, D5 or D10 0.2% NS þ 20 to 40 mEq/L (20 to 40 mmol/L) KCl is usually appropriate for replacement over 48 hours. Frequent monitoring, generally every 4 to 6 hours, for the change in serum sodium is paramount to a good clinical outcome. Overall, the rate of fluid replacement should be adjusted rather than the composition of the fluid to ensure the appropriate rate of correction because brain cells generate idiogenic osmols in response to hyperosmolality to maintain intracellular tonicity and size. These substances are not diffusible or transportable out of the brain cells. Therefore,too rapid correction of the sodium can result in too much water acutely entering the cells, causing cerebral edema and seizures. If seizures do occur, the serum sodium should be acutely increased. An infusion with 3% saline can raise the serum sodium most efficiently while providing the least amount of free water. In general, 1 mL/kg of 3% saline increases the serum sodiumconcentration by about 1 mEq/L (1 mmol/L). Most seizures abate following administration of 4 mL/kg of 3% saline. Pediatrics in Review July 2015, VOLUME 36 / ISSUE 7Karen S. Powers, MD, FCCM**Pediatric Critical Care, Golisano Children’s Hospital, University of Rochester School of Medicine, Rochester, NY pedsinreview.aappublications.org/content/36/7/274?sso=1&sso_redirect_count=3&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token
I respect your great effort.
I wish you to clarify some points:
**Regardless to the type of dehydration, what's the maximum rate of IV fluids to avoid over volume heart failure ?
**IV re hydration with special situation:
^Ongoing losses of urine output more than 3 ml/kg/hour (e.g. in DKA )
^Fever
^Burn
^Increase intracranial pressure
^If the child can tolerate some oral fluids (e.g. 75 ml after 8 hours from starting IV fluids) this amount must be subtracted from the total ?
Simply excellent. Very grateful for clear, concise and well presented video. Thank you for the great channel. 😊😊 4/9/2019
Thank you!
Respected Sir, yours is an excellent presentation, infact my students, PG residents also liked it very much. Sir no confrontation at all. Please don’t misunderstand me.
Just thinking, giving HYPOTONIC ( more specific as hypo-osmolar) N HYPONITREMIC FLUID as maintenance in Isotonic and Hyponitremic dehydration , will exacerbate the dehydration as Fluid Will shift from ECF to ICF , making exacerbation of Hypovolemia in intravascular compartment. Hence it would be logical also to give iso- osmolar Fluid ie D5NS as maintenance? Please opine sir. Be a friend of mine. Mine ABG PPT is highest read in the world, may send you on your email. Thanks n best wishes 🙏.
Dear Dr. Buche, It is my pleasure to be your friend, I am sorry when you were sending all the comments I was overseas and traveling with limited access. Please email me the ABG PPT. Osamanaga@yahoo.com Thank you. Osama
جزاكم الله خيرا علي تعبك. محاضره رائعه وملخصه جدا
its de best thing that i hav ever learned,,,, thank u so much for amazing videos,,,, hope 2 c many more,,,,
You are very welcome. Thanks.
Kindly check recent edition of Harriet lane, they have recommended, I stress, D5NS for isometric and hyponatremic denydration and D5 1/2 N.S. for hyperntremic dehydration, please go through now
Sir I respect your so much efforts to educate.its great thank you sir
Thank you!
Excellent video thank you a lot
You are very welcome
ممتاز شرح ولا افضل شكرا لك 👍🏻
Finally so happy to understand this subject . Thank you very much 🙏
Useful to memorize for lifesaving
Thank you!
Dear Sir.Thank you very much for those valuable videos.I want to 1/ understand how to calculate the ongoing losses by using bicarbonates if there is severe acidosis. 2/ there is overlap in rapid calculation of the rate in isonatremic dehydration : you said the rate is 1.5 or double or 2.5- 3 times the maintenance according to the severity OK. then at 32.19 you mention the maintenance plus the deficit volumes can be infused over 24 hours. please give another clinic case scenario with complete RAPID calculation of isonatremic dehydration.
you are seriously the best, big thanks to you dr!! are you not doing more videos?
You are very welcome. I just published one video a week ago. The Floppy infant. The free time to do that is extremely limited. Thank you very much!
th-cam.com/channels/FO_CjLDvWxmAexhDDXC53Q.htmlvideos
i understand, your videos are very appreciated!
Thanks
Great 👏🙏
all your videos are excellent..thanks..
Thanks
كيف اقدر القى السلايدات 😭💔💔 ؟
Do you know of any good fluid calculator online?
very helpful video .. Thank you
Thanks.
Thanks for sharing this video
You're welcome!
For the calculations, does anyone actually calculation for the first 8-hr and then the next 16-hrs? Or in practice people generally only use a 24-hr period?
So for what do we use the fluid deficit containing electrolytes 24:30
Youe lecture 👌 is very good thanks can you explain to me how and when to give bicarb to correct metabolic acidosis
ماشاء الله ربي يباركلك ممتاز
Thank you!
Many thanks my prof Dr Naga for your most appreciated effort
I just want to clarify apoint
For example in hyponatremic dehydration
We use D5/half NS
It means
If we are preparing 100cm fluid it will be formed of 50cm glucose 5%+25cm distelled water and 25cm saline 0.9%
Am I right or wrong?
I am sorry I do not know!, I never prepared IVF for children. Our in-patient pharmacists do it for us.
I think u prepare it by adding half 10% dextrose and half NS
I think 10 % should be added
@@Roqya22true
God bless you
We hope to fulfill all subjects and continue infectious diseases
then solve MCQ and demonstrate cases as seen in clinic (including videos, heart sounds, adventitious respiratory sounds and syndromes)
( updating ) نريد مجموعة محاضرات( د/أسامة نجا ) مرجعية عالميه مع عمل
(guidelines )بإستمرار على حسب ال
Dear Doctor Sami. Thank you very much for your notes. I hope I have the time and ability to do all of that. Regards.
I think there is a very minor error at 18:00... in the example, deficit of Na is 84mEq and not 84mEq/L because the 1L deficit of fluid was already counted... same for K, deficit is equal to 60mEq and not 60mEq/L
Thank you so much for the comment, this is what I meant. Na deficit for every 100ml lost is 8.4mEq means for each 1000ml is 84mEq. Same with K. Approximately 60% of acute fluid and electrolyte losses come from the extracellular space, with about 40% of fluid and electrolyte shifts coming from the intracellular space. Sodium in the extracellular space (content of about 140 mEq/L [140 mmol/L]) and potassium in the intracellular space (content of 150 mEq/L [150 mmol/L]) are the major electrolyte components that are lost. For every 100 mL of water lost, 8.4 mEq (8.4 mmol) of sodium {(140 mEq/L [140 mmol/L] × 0.60) ÷ 10} and 6 mEq (6 mmol) of potassium {(150 mEq/L [150 mmol/L] × 0.40) ÷ 10} are lost. Source. Pediatrics in Review. Please correct me if I am wrong. Thanks again.
i totally agree with you. I just want to comment the fact that at 18:00 Na deficit for 1000mL is just 8.4 x 100 = 84 mEq and not 84mEq/L ... you are counting the Na deficit in mEq and therefore mEq/L is not absolutely correct as only mEq is. Having said this, I have also to say that my comment is just my opinion and it is not an important comment at all, so forgive me and thank you again for the wonderful and precious videos you make. Regards.
Okay. Now I understand your point. Thank you very much for the clarification. Will make sure to clarify this point in the next updated videos. Thanks again.
Also there's minor error in calculating example of hypernatremic dehydration you forgot to subtract free fluid deficit 3000 ( 2000+980) you made it 3500 then 3300
@@pediatricboardalastminuter1892 🤔
excellent video dr, i appreciated. thanks so mutch
You're very welcome! Thanks.
@@pediatricboardalastminuter1892 thnx excellente
excellent !!!
salam alikom
first of all thank you for this effort
i would like to ask about the source of the lecture?!
and i would like to ask you to revise the calculation of case scenario regarding hypernatremic dehydration as there is a mistake
Thank you, the lecture and cases from an article in Pediatrics in Review AAP, including the cases calculations, I used the exact same examples, please specify the mistake and give the correct calculation. Thanks again.
Regarding the calculation of total fluids in the case of hypernatremic dehydration
It should be 2980 not 3300
The calculation is correct. 2000+1500=3500-200=3300. NOT 2980.
Sir in case of hypernatremic dehydration patient will remain nill per oral till 48 hours while on IV fluids as taking orally will disturb our calculations which we would do for 48 hours and might decrease sodium rapidly
Thank you so much, this was helpful.
This is super useful!!Thx for adding this
You are very welcome. Thank you.
Lactated Ringers is an isotonic solution. it's equivalent to normal saline
This is true, LR may be superior to NS in trauma and hemorrhagic shock. But we do not use routinely in pediatric patients with dehydration. " Lactated Ringer solution should not be used routinely because it is relatively hypotonic (130 mEq/L [130 mmol/L]) of sodium and could adversely lower the patient’s serum sodium. In addition, it contains 4 mEq/L (4 mmol/L) of potassium that could contribute to hyperkalemia. Finally, children with significant emesis may have a contraction alkalosis (increase in blood pH) as a result of fluid losses that could be worsened by the lactate content of the fluid being converted to bicarbonate."
pedsinreview.aappublications.org/content/36/7/274?sso=1&sso_redirect_count=3&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token
Thanks.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4029282/
RL is not recommended in the case of vomiting because the pt. already has alkalosis because the loss of HCL and lactate turns into bicarbonate when enters the body
soooo for vomiting N/S is superior
Thank you for posting. I found this quite helpful. My only question is are patients kept NPO while providing IVF at these calculated rates ?
+shauna harvey All patients presents with dehydrations, who are stable, alert, and able to drink, should be encouraged for PO intake all the time e.g. regular diet, formula or breast feeding as tolerated, and IV fluids can be discontinued once they are hydrated and their electrolytes are normalized and no more acidosis.. PO always is the best. On the other hand you can not correct hypernatremic dehydration with PO fluids, at the same time we do not place them NPO. Encourage PO intake even with a syringe or dropper even during IV hydration, e.g. cases of herpangina, because this is the ultimate goal. ORS or Pedialyte are the best fluids, breast milk or formula for infants even better.
@@pediatricboardalastminuter1892 too good 👍 👌
What if I calculate in hypernatremic dehydration the first 24 hrs first ?
The deficit is divided over 48 hours in order to avoid rapid correction and neurological complications.
Sandra Milan
Friend, yes u can correct Hypernitremic dehydration in 24 hrs maximum correction upto 10 meq/ L provided change in Sr Na is 10 or less than 10.
Any link for this course file tables
Thank you so much for this video. Highly appreciated.
Thanks
thank you so much! 9/12/2020
Most welcome
Amazing thank you
Thank you too!
Hello sir can you please send the originals article
Thanks.
hello doctor thanks a lot for video. one question , Does the same fluid and electrolyte principle apply to adult or they have diffrent?
I think a doctor who practice internal medicine will be able to help you with adults fluids and electrolytes, I have no idea about adult medicine, thanks.
anyway thank you doc
In hypernatremic dehydration: logically, the more Na concentration the more free fluid deficit so, why we calculate free fluid deficit as 3 ml/kg (instead of eg. 5 ml/kg) if Na is more than 170 mEq/l
This formula is to calculate the fluid containing electrolytes (IV fluid), in order to avoid fast correction. In this case we will use less Na in the IV fluids if the serum Na is 170 or more, and slightly more Na if the level is more than 145 and less than 170. Try one example with serum Na 150 and another example with serum Na 170.
Really wonderful video thanks alot
But i wanna ask why you didn't subtract free fluid deficit in hyoertonic dehydration example?
Thank you!!
hyoertonic dehydration example?
Thanks a ton
Thank you!
THANK YOU SO MUCH DOCTOR FOR YOUR NICE LECTURES
You are very welcome. Thanks.
THANK YOU SO MUCH .......
You're very welcome!
داسامه كل عام وانتم بخير
Excellent!!!
Thanks
if you give hypotonic saline( as per your video) to correct isonitremic and hyponitrmic dehydration, will it not push child in to more dehydration, as it will push fliud in to ICF?????????
No sir, it will not. It is all calculated per kg. It is the standard. Review Harriet Lane. and other sources.
27:00
Excellent video. Question: when correcting the sodium deficit in hyponatremic dehydration, where does the 0.6 in the equation come from?
Thanks. Its the percentage of fluid loss from the extracellular space in a child ill 3 days or more "of course the fluid in ECF containing Na". I explained this in the beginning in two slides in this video, please go back to the video one more time. Thanks.
Thank you. Just needed to clarify that it was indeed in respect to three days. Thus, will be 0.8 had the illness been 1-2 days.
Thank you
You're welcome
thank u so much!
You're very welcome!
Where can I get this book
www.amazon.com/Pediatric-Board-Study-Guide-Minute-dp-3030212661/dp/3030212661/ref=mt_other?_encoding=UTF8&me=&qid=1615495029
www.springer.com/us/book/9783030212667
لوسمحت dehydration مختصراوي عن شرح الفيديو ايه الحل بعد اذنك. شاكر فضلك
In the new edition. We added a new chapter for Fluilds and Electrolytes. The 2nd edition will be released at the end of 2019.
I didnt like the add of orange juice to ors
Thanks, I want to know how to manage case of atopic dermatitis
Thank you very very very much
You are very welcome. You can watch the dermatology lecture as well.
Okay thanks
Hello professor Naga, respectfully I think there is a mistake in the management of hypernatremic seizure, you can´t treat a hypernatremia with 3% NS.
Hello Dr Restrepo. Thank you so much for your comment. The most common cause of seizure in cases of hypernatremic dehydration is rapid infusion of hypotonic solution and rapid drop in serum Na in a short time > cerebral edema > seizure > herniation of brain stem and even death. The best way is to correct that by giving the Na back acutely > giving hypertonic Na 3 %. Actually in this case you are treating the rapid and inappropriate drop in serum high Na level and cerebral edema not hypernatremia. This is the idea. Please let me know if you have any question. Thanks again. The source of that is Pediatrics in Review by AAP. "The calculation ordinarily equates to 0.2% NS. Potassium
should be added once the infant is voiding and is
clearly without intrinsic renal disease. Thus, D5 or D10
0.2% NS þ 20 to 40 mEq/L (20 to 40 mmol/L) KCl is
usually appropriate for replacement over 48 hours.
Frequent monitoring, generally every 4 to 6 hours, for the
change in serum sodium is paramount to a good clinical
outcome. Overall, the rate of fluid replacement should be
adjusted rather than the composition of the fluid to ensure the
appropriate rate of correction because brain cells generate
idiogenic osmols in response to hyperosmolality to maintain
intracellular tonicity and size. These substances are not
diffusible or transportable out of the brain cells. Therefore,too rapid correction of the sodium can result in too much
water acutely entering the cells, causing cerebral edema and
seizures. If seizures do occur, the serum sodium should be
acutely increased. An infusion with 3% saline can raise the
serum sodium most efficiently while providing the least
amount of free water. In general, 1 mL/kg of 3% saline
increases the serum sodiumconcentration by about 1 mEq/L
(1 mmol/L). Most seizures abate following administration of
4 mL/kg of 3% saline.
Pediatrics in Review
July 2015, VOLUME 36 / ISSUE 7Karen S. Powers, MD, FCCM**Pediatric Critical Care, Golisano Children’s Hospital, University of Rochester School of Medicine, Rochester, NY
pedsinreview.aappublications.org/content/36/7/274?sso=1&sso_redirect_count=3&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token
Hi Professor Naga, I saw the slide out of context. Thanks a lot.
I added annotation to the slide to clarify this point. Thanks
Kindly give feedback please sir
I will review other sources and will get back to you. Thank you.
35:10
L bs