Ppt fl & el

Dr Vivek Khanna
Senior Resident
Sanjay Gandhi Memorial Hospital
www.dnbpediatrics.com

 contents of different fluid compartments in body
 how to estimate maintenance fluid and
electrolyte needs
 contents of different intravenous and oral
rehydration solutions
 fluid management for patients with
› Isonatremic dehydration
› Hyponatremic dehydration
› Hypernatremic dehydration
 fluid therapy in special situation

•TBW as a % of body weight varies with age.
•Term neonate = TBW is 75% of body weight
•Preterm > Term
•Infant  60% of weight ……almost constant till puberty
•Puberty:
Females  more fat ---- TBW decr. To 50-55%
Males  more muscle ---- TBW remains at 60%
Nelson textbook of Pediatrics

ECF ( 20- 25%) ICF ( 30- 40% )
Plasma
(5%)
Interstitial fluid
( 15% ) Fetus & newborn….. ECF > ICF
By 1 yr reaches adult ratio
Pubertal males …. Incres. Muscle… incres ICF
Post puberty… both sexes ... Almost same ratio.
Increased in :
-Heart failure
-Nephrotic syndrome
-Liver failure
-Protein losing enteropathy
- hypoproteinemia
- Pleural effusion, ascites Nelson textbook of pediatrics

ICF (mEq/L) ECF (mEq/L)
Sodium 20 135-145
Potassium 150 3-5
Chloride --- 98-110
Bicarbonate 10 20-25
Phosphate 110-115 5
Protein 75 10
ECF and ICF Composition

1. Maintenance: Determined by a ‘system’:
a. Holliday-Segar method
b. Surface area method
2. Deficit: Determined by acute weight
change or clinical estimate
3. Ongoing losses: Determined by measuring

 Prevent dehyration
 Prevent electrolyte disorder
 Prevent ketoacidosis
 Prevent protein degradation
Glucose
- 5% dextrose (D 5 )
- Provides 17 cal/ 100ml
- 20% of daily calorie need
- Prevent gluconeogenesis , protein catabolism and ketogenesis
Nelson textbook of Pediatricswww.dnbpediatrics.com

Two systems have been proposed to relate
maintenance fluid and electrolyte needs to
the body weight.
› Holliday-Segar method
› Surface area method

H
oll
id
ay
-
Seg
ar
Met
hod
Bod
y
Surf
ace
area
met
hod
 Most widely used method
 Landmark paper by Holliday and
Segar in 1957
 Assumes …. each 100 calories
metabolized, 100 ml H2O will be
required
 Not suitable for newborns
especially < 14 days old
 Not used if < 10 days old
BSA ( m2)= √ (height in cm× weight in kg
/ 3600)
Johns Hopkins: The Harriet Lane , 18th ed

Holliday segar Body
surface area
Water 0-10 kg–- 100ml/kg
11-20 kg– 1000 ml + 50 ml/kg for each kg >10
>20 kg--- 1500 ml + 20 ml/kg for each kg >20
1500 ml/m2
Sodium 3 meq/100 ml 30-50 meq/m2
Potassium 2 meq/100 ml 20-40 meq/m2
Johns Hopkins: The Harriet Lane , 18th edwww.dnbpediatrics.com

 Based on weight categories
Weight Type of Fluid Brand
< 10 kg N/6 in D 5% with 20 meq/lit of K Isolyte P
11 - 25 kg N/4 in D5% with 25 meq/lit of K
26 - 35 kg N/3 in D 5% with 30 meq/lit of K
> 35 kg N/2 in D 5% with 40 meq/lit of K
• Use 20 meq/lit of K+ as standard and
change K+ conc. based on K+ levelswww.dnbpediatrics.com

Solution
Glucose
(g/L)
Na+ K+ Cl- Lactate mOsm/l
10% Dextrose 100 0 0 0 0 500
5% Dextrose (D5W) 50 0 0 0 0 250
0.9% NS 0 154 0 154 0 308
D5½NS ( 0.45%) 50 77 0 77 0 406
D51/3 NS 50 51 0 51 0 353
D51/5 NS 50 31 0 31 0 311
RL 50 130 5 109 28 531
Isolyte-P 50 25 20 22 0 368Isolyte-P 50 25 20 22 0 368
Johns Hopkins: The Harriet , 18th edwww.dnbpediatrics.com

Modifications for Maintenance Fluids
Increase Decrease
_______________________________________
•Fever * Renal failure
•High ambient temperature Postoperative
. Vigorous exercise Heart failure
* 10 – 15% increase in maintenance water need for each 1
degree C increase in temp. above 38 degree C .

Symptom/Sign
Mild
Dehydrat
ion
Moderate
Dehydration
Severe Dehydration
Level of
consciousness
Alert Lethargic Obtunded
Thirst normal Drinks eagerly decreased
Mucous
membranes
Normal Dry Parched, cracked
Tears Normal Decreased Absent
Heart rate
Slightly
increased
Increased Very increased
Respiratory
rate/pattern*
Normal Increased Increased
Blood pressure Normal
Normal, but
orthostasis
Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor* Normal Slow Tenting
Fontanel Normal Depressed Sunken
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria

Estimated Fluid Deficit
Severity
Infants
(weight <10
kg)
Children
(weight >10
kg)
Mild
dehydration
5%
(50 mL/kg)
3%
(30 mL/kg)
Moderate
dehydration
10%
(100 mL/kg)
6%
(60 mL/kg)
Severe
dehydration
15%
(150 mL/kg)
9%
(90 mL/kg)

No signs of
dehydration
Some
dehydration
Severe
dehydration
Look at Condition Well Restless ,irritable Lethargic,
unconscious
Eyes Normal Sunken Very sunken
Tear Present Absent Absent
Mouth ,Tongue Moist Dry Very dry
Thirst Drinks no thirsty Thirsty ,drinks
eagerly
Drink poorly, not
able to drink
FEEL SKIN PINCH Goes back quickly Goes back slowly Goes back very
slowly
DECIDE Two or more signs Two or more signs
Treat Plan - A Plan - B Plan - C

AGE Amt of ORS or ORT after
each stool
< 2 years 50 – 100 ml
2 yrs to 10 years 100 – 200 ml
>= 10 years As much as wanted

Approximate amount of ORS in 4 hrs
Age < 4 mths 4-11
mths
12-23
mths
2-4 yrs 5-14 yrs >=15
yrs
Wt. in kg < 5 5 - 8 8 - 11 11 – 16 16 – 30 > 30
ORS (ml) 200- 400 400 –
600
600 –
800
800 –
1200
1200 –
2200
>2200
Glass 1-2 2 – 3 3 – 4 4 – 6 16 – 30 12 – 20
Approx. amount = 75 ml/kg over 4 hrs
Encourage breast feedingwww.dnbpediatrics.com

Age First give Then give
< 12 mths 30 ml/ kg in 1 hour* 70 ml/kg in 5 hrs
1 yr to 5 years 30 ml/ kg in 30 min* 70 ml/kg in 2.5 hrs
Start I V fluids immediately….
Best solution ……… R L .(ideal sol. is R L + 5% Dextrose )
If not available…….0.9% NaCl
Give 100 ml/kg of chosen solution.
If unable to give iv…....ORS at 20 ml/kg by nasogastric tube
*Repeat again if the radial pulse is still very weak or not
detectable www.dnbpediatrics.com

 NaCl 2.6 gm
 Dextrose 13.5 gm
 Potassium 1.5 gm
 Sodi. citrate 2.9 gm
Electrolyte meq/l
 Sodium 75
 Potassium 20
 Chloride 65
 Citrate 10
 Dextrose 75
 TOTAL 245

 Restore intravascular volume
N S : 20 ml/kg over 20 min
repeat as needed
 Rapid volume repletion : 20ml/kg N S or R L over
2hr
 Calculate 24 hr fluid needs : maintenance + deficit
vol.
 Subtract isotonic fluid already administered from
24hr fluid needs
 Administer remaining volume over 24 hr
 Replace ongoing losses as they occur

% dehydration = 100
Pre illness wt
Pre illness wt – illness wt
Fluid deficit (L) = pre illness wt (kg)– illness wt (kg)
*
Assessment of dehydration
Example: child with pre illness wt of 10 kg found to have
illness weight of 9.5 kg
what is % dehydration ? & fluid deficit ?
% dehydration =
Fluid deficit =
(10-9.5)/10 *100 = 0.5/10*100 = 5%
0.5 l =500 ml

DEHYDRATION
Isotonic
Na = 135 – 150
Proportional loss from
ECF and ICF
Hypotonic
Na < 130
Implies excess
Na loss from ECF
Water moves
from ECF to ICF
Further
contracting the
ECF leading to
shock
Hypertonic
Na > 150
Excessive loss of water
from ECF
Water moves from ICF to
ECF
Intracellular dehydration
Clinical signs less
evidentwww.dnbpediatrics.com

If losses occur over short period of time …… losses are
mainly from ECF
Duration ECF ICF
< 3 days 80% 20%
≥ 3 days 60% 40%

 Intracellular and extracellular fluid compartments
› Estimate % dehydration from ECF and ICF related to duration of disease
› Na deficit = fluid deficit (l) * proportion from ECF * 145
› K deficit = fluid deficit (l) * proportion from ICF * 150
 Free water deficit in hypernatremic dehydration
 FW needed to decre. Na by 1 meq/l = 4 ml/kg ( 3 ml/kg if Na > 170)

Isotonic dehydration (Na 130-145 mEq/L)
Example 1 ;-
7 kg child with 10% dehydration of illness of >3 days
Na = 137 . Illness weight 6.3 kg
What are the fluid and electrolyte requirements?

Maintenance
DEFICIT
0.6*0.7*145
0.4*0.7*150
T0TAL
700 21 14
K (meq/l)Na (meq/l)Water (ml)
700
61 -
1400 82 56
- 42
First 8 hrs…..
½ deficit + 1/3 mainte 583 38 26
Next 16 hrs…..
Isotonic dehydration calculation

Which fluid ???
Rate ….. 583/8 = 73 ml/hr
Sodium …….38 meq … N/2 (Na =77meq/l)
Potassium…………..26 meq
Rate ….. 817/16 = 51 ml/hr
Sodium ……………44 meq/…… N/2 ( Na=77 meq/l))
Potassium………..30 meq
583 ml N/2 5% dextrose
+ 13 ml KCl @ 73 ml/hr
First 8 hrs….. Vol sodium potassium
Next 16 hrs….. Vol sodium potassium

Hypernatremic Dehydration (Na+ > 150 mEq/L)
•Mortality can be high
•Often iatrogenic
•The intravascular volume(extracellular space) is
preserved at the expense of the intracellular
volume
•The patient looks better than you would expect
based on fluid loss
• Irritable, lethargic, fever, hypertonicity ,
hyperreflexia www.dnbpediatrics.com

Free Water Deficit
Use 4 ml/kg of body weight for each mEq of Na+
above 145 mEq/L as the
Free Water Deficit=
(Serum Na+ -145 mEq/l) x weight x 4
= total amount of free water needed to dilute
the serum to get a normal concentration Na+
Only correct half of total Free Water Deficit in
first 24 hours if Na+ < 170 mEq/l
Solute fluid deficit (L) = Total F D (L) – FWD(L)

o In phase 2 management,
o correct sodium levels……….not more than 12 mEq/L/24h.
o Rapid correction .….. disastrous neurologic consequences,
……including cerebral edema and death.
o Hyperglycemia and hypocalcemia are sometimes
associated with hypernatremic dehydration.
o Serum glucose and calcium levels should be monitored
closely.

Hypernatremic Dehydration Example

Maintenance
Solute fluid deficit
( 700 – 280)
0.6*0.42*145
0.4*0..42*150
T0TAL
700 21 14
420
37 -
1400 58 39
- 25
First 24 hrs…..
½ free water deficit 140 - -
+solute fluid deficit 420 37 25
+ Maintenance 700 21 14
Hypernatremic dehydration calculation
Free Water
(4*wt*155-145)
280
T0TAL 1280 58 39www.dnbpediatrics.com

Which fluid ???
First 24 hrs….. Vol. Sodium Potassium
deficit + mainte 1280ml 58 meq 39 meq
+ ½ free water deficit
Rate ….. 1280/24 = 53 ml/hr
Sodium …….58 meq … N/3 (Na =51 meq/l)
Next 24 hrs….. Vol. Sodium Potassium
mainte + 840ml 21 meq 14 meq
½ free water deficit (700+140)
………N/5 (Na=30 meq/l) …….840 ml N/5 D 5% + 7 ml KCl @ 35 ml/hr

 Correct dehydration first with NS (not RL ) for
restoration of intravascular volume, before
correction of hypernatremia
 Type of fluid- D5 ½ saline(with 20meq/l KCL unless
c/i)
 Duration of correction- 48-72 hrs
 Seizures during correction- 3% NaCl by 4-6ml/kg
( Each 1ml/kg of 3% NaCl………increase S.Na 1mEq/l)

Hypotonic Dehydration (Na+ < 135 mEq/L)
•Combination of sod. and water loss and water retention
to compensate for the volume depletion
•Children with vomiting and diarrhea who have received
hypotonic fluids as oral replacement
•Shock is an early symptom.
•Neurological symptom – anorexia, nausea, emesis, malaise
lethargy, headache, seizures, coma.
•Physical exam findings usually exaggerate
amount of dehydration.

› slow correction (>0.5 mEq/L/h or 12 meq/l/day)
› Rapid correction (>2 mEq/L/h) of chronic
hyponatremia ………central pontine myelinolysis.
› Rapid partial correction of symptomatic hyponatremia
has not been associated with adverse effects.
› Therefore, if the child is symptomatic (seizures)…..
 Each ml/kg Hypertonic (3%) NaCl increases S.Na 1meq/L.
 4 mL/kg ….raises the serum sodium by 4 mEq/L.

•To calculate the Na+ Deficit, multiply 0.6
mEq/kg of body weight for each mEq of Na+
below 135 mEq/L.
Na+ Deficit = 0.6 * b. wt. *( 135 – Na+)

Hypotonic Dehydration Example

Hypotonic Dehydration Example
Maintenance
Excess Na deficit
( 135-115)*0.6*7
Na (0.6*0.7*145)
K (0.4*0.7*150)
T0TAL
700 21 14
84
61 -
1400 166 56
- 42
Deficit 700
T0TAL 1280 166 56
First 8 hrs…..
Next 16 hrs…..

Which fluid ???
First 8 hrs….. Vol. Sodium Potassium
½ deficit + 1/3 mainte 583 ml 79 meq 26 meq
Rate ….. 583/8 = 73 ml/hr
Sodium …….79 meq … NS (Na =154meq/l)
Next 16 hrs….. Vol.Sodium potassium
Rate ….. 817/16 = 51 ml/hr
Sodium ……………87 meq…… N/2 ( Na=77 meq/l)
Potassium………..30 meq
583 ml NS 5% dextrose

 Correct dehydration first with NS / RL
 Type of fluid- D5 ½ saline(with 20meq/l KCL unless c/i)
 Amount of fluid- 100% of maintainance
 Duration of correction- 48-72 hrs
 seizures…………3% hypertonic saline
 Monitored S.Na concentration ……..to ensure appropiate
correction

 Gastrointestinal tract is potentially a source
of considerable water & electrolyte loss.
 G. I. losses are to be precisely measured &
to be added to calculated maintenance water
 Losses should be replaced as they occur
using a solution with same approximate
electrolyte conc. as the G. I. fluid.

Adjusting fluid therapy for Diarrhea
Avg . Composition of diarrheal fluid.
Sodium : 55 mEq/L
Potassium : 25mEq/L
Bicarbonate : 15mE/L
*Cholera Na loss : 90 – 110 mEq/L
Replacement of ongoing losses :-
D5 0.2 N S +20mEq/L sod. bicarb.+20mEq/L KCL
Replace stool ml/ml every 1 – 6 hrs

Adjusting Fluid therapy for Emesis/ Nasogastric
loss
Avg . Composition of gastric fluid
Na : 60mEq/l
K : 10mEq/l
CL : 90mEq/l
Replacement of ongoing losses :-
N S + 10mEq/l KCL
Replace output ml/ml every 1 – 6 hr

Adjusting fluid therapy for Altered Renal Output
 OLIGURIA /ANURIA
Place patient on insensible fluid (25% - 40% of
mainte. or 1/3rd of maintenance)
Replace urine output ml/ml with ½ N S
 POLYURIA
Place patient on insensible fluid (25% - 40% of
mainte. )
Measure urine electrolytes
Replace urine output ml/ml with solution based on
measured urine electrolytes

 Surgical Drains & Chest tubes can produce
measurable fluid output .
 If it is significant….can be measured & replace
with appropriate replacement solution.
 Third space losses & chest tube output are
isotonic & they usually require replacement with
isotonic fluids as N S or R L .
 Postoperatively……..fluid intake should be limited
for 24 hr.
usual maintenance therapy is
resumed gradually

 Consider Fluid Therapy for
› >10% BSA 30
› >15% BSA 20
› >30-50% BSA 10 with accompanying 20
 LR using Parkland Burn Formula
› 4 cc/kg/% burn
› 1/2 in first 8 hours
› 1/2 over 2nd 16 hours

 Example of fluid management
 A 10kg patient with 50% body surface area burn would
require:
 4 x 50 x 10 = 2000mls of fluid over 24 hours.
 Therefore 1 litre should be given in the first 8 hours
and 1 litre over the following 16 hours
 Blood products and colloid may also be given in addition
to these requirements .

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