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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
www.dnbpediatrics.com
•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
www.dnbpediatrics.com
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
www.dnbpediatrics.com
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
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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
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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
www.dnbpediatrics.com
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
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H oll id ay -
Seg
ar
Met
hod
Bod
y
Surf
ace
are
a
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
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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 ed www.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+ levels
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SolutionGlucose
(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 ed www.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 .
Nelson textbook of Pediatricswww.dnbpediatrics.com
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 rateSlightly increased
Increased Very increased
Respiratory rate/pattern*
Normal Increased Increased
Blood pressure NormalNormal, but
orthostasisDecreased
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/anuriawww.dnbpediatrics.com
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)
Johns Hopkins: The Harriet Lane , 18th ed www.dnbpediatrics.com
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
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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
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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
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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
Nelson textbook of Pediatrics
www.dnbpediatrics.com
% dehydration = 100Pre 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 Johns Hopkins: The Harriet Lane , 18th ed www.dnbpediatrics.com
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 toECF
Intracellular dehydration
Clinical signs less evident
www.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%
Johns Hopkins: The Harriet Lane , 18th ed www.dnbpediatrics.com
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)
Johns Hopkins: The Harriet Lane , 18th ed
www.dnbpediatrics.com
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?
Johns Hopkins: The Harriet Lane , 18th ed www.dnbpediatrics.com
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….. ½ deficit + 2/3 mainte 817 44 30
Isotonic dehydration calculation
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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
817 ml N/2 5% dextrose+ 15 ml KCl @ 51 ml/hr
First 8 hrs….. Vol sodium potassium
½ deficit + 1/3 mainte 583 38 26
Next 16 hrs….. Vol sodium potassium
½ deficit + 2/3 mainte 817 44 30
www.dnbpediatrics.com
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 expectbased on fluid loss
• Irritable, lethargic, fever, hypertonicity , hyperreflexia www.dnbpediatrics.com
Free Water DeficitUse 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)
Johns Hopkins: The Harriet Lane , 18th ed
www.dnbpediatrics.com
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.
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Hypernatremic Dehydration Example
7 kg child with 10% dehydration of illness of >3 daysNa = 155 . Illness weight 6.3 kg
What are the fluid and electrolyte requirements?
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Maintenance
Solute fluid deficit ( 700 – 280)
0.6*0.42*145
0.4*0..42*150
T0TAL
700 21 14
K (meq/l)Na (meq/l)Water (ml)
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)Potassium…………..39 meq
1280 ml N/3 5% dextrose+ 20 ml KCl @ 53 ml/hr
Next 24 hrs….. Vol. Sodium Potassium
mainte + 840ml 21 meq 14 meq½ free water deficit (700+140)
………N/5 (Na=30 meq/l) …….840 ml N/5 D 5% + 7 ml KCl @ 35 ml/hr
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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)
www.dnbpediatrics.com
Hypotonic Dehydration (Na+ < 135 mEq/L)
•Combination of sod. and water loss and water retentionto compensate for the volume depletion
•Children with vomiting and diarrhea who have receivedhypotonic fluids as oral replacement
•Shock is an early symptom.
•Neurological symptom – anorexia, nausea, emesis, malaiselethargy, headache, seizures, coma.
•Physical exam findings usually exaggerateamount of dehydration.
Johns Hopkins: The Harriet Lane , 18th ed www.dnbpediatrics.com
› 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.
www.dnbpediatrics.com
•To calculate the Na+ Deficit, multiply 0.6mEq/kg of body weight for each mEq of Na+
below 135 mEq/L.
Na+ Deficit = 0.6 * b. wt. *( 135 – Na+)
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Hypotonic Dehydration Example
7 kg child with 10% dehydration of illness of >3 days
Na = 115 . Illness weight 6.3 kg
What are the fluid and electrolyte requirements?
www.dnbpediatrics.com
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
K (meq/l)Na (meq/l)Water (ml)
84
61 -
1400 166 56
- 42
Deficit 700
T0TAL 1280 166 56
First 8 hrs….. ½ deficit + 1/3 mainte 583 79 26
Next 16 hrs….. ½ deficit + 2/3 mainte 817 87 30
www.dnbpediatrics.com
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)Potassium…………..26 meq
Next 16 hrs….. Vol.Sodium potassium
½ deficit + 2/3 mainte 817 87 30
Rate ….. 817/16 = 51 ml/hr Sodium ……………87 meq…… N/2 ( Na=77 meq/l)Potassium………..30 meq
583 ml NS 5% dextrose+ 13 ml KCl @ 73 ml/hr
817 ml N/2 5% dextrose+ 15 ml KCl @ 51 ml/hr
www.dnbpediatrics.com
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
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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.
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Adjusting fluid therapy for Diarrhea
Avg . Composition of diarrheal fluid.Sodium : 55 mEq/LPotassium : 25mEq/LBicarbonate : 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
Nelson textbook of Pediatrics
www.dnbpediatrics.com
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
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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
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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 limitedfor 24 hr.
usual maintenance therapy is resumed gradually
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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
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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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