Ppt fl & el

Dr Vivek KhannaSenior 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


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

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


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


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)


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 = 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


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….. ½ deficit + 2/3 mainte 817 44 30

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

½ deficit + 1/3 mainte 583 38 26

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 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)



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

7 kg child with 10% dehydration of illness of >3 daysNa = 155 . Illness weight 6.3 kg



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)Potassium…………..39 meq


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


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 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.


› 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 0.6mEq/kg of body weight for each mEq of Na+

below 135 mEq/L.

Na+ Deficit = 0.6 * b. wt. *( 135 – Na+)


Hypotonic Dehydration Example

7 kg child with 10% dehydration of illness of >3 days

Na = 115 . Illness weight 6.3 kg



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….. ½ deficit + 1/3 mainte 583 79 26

Next 16 hrs….. ½ deficit + 2/3 mainte 817 87 30


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


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



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/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



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 limitedfor 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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Ppt fl & el