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Fluids & Electrolytes
Dr Ahmed SafwatNeonatology department
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Objectives
To discuss:
♦ Physiology of body fluid compartments
♦ Maintenance IV fluid requirements
♦ Types of Dehydration
♦ Management of Dehydration
♦ Electrolyte Abnormalities
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Composition of Body Compartments
Total Body Water represents 50 - 75% of Total Body
Mass• ICF: 2/3 of TBW
• ECF (Plasma - intravascular + Interstitial fluid ): 1/3 of TBW
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Body Water Compartments Related to Age
0
10
20
30
40
50
60
70
80
0 years 1 year 10 years 20 years
TBW
ICF
ECF
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Distribution of Body Water
Intravavascular
Interstitial
IntracellularICF
ECF
K+
Na+
CL-
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Extracellular Intracellular
Cations (+) Anions (-) Cations (+) Anions (-)
Na (99%) CL (70%) K (78%) PO4/Org (56%)
K (3%) HCO3 (16%) Mg (12%) Proteins (37%)
Ca (3%) Proteins( 10%) Na (7%) Hco3: (5%)
Mg (2%) PO4/Org (4%) Ca (3%) Cl (2%)
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Regulation of Body Fluids and Electrolytes
♦ Anti-Diuretic Hormone (ADH)• Secretion is regulated by tonicity of body fluids• Increases water reabsorption by the kidneys
♦ Thirst • Physiological stimulation only occurs when plasma
osmolality is 290 mosmol/lit>
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♦ Aldosterone• Released from the adrenal cortex
– Stimulation by Renin-Angiotensin - Aldosterone axis– ,, ,, Decrease circulating volume– ,, ,, Increase plasma K
• Action: Enhanced renal reabsorption of Na in exchange for K ( Na = expansion of ECF)>
♦ Atrial Natriuretic Factor• Secreted by the cardiac atrium in response to atrial dilatation • Action: Regulates blood volume by reducing water, sodium in
the circulatory system by inhibition of Renin & vasopressin secretion & by Increasing GFR and Na excretion
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• Plasma Osmolality = Concentration of solutes in blood
• Normal plasma osmolarity = 280 - 295 mosmol/lit.
• Calculated Plasma Osmolality = 2 x (Na + K) + Glucose + Urea
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• Causes of Hyperosmolarity :- Hypernatremia- Hyperglycemia- Uremia• Effects of Hyperosmolarity:- Cellular disruption- Systemic acidosis - Cytotoxic brain edema- Renal failure
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Commonly Used IV Fluid Solutions
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Solution Electrolyte Content (mEq/lit)Na CL K Ca Lactate
Glucose (gm/lit)/ Osomlarity
Ringer’s Lactate
130 109 4 2.7 27.7 273 mosmol/lit
Sodium Chlor ide 3% 300 616 mosmol/lit
Normal Saline 0.9% 154 154 308 mosmol/lit
I/2 Normal Saline 0.45% 77 77 154 mosmol/lit
D5: Saline 0.45% 77 77 5.5gm 431 mosmol/lit
D5: Saline 0.225% 38.5 38.5 5.5gm 354 mosmol/lit
D5: Saline 0.18% 30.8 30.8 5.5gm 339 mosmol/lit
D10% 11gm 555 mosmol/lit
D5% 5.5gm 277 mosmol/lit
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Daily Maintenance Requirements Body Weight:
0-10 kg 10-20 kg >20 kg
Total Water Volume:
100 ml/kg/d 1000 ml + 50 ml/kg for each kg above 10 kg
1500 ml + 20 ml/kg for each Kg above 20 kg
Sodium: 3 meq/kg/d 3 meq/kg/d 3 meq/kg/d
Potassium: 2 meq/kg/d 2 meq/kg/d 2 meq/kg/d
Chloride: 5 meq/kg/d 5 meq/kg/d 5 meq/kg/d
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For quick calculations: Rate of Infusion :(4cc, 2cc, 1cc ) X BW
• 4 ml for the first 10 kg• 2 ml for the next 10 kg• 1 ml for each kg after
Example:27 kg child
– 4 cc for the first 10 kg = 40ml– 2 cc for the next 10 kg = 20ml– 1 cc for each kg after = 7 ml
Rate of IVFs = 67 ml/hr
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Maintenance Fluids Weight & age dependent:
Age 2 - 3 years: >D5: NS (0.45 sol) + 20 mEq KCl/liter½(add 1ml KCL to each 100ml IVFs)
Up to age 2 - 3 years: D5:1/4 NS (0.225 sol) + 20 mEq KCl/liter(add 1ml KCL to each 100ml IVFs)
NB: - The amount of KCL in IV solution should not exceed 35 - 40mEq/lit- KCL should not be added to patients with suspected renal failure except
after adequate urine flow is obtained.
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The amount is increased in the following conditions
The amount is decreased in the following conditions
1. Fever: Add 10% for each degree above 38%
1. CNS infection or brain edema: Subtract 30%
2. Phototherapy: Add 10%
2. Heart failure: Subtract 30%
3. Infants placed under radiant warmer: Add 20%
3. Mechanical ventilation: Subtract 10%
4. Continued losses as diarrhea: Add 30%
5. Burns
4. Severe oligurea or anuria: Give only the insensible water losses = (300ml/m2)
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Body surface area calculation
( BW x 4 ) + 7BW + 90
E.g.: Body surface area for a 10 kg child = 0.47m2
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Practical Examples
A 2.5 years old child ,15 Kg was kept NPO after tonsillectomy operation?
• Solution used: D5:1/4 NS (0.25%) + KCL
• Amount/day: (10 x 100) + (5 x 50) = 1250ml/day Add KCL 1ml for each 100ml (add 12ml KCL over the solution).
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A 10 kg infant with Severe acute congestive heart failure?
• Solution used: D5 :1/4 NS (0.25%)+ KCL
• Amount/day: (10 x 100) =1000ml/day Add KCL 1ml for each 100ml (add 1ml KCL over the solution).
• Subtract 30% (300ml) from the total amount, so the amount is 700 ml/day.
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DehydrationEpidemiology:
♦ One of the most common medical problems
♦ Worldwide, over 3 million children under 5 years die
from dehydration
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Fluid Losses in Infants
LUNGS
URINE, FEACES, Vomiting SKIN
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Estimation of Dehydration Mild Moderate Severe
Weight Loss 3-5% 6-9% >10%
Blood pressure Normal Orthostatic Shock
Pulse Normal Increase Tachycardic
Behavior Normal Irritable Lethargic
Membranes Moist Dry Parched
Tears Present Decrease Absent
Cap. Refill 2 seconds 2-4 seconds >4 seconds
Urine SG >1.020 >1.030 Oliguria
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DehydrationClassification:
♦ Isotonic
Serum Sodium 130 -150 mEq
♦ Hypotonic
Serum Sodium 130 mEq<
♦ Hypertonic
Serum Sodium 150 mEq>
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Assessment of dehydration
• Vital signs• Weight
• Urine output.• Behavior—changed—Response to stimuli• Skin changes• General Body assessment—sunken eyes,
no tears, sunken fontanel
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Management of Dehydration
General Pr inciples:
♦ Supply Maintenance Requirements
♦ Correct volume and electrolyte deficit
♦ Replace ongoing abnormal losses
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Management of Dehydration
Oral Rehydration:♦ Effective for mild and some moderate
dehydrations ♦ Child is able to tolerate oral intake♦ Small amounts as tolerated
• Mild: 50 cc/kg over 4 hours• Moderate: 100 cc/kg over 4 hours
♦ 2 types of oral solution• Maintenance • Rehydration
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Commercial Oral Solutions Na mEq/L K mEq/L Cl mEq/L Base CHO %
Maintenance
• Reosol 50 20 50 Citrate Glucose 2
• Ricelyte 50 25 45 Citrate Rice syrup 3
• Pedialyte 45 20 35 Citrate Glucose 2.5
Rehydration
• Rehydralyte 75 20 65 Citrate Glucose 2.5
• W.H.O For cholera use
90 20 80 HCO3 Glucose 2
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Management of Dehydration: By IV infusion
1. Replacement of Fluid Deficit Based on % Dehydration.
2. Initial: NS or LR 20 cc/kg Bolus in first hour3. Then Remainder of Deficit
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The IV amount needed for deficit therapyThe type of fluid used and the rate of infusion depends on the age and Na
status of the patient
In a child with body weight less than 10kg:• In Mild dehydration: 40 – 60 ml/kg..• In Moderate dehydration: 80 ml/kg..• In Severe dehydration: 120 ml/kg..
In a child with body weight more than 10kg:• In Mild dehydration: Maintenance x 0.4• In Moderate dehydration: Maintenance x 0.8• In Severe dehydration: Maintenance x 1.2
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Steps in Fluid ReplacementA. Phase I: Rapid Phase Restore intravascular volume
a) Use Isotonic Fluid (NS/LR)b) Replace other components (Ca/glucose) separately based on documented deficitc) Volume: 10 - 20cc/kg; repeat up to 60cc/kg then re-evaluate
B. Phase 2: Replacement PhaseDetermine type of dehydration based on Na-level (Isotonic, Hypotonic, or Hypertonic) Calculate maintenance needs Calculate deficit needs Calculate 24 - hr electrolyte needs
Hypotonic and Isotonic Dehydration: Administer ½ calculated fluid during the 1 st 8 hrs. Administer remainder over the next 16 hrs.C. Phase 3: Stabilization Replace ongoing losses (eg: diarrhea) Measure every 4-6 hrs and replace with appropriate fluids
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Practical example
5 kg child who is 8% dehydrated what is the amount of fluids to be used?
Replacement: total replacement: 80ml/kg– first hour: 20 cc/kg = 20 x 5 = 100 cc – Replace the rest: 30 cc/kg (Over 6-8 hours)– 30 cc/kg (Over 12 hours)
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Hyponatremia
(Serum Sodium concentration below 130mEq/L)
Mild: 120 – 130 mEq/L
Moderate: 110 – 120 mEq/L
Severe: Below 110 mEq/L
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Hyponatremia
Predisposing Factors:♦ Diabetes mellitus (hyperglycemia)♦ Cystic fibrosis♦ CNS disorders ( SIADH)♦ Gastroenteritis♦ Excessive water intake (formula dilution)♦ Diuretics (thiazides and furosemide)♦ Renal disease
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Hyponatremic Dehydration♦ Hypovolemic Hyponatremic Dehydration
• High urine output and Na excretion• Increase in atrial natriuretic factor
♦ Euvolemic Hyponatremic Dehydration• ADH mediated water retention
♦ Hypervolemic Hyponatremic Dehydration• Edematous disorder (nephrotic syndrome, CHF, cirrhosis)• Water intoxication
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Hyponatremia
♦ Early Onset (Serum Sodium 120 meq/L) <• Nausea • Vomiting • Headache
♦ Later or Severe (Serum Sodium 120 meq/L) <• Seizure • Coma • Respiratory arrest
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Management of Hyponatremia
♦ Treatment of Asymptomatic hyponatremia can be made by increasing the Saline content in IVFs or by IV infusion of normal Saline.
♦ Symptomatic hyponatremia necessitates therapy with hypertonic Saline ( Sodium Chloride 3% solution)
Rise in serum Na should not exceed 2 mEq/L/h toprevent Central Pontine Myelinolysis.
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In Severe symptomatic Hyponatremia
Give slow IV infusion of hypertonic saline solution (NaCl 3% solution) in a dose which raises the serum sodium level to 125 mEq/L.
As 1 ml/Kg of this solution will increase the serum sodium level by about 1 mEq/L.The required dose in ml/kg = (125 – actual serum sodium level)..
Two precautions are important:1.The maximum dose per time is 10ml/kg2.The rate of infusion should not exceed 60ml/hr
The dose should be given over 2 - 4 hours & Serum sodium level should be measured after each dose
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Practical example
A child 10kg is presenting with seizers, dehydration, Serum Na level 115mEq/L?
treatment: (125 - 115)= 10ml/kg (100ml NaCl 3% solution over 2 hours)
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Hypernatremia
(Serum Sodium concentration above 150mEq/L)
Mild: 150 - 160mEq/L
Moderate: 160 - 170mEq/L
Severe: Above 170mEq/L
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Hypernatremia
Hypernatremia leads to hypertonicity:♦ Increase secretion of ADH♦ Increase thirst
Patients at risk:♦ Inability to secrete or respond to ADH♦ No access to water
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HypernatremiaEtiology
♦ Pure water depletion • Diabetes insipidus (Central or Nephrogenic)
♦ Sodium excess• Salt poisoning (PO or IV)
♦ Water depletion exceeding Na depletion• Diarrhea, vomiting, decrease fluid intake
♦ Pharmacologic agents• Lithium, Cyclophosphamide, Cisplatin
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Hypernatremia
Signs and symptoms:♦ Disturbances of consciousness
(Lethargy or Confusion)♦ Neuromuscular Irritability
(Muscle twitching, hyperreflexia)♦ Convulsions♦ Hyperthermia
(Skin may feel thick or doughy)
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Drop in serum Na should not exceed 10-12 mEq/L per day or 0.5mEq/L/hr < to prevent brain edema.
• Goal: Replace deficit of fluids and electrolytes and daily maintenance
• Amount: Deficits + daily maintenance Fluid: Give over 24-48 hours
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• Administer fluid at a constant rate over the time for correction
• Typical fluids: D5 NS or D5 NS (with 20mEq/L KCl unless contraindicated)¼ ½
• Follow serum Na level: (Decrease Na concentration at a rate of 0.5 mEq/hr or 10 mEq/day)
If Sodium decreases too rapidly: (Increase [Na] content of IVF or decrease rate of IVF)
If Sodium decreased too slowly: (Decrease [Na] of IVF or increase rate of IVF)
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Potassium
• Most abundant intracellular cation
• Normal serum values 3.5-5.5 mEq
• Abnormalities of serum K are potentially life-
threatening due to effect in cardiac function
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HypokalemiaDiagnosis : Serum K 3mEq/L<♦ Symptoms
• Arrhythmias• Neuromuscular excitability (hyporreflexia, paralysis)• Gastrointestinal (decreased peristalsis or ileus)
♦ ECG:• Flat T waves• Short P-R interval and QRS• U waves
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Causes of Hypokalemia
Nutritional GI Loss Renal Loss Endocr inePoor intake Diarrhea Renal tubular acidosis Insulin therapy IVF low in K Vomiting Chronic renal disease Glucose therapy Malabsorption Fanconi's syndrome DKA
Intestinal fistula Gentamicin, Hyperaldosteronism Laxatives Amphotericin Adrenal adenomas Enemas Diuretics Mineralocorticoids
Bartter's syndrome
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Hypokalemia
Management:♦ Cardiac Arrhythmias or Muscle Weakness
• KCl IV 35mEq/Liter (cardiac monitor is essential)♦ PO K - Depend of etiology
• Hypophoshatemia = KPO4• Renal tubular acidosis = K citrate
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HyperkalemiaDifferential Diagnosis
♦ Pseudohyperkalemia - from blood hemolysis♦ Metabolic Acidosis♦ Chronic Renal Failure♦ Congenital Adrenal Hyperplasia
• Females = Usually Dx at birth - Ambiguous Genitalia• Males = Dehydration, hyponatremia, hyperkalemia
♦ Medications• ACE inhibitors and NSAID’s
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HyperkalemiaDiagnosis:
♦ Symptoms• Cardiac Arrhythmias• Paresthesias• Muscle weakness or paralysis
♦ ECG• Peaked T waves• Short QT interval (K 6 mEq)>• Depressed ST segment• Wide QRS (K 8 mEq)>
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Hyperkalemia
Management:♦ Close cardiac monitoring♦ Life -threatening hyperkalmia
• Intravenous Calcium • IV NaHCO3 , glucose and insulin infusion
♦ Ion exchange resins• Sodium polystyrene sulfonate (Kayexelate)
– PO or Enema
♦ Haemodyalisis
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Management of hyperkalemia
• Calcium gluconate 10%: 0.5ml/kg• Sodium bicarbonate 5%: 4ml/kg IV over 10
minutes• Glucose & Insulin infusion: Glucose 50%
(1ml/kg) with regular Insulin (1U for each 10ml glucose 50%)
• Peritoneal dialysis
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Take Home Message• Oral rehydration is a safe and effective intervention
in patients with mild-to-moderate dehydration who are able to tolerate oral regimen.
• Deficit fluid requirements are based on classification of dehydration.
• Hypotonic and isotonic dehydration are corrected in 8-hr and 16-hrs.
• Hypertonic dehydration is corrected based on Na level (usually over 48hrs).
• Slow correction of both hyponatremia and hypernatremia.
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References• Fleisher, G. et al. (2005). Renal and Electrolyte Emergencies. In
Cronan, K. & Kost (Eds), Textbook of Pediatric Emergency Medicine. • Kleigman, R. et al. Nelson Essentials of Pediatrics. Chapter 32:
Fluids and Electrolytes. 5th edition. pp.157-163.• Robertson, J. & Shilfoski, N. (2005). Fluids and Electrolytes. The Harriet
Lane Handbook. (pp. 287-300).• Sykes, R. (2007). Pediatric Fluids and Electrolytes. [PowerPoint slides]• Dr Mohamed El Najar , Pediatric Critical Care, Third edition: Chapter
11 PP. 287- 292
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