Pediatric Fluid and Electrolyte Therapy

Nanda Cendikia 112014228

Fluid Therapy •Maintenance

•Deficit

•Replacement

Maintenance Fluids • Maintenance Fluids are given to compensate for ongoing

losses.

• Sensible losses : Urine output, fecal water (majority of on going losses)

• Insensible losses: Respiration, perspiration

• Requirements for children are higher than adults, because:1. The higher metabolic rate of children. 2. Children especially infants, have a much higher body surface area to weight

ratio. 3. Children, especially infants, have higher respiratory rates.

Respiratory Rates in ChilldrenAge

(months)Mean Respiratory Rate

(breaths per minute)<2 48

2 to <6 44,16 to <12 39,1

12 to <18 34,518 to <24 3224 to <30 3030 to 36 27,1

• Patients suffering from fever, burn injuries, pain, asthma, pneumonia, and increased intestinal losses may all have elevated maintenance fluid requirements

• Patient with mild to moderate dehydration may be rehydrated with oral therapy, even if diarrhea and vomiting continues.

• 5o mL/kg over 4 hours for mild dehydration • 100 mL/kg over 4 hours for moderate

dehydration

• 140 mmol/L of carbohydrate, 45 mmol/L (mEq) of sodium, 20 mmol/L (mEq) of potassium

Holliday-Segar Method for Calculating Maintenance Fluid Requirements in Children

Holliday-Segar Method

Holliday-Segar Estimate

First 10 kg 100 mL/kg/day 4mL/kg/hrSecond 10 kg 50 mL/kg/day 2mL/kg/hrEvery kg thereafter 20mL/kg/day 1mL/kg/hr

Deficit Fluids• Fluid lost prior to medical care are termed “deficit

fluids”.

• Examples: gastrointestinal illness with vomiting and diarrhea, traumatic injuries with significant blood loss, and inadequate intake of fluids over a period of time.

• Clinical sign of dehydration which can be use is weight loss. So, we have to know the pre-illness weight.

• The degree of dehydration calculated should always be compared to the clinical signs, which may better indicators of dehydration status and are also especially useful when a pre-illness weight is unknown.

Clinical Sign of Dehydration Clinical Sign Mild

Dehydration Moderate

DehydrationSevere

DehydrationWeight loss (%) 3-5 6-9 ≥ 10

Behavior Normal Normal to listless Normal to lethargic

Thirst Slight Moderate Intense Mucous

MembranesMay be normal Dry Dry

Anterior fontanelle

Flat Sunken Sunken

Eyes Normal Sunken Deeply sunken Skin turgor Normal Decreased Decreased

Blood preasure Normal Normal Normal to decreased

Heart rate Normal rate Increased Increased Urine output decreased Markedly

decreasedAnuria

Degrees of Dehydration

Mild dehydration

Moderate dehydration

Severe dehydration

Older child 3% (30 mL/kg) 6% (60 mL/kg) 9% (90 mL/kg)Infant 5% (50 mL/kg) 10% (100

mL/kg) 15% (150 ml/kg)

Type of Dehydration, Define by Serum Sodium concentration

•> 135 mEq/L : Hypotonic dehydration

•135-145 mEq/L : Isotonic dehydration

•> 145 mEq/L : Hypertonic dehydration

Method for Calculating Rehydration Fluid in Isotonic or Hypotonic

Rehydration Phase Fluid Volume Example 10-kg Child with 1-kg weight

loss (deficit = 1000 mL)

Phase I Emergency Phase

20 mL/kg May repeat if

necessary

200 mL (Remaining deficit = 800 mL)

Phase IIFirst 8 hours

½ remaining deficit + 1/3 daily maintenance

400 mL + 333 mL = 733

733 mL /8 hr = 92 mL/hr

Phase IINext 16 hours

½ remaining deficit + 2/3 daily maintenance

400 mL + 666 mL = 1066

1066 mL /16 hr = 67 mL/hr

•During phase II, 5% dextrose with 0,45% sodium chloride should be used, with 20-30 mEq / L of potassium chloride added only if patient has voided

•During phase III, 5% dextrose with 0,2% sodium chloride should be used, with 20-30 mEq / L of potassium chloride added only if patient has voided

Rehydration Fluid in Hypertonic • The deficit fluid volume should be added to the maintenance

fluid volume needed for 48 hours, and the total should be administered over 48 hours.

• Administering the deficit fluid faster causes osmotic fluid shift, which can result in cerebral edema and convulsions.

• Serum sodium corrected by no more than 10 mEq/L/day.

• Serum sodium should be checked frequently (every 2 to 4 hours) to ensure the rehydration is not occurring so quickly as to cause an overly rapid decreased in serum sodium.

• The fluid used should be hypotonic, such as 5% dextrose with 0,2 sodium chloride.

Replacement Fluids • Defined as those given to meet ongoing losses due to the

medical treatment.

• Example of clinical situations where replacement fluids are needed include patients with chest tube in place, or externalized cerebrospinal fluid shunts.

• Each of these examples demonstrates a situation where there is an ongoing loss which would not be met by administering only maintenance fluids.

• Replacement fluid are different from deficit fluids in that they are ongoing, as opposed to a loss of fluid that occurred prior to receiving medical treatment.

Electrolytes Abnormalities• Severe Hyponatremia

- Patient with serum sodium of less than 125 mEq/L are at high risk for serious central nervous symptoms; lethargy followed by seizures is common.

- Th/ boluses with hypertonic saline, usually 3% sodium chloride (desired serum sodium concentration – current serum sodium concentration) x 0,6 x (weight in Kg)

•Hyperkalemia

- Serum potassium of gretaer than 6 mEq/L

- In emergencies, agent which cause a rapid influx of potassium intracellularly are useful as they provide an acute decrease in serum levels. These medications include insulin and beta adrenergic agonist such albuterol.

- less emergency situations: Sodium polystyrene sulfonate is an exchange resin which exchange sodium for potassium in the gut.

Determining Maintenance Fluids, Step by Step.

Description of Steps

ExampleDetermine the appropriate fluid and delivery rate for maintenance fluids and electrolytes for a 28-kg child

Calculation Answer to each step

Step 1 Determine daily maintenance fluid requirement. Using the Holliday-Segar method, determine the patient’s fluid requirements (volume in liters) for 24 hours

a. 100 mL/kg x 1st 10 kg = 1000 mL

b. 50 mL/kg x 2nd 10 kg = 500 mLc. 20 mL/kg x each additional kg

(8) = 160 mL

1660 mL = 1,66 L

Step 2 Deliver appropriate dose of electrolytes. Choose a commercially available fluid and determine how much sodium and potassium will be delivered considering the volume that will be administered.

Sodium requirements: 3 mEq/kg x 28 kg = 84 mEq sodium a. D5 ¼ NS x 1,66L = 38,5 mEq

sodium/L x 1,66L = 63,9 mEq Sodium

b. D5 ½ NS x 1,66L = 77 mEq sodium/L x 1,66L = 128 mEq Sodium

c. D5 NS x 1,66L = 154 mEq sodium/L x 1,66L = 255,6 mEq Sodium

Potassium requirements: 2 mEq/kg x 28kg = 56 mEq Potassiumd. 10 mEq/L x 1,66L = 16,6 mEq

Potassium e. 20 mEq/L x 1,66L = 33,2 mEq

Potassium f. 30 mEq/L x 1,66L = 49,8 mEq

Potassium g. 40 mEq/L x 1,66L = 66,4 mEq

Potassium

D5 ¼ NS provides the most appropriate amount of sodium for this patient.

Generally, when beginning fluid therapy, more conservative potassium amounts, in this case 20 mEq/L , are used due the risk of accumulation, particularly in hospitalized children.

Step 3 Choose a fluid. Pick a commercially available fluid that delivers the desire amount of electrolytes.

Answer D5 ¼ NS with 20 mEq KCl per Liter at 69 mL/hr

Step 4 Monitoring. Monitor patient fluid status and electrolytes and adjust the rate and fluid type accordingly

Pengganti Cairan Intra operatif • Terapi cairan intraoperatif meliputi kebutuhan cairan dasar dan

penggantian deficit cairan preoperative seperti halnya kehilangan cairan intraoperative ( darah, redistribusi dari cairan, dan penguapan).

• Untuk semua prosedur yang lain Ringer Lactate biasa digunakan untuk pemeliharaan cairan. Idealnya, kehilangan darah harus digantikan dengan cairan kristaloid atau koloid untuk memelihara volume cairan intravascular ( normovolemia).

• Pada kehilangan darah dapat diganti dengan transfuse sel darah merah. Transfusi dapat diberikan pada Hb 7-8 g/dL (hematocrit 21 - 24%). Hb < 7 g/dL cardiac output meningkat untuk menjaga agar transport Oksigen tetap normal. Hb 10 g/dL biasanya pada pasien orang tua dan penyakit yang berhubungan dengan jantung dan paru-paru.

Perkiraan Volume Darah Rata-rataUmur Volume darah Neonates

PrematureFull term

95 ml/kg85 ml/kg

Infants 80 ml/kgAdult

MenWoman

75 ml/kg65 ml/kg

•Banyaknya transfusi dapat ditentukan dari hematocrit preoperatif dan dengan perkiraan volume darah.

•Pasien dengan hematocrit normal biasanya ditransfusi hanya setelah kehilangan darah >10-20% dari volume darah mereka.

•Tergantung daripada kondisi pasien dan prosedur dari pembedahan 

•Jumlah darah yang hilang untuk penurunan hematocrit sampai 30%, dapat dihitung sebagai berikut: 

1. Estimasi volume darah dari tabel sebelumnya. 2. Estimasi volume sel darah merah (RBCV)

hematocrit preoperative (RBCV preop).3. Estimasi RBCV pada hematocrit 30%

( RBCV30%), untuk menjaga volume darah normal.

4. Memperkirakan volume sel darah merah yang hilang ketika hematocrit 30% adalah RBCV lost = RBCV preop - RBCV 30%.

5. Perkiraan jumlah darah yang hilang = RBCV lost X 3

Contoh• Seorang anak perempuan 20 kg mempunyai suatu

hematocrit preoperatif 35%. Berapa banyak jumah darah yang hilang untuk menurunkan hematocritnya sampai 30%?

Volume Darah yang diperkirakan = 80 mL/kg x 20 kg = 1600 ml.RBCV 35 % =  1600 x 35 % = 560 mL. RBCV 30% = 1600 x 30 % = 480 mL Kehilangan sel darah merah pada 30% = 560 - 480 = 80 mL. Perkiraan jumlah darah yang hilang = 3 x 80 mL = 240 mL.

Guidelines for Fluid Administration of Balanced Salt Solution in Children According to the Age and to the Severity of Tissue Trauma

First hour 25 mL/k g in children aged 3 yr and under15 mL/kg in children aged 4 yr and over

All other hours Maintenance + trauma = basic hourly fluid Maintenance volume = 4 ml/kg/hMaintenance + mild trauma = 6 ml/kg/h Maintenance + moderate trauma = 8ml/kg/hMaintenance + severe trauma = 10 ml/kg/h

Blood replacement

1:1 with blood or colloid or 3:1 with crystalloid

Redistribusi dan evaporasi kehilangn cairan saat pembedahan

Derajat dari Trauma Jaringan Penambahan Cairan Minimal (hemioraphy) 0-2 ml/kgSedang (cholecystectomi) 2-4 ml/kgBerat (reseksi usus) 4-8 ml/kg

Menggantikan Hilangnya Cairan Redistribusi dan Evaporasi

• Sebab kehilangan cairan ini dihubungkan dengan ukuran luka dan tingkat manipulasi dan pembedahan, dapat digolongkan menurut derajat trauma jaringan. Kehilangan cairan tambahan ini dapat digantikan menurut tabel di atas, berdasar pada apakah trauma jaringan adalah minimal, moderat, atau berat. Ini hanyalah petunjuk, dan kebutuhan yang sebenarnya bervariasi pada masing-masing pasien.