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Katinka Kersten, MD
Extracellular space refers to fluids outside our cells which may be interstitial fluid or plasma Total body water = 0.6 X weight (kg) for children and adults and 0.78 X weight (kg) for neonates and infants
Maintenance Fluids
Holliday-Segar Method
Quick, simple formula that estimates caloric expenditure from weight alone Assumes that for each 100 calories metabolized, 100 ml H2O will be required (50 ml/100 calories for insensible loss, 67 ml/100 calories for urine and 17 ml/100 calories gained from metabolism) Not suitable for neonates < 14 days old
Holliday-Segar cont.
WEIGHT (kg)
0 - 10 11 20 >20
FLUIDS
100 ml/kg/day 1000 ml + 50 ml/kg for each kg above 10 1500 ml + 20 ml/kg for each kg above 20
Examples
A 6 kg child needs 600 ml/day, which equals 25 ml/hr
A 35 kg child needs 1800 ml/day,which equals 75 ml/hr A 14 kg child needs 1200 ml fluids with: Na K Cl 36 mEq (3 mEq/100 cal) 24 mEq (2 mEq/100 cal) 48 mEq (4 mEq/100 cal)
Modifications
Increase Fever (12% for each oC above 37 oC ) High ambient temperature Diabetes mellitus Diabetes insipidus Vigorous exercise Decrease Renal failure Heart failure Inappropriate secretion of ADH High-humidity respiratory therapy
Neonates
Insensible losses in neonates vary with gestational age and birth weight and may be dramatically increased by phototherapy or radiant warmers Newborns cannot concentrate urine as well and GFR is lower so they are more prone to fluid overload
Deficit Therapy
Clinical Observations
Examination Skin turgor Skin-touch Buccal mucosa/lips Eyes Crying/tears Fontanelle CNS Pulse Urine output 3-5% (mild) Normal Normal Moist Normal Present Flat Consolable Regular Normal 10% (moderate) Tenting Dry Dry Deep set Reduced Soft Irritable Slight increase Decreased >10% (severe) None Clammy Parched Sunken None Sunken Lethargic Increased Anuric
Tenting
Renal function
Isonatremic Dehydration
Patient is dehydrated and Na+ is 135-145 mEq/L Determine fluid deficit as percentage of weight based on clinical findings Determine which parts of deficit come from ICF versus ECF compartments based on duration of illness ECF Na+ loss = Fluid deficit (L) X % from ECF X 145 ICF K+ loss = Fluid deficit (L) X % from ICF X 150
Hyponatremic Dehydration
Na+ is < 135 mEq/L Follow same steps as for isonatremic dehydration Additional Na+ requirement = (CD CP) X fD x wt
-CD is concentration desired -CP is concentration present -fD is distrubution factor as fraction of body weight (L/kg); 0.6-0.7 for Na+
Hypernatremic Dehydration
Before you start any fluid and electrolyte calculations you need to determine free water (FW) amount
(Na+)actual (Na+)desired x 100 ml/L x 0.6L/kg of body weight = ml/kg FW + (Na ) actual
Based on above formula for Na+ < 170 mEq/L approximately 4 ml of FW needed to bring Na+ down by 1 mEq/L/kg; for Na+ > 170 mEq/L approximately 3 ml of FW needed to bring Na+ down by 1 mEq/L/kg Subtract FW from total fluid deficit and replace remainder in same way as done for isonatremic dehydration
Isonatremic Dehydration
A 2 year old has a 4-day history of gastroenteritis, poor fluid intake and infrequent urination. On exam you find dryness of the mucous membranes, sunken eyes with mild tenting of the skin. The serum sodium is 137 mEq/L. The weight is 10 kg. You determine the child is suffering from about 10% dehydration. What are the fluid and electrolyte requirements?
Isonatremic Dehydration
H2O Na K Cl (ml) (mEq) (mEq) (mEq) 1000 30 20 40
60
Maintenance Total deficit = 1000 ml Extracellular fluid deficit 600 87 (60% of total) Intracellular fluid deficit 400 (40% of total) Total 2000 117
60
80
100
Hyponatremic Dehydration
You see a 3 year old who has had diarrhea and been vomiting for 3 days. She has been drinking tap water most of this time. Examination shows sunken eyes and marked tenting of the skin but the child is not in shock. The serum Na+ is 120 mEq/L. The weight 14 kg. You estimate the deficit as 7%. What are the fluid and electrolyte requirements for this patient?
Hyponatremic Dehydration
Maintenance Deficit (7% of 14 kg) Extracellular fluid (60%) Intracellular fluid (40%) Additional sodium {(135-120) x 0.6 x 14} Additional chloride {(135-120) x 0.4 x 14} Total H2O Na K Cl (ml) (mEq)(mEq)(mEq) 1200 36 24 48 600 87 400 126 60 84 60 84 192
2200 249
Hypernatremic Dehydration
You see a 6 month old suffering for 4 days from severe diarrhea. The mucous membranes are dry, skin feels doughy and the child is somnolent and lethargic. The serum Na+ is 165 mEq/L. The child weighs 5 kg and you assume the fluid deficit is at least 10%.
What are the fluid and electrolyte requirements?
Hypernatremic Dehydration
Maintenance Total deficit = 500 ml Free water deficit {(165-145)x1/2x4x5} Remainder of deficit (500-200) = 300 ml Extracellular (60%) Intracellular (40%) Total H2O Na K Cl (ml) (mEq)(mEq)(mEq) 500 15 10 20
200
180 120
26 -
18 29
18 38
1000 42
Phase Approach
PHASE 1
Emergency restoration of circulation if patient is hypovolemic 10-20 ml/kg of isotonic fluids only
PHASE 2
Replacement of of the fluid loss (deficit and maintenance) in first 8 hours
PHASE 3
Replacement of remaining of the fluid loss (maintenance and remaining deficit) in next 16 hours Replacement of potassium after voids
Nursing Orders
Write the type of basic fluid
D51/2 NS most commonly used on pediatric wards (premixed bags are present) Can create any fluid you desire but may take longer to get if not premixed available
Write how fast you want it to run in ml/hr For example for 15 kg non-dehydrated child write D51/2NS + 20 mEq/L of KCL to run at 50 ml/hr
Patient Rounds
Report total 24 hr intake Report what part of total intake was oral v.s. intravenous v.s. G-tube Subsequently report intake as ml/kg/day for children with weight < 10 kg Intake for children with weight > 10 kg should be reported as % of maintenance For example a 25 kg afebrile child had a total intake of 2000 ml for the past 24 hr, 1600 ml was from iv fluids and 400 ml was po, this represents 125 % of maintenance need for this child