Fluids and Electrolytes

TUMS-III Lecture Series

M. Kwan Chan-House, MD

Objectives
Learn to calculate maintenance fluids Learn maintenance electrolyte needs Learn the signs and symptoms of dehydration Learn to calculate replacement fluids for isonatremic/hyponatremic/hypernatremic dehydration Oral Rehydration Therapy

Just Start Maintenance

Maintenance fluid provide the water and electrolytes equal to those lost simply for being alive and having a basal metabolic rate Metabolism makes heat and solute that you need to get rid of to maintain homeostasis
Insensible fluid loss dissipates heat by evaporation of water from skin and URT (50% of maintenance needs) Soluble waste is excreted in urine (50% of maintenance needs)

Some Conversions

1 mL = 1 cc 30 cc = 1 ounce

Calculating Maintenance Fluids

The Holliday-Segar Formula
(Burn these numbers into your mind)

100-50-20 4-2-1

Calculating Maintenance Fluids

The Holliday-Segar Formula
Based on calorie expenditure 1 mL of water needed for each kcal used
Weight (kg) 0 to 10 kg 11 to 20 kg >20 kg kcal/d or mL/d 100/kg/d (1000) + 50/kg/d
For each kg > 10

kcal/h or mL/h 4/kg/h (40) + 2/kg/h

For each kg >10

(1,500) + 20/kg/d
For each kg > 20

(60) + 1/kg/h
For each kg > 20

Calculating Maintenance Fluids

The Holliday-Segar Formula
Case #1

An 32 kg girl is admitted for elective surgery and is NPO. She has normal renal function, no diarrhea and no fever. What would her maintenance fluids be?

Calculating Maintenance Fluids

The Holliday-Segar Formula
First 10 kg 100 ml/kg/day x 10 = 1000 ml Second 10 kg 50 ml/kg/day x 10 = 500 ml Last 12 kg 20 ml/kg/day x 12 = 240 ml ________________________________________ Total 32 kg 1740 ml/day or 72.5 ml/hr

Calculating Maintenance Fluids

The Holliday-Segar Formula
First 10 kg 4 ml/hr x 10 = 40 ml Second 10 kg 2 ml/hr x 10 = 20 ml Last 12 kg 1 ml/hr x 12 = 12 ml ___________________________________ Total 32 kg 72 ml/hr

Maintenance Electrolytes
Electrolyte loss can all be considered urinary
Sodium 3 mEq/100 ml

Potassium
Chloride

2 mEq/100 ml
2 mEq/100 ml

We all need some Sugar

Glucose is added to:
Prevent ketosis Limit protein catabolism

20% of caloric need made up of glucose is sufficient to prevent severe catabolism

5 grams glucose for every 100 cal D5W (5% dextrose water) is an appropriate base for electrolyte solutions

Putting it Together
Maintenance IVF will need:
Water Glucose Sodium Potassium Chloride

Your choices:
D5 0.2 NS with 20 mEq KCl/L (<18 month old) D5 0.45 NS with 20 mEq KCl/L (PEARL Do not add KCl until after first void and potassium level is known)

Dehydration
Any combination of abnl intake and/or abnl losses can lead to dehydration
Most common cause in pediatrics is diarrhea

Types of dehydration:
Isonatremic Hyponatremic Hypernatremic

Taking the History

Vomiting Diarrhea Urine output (number of wet diapers) Decreased po intake Weight changes (acute) Fever Length of illness

The Physical Exam

Fever Elevated HR Orthostatic changes (10 mmHg Diastolic BP and/or 10 bpm from lying to standing) Sunken fotanelle Sunken eyes Lack of tears Dry lips/mucosal membranes Poor skin tugor (tenting) Prolonged capillary refill time/Skin color

The Labs
Lytes (Na, K, Cl, HCO3) BUN/Cr (ratio > 20) Urine specific gravity Elevated hematocrit (hemoconcentration) FeNa

Degree of Dehydration
Clinical Signs in body weight Fontenelle/Skin turgor/Eyes Skin Color Mucus Membranes Cap Refill Mild 3-5% Normal (+/-) Normal Normal to Dry 2-3 seconds Moderate 6-10% Pale Dry 3-4 seconds Severe 11-15% Grey Parched > 4 seconds

Heart Rate
Blood Pressure Urine Output Tears

Normal
Normal Normal to slight

Postural changes Oliguria to absent

Hypotension Severe oliguria or anuria Absent

Urine Spec Grav

>1.020

or anuria

How dry are you?

Only with accurate weights can you be precise how often does that happen? Level of dehydration can be estimated using the H&P and labs

A Case of Dehydration
A 10 kg infant has had severe diarrhea for the past 2 days, decreased formula intake, a sunken fontenelle, no tears and oliguria. How dehydrated is this infant? What laboratory values do you want to obtain? How do you want to manage this infant?

Management of Dehydration
Step 1 Determine the presence and degree of dehydration Step 2 Obtain appropriate laboratory data (iso/hypo/hyper-natremia) Step 3 Bolus 20 mL/kg of NS (isotonic and will stay in the intravascular space) Step 4 Determine patients needs for next 24 to 48 hours
Maintenance + Deficit + On-going losses

A Case of Dehydration
This infant is ~10% dehydrated given the history and PE findings Na 140, K 3.7, Cl 107, HCO3 22 Bolus 20 mL/kg NS improved urine output Still refusing po intake and still stooling at a rate of 20 mL/hr Now what?

A Case of Dehydration
PEARL 1000 mL (1L) = 1000 gm (1 kg) Maintenance = 1000 mL (100 mL/kg/day) Deficit = 1000 mL (10% of a 10 kg infant)
1000 mL 200 mL (bolus given) = 800 mL remains to be given

On-going losses = 20 mL/hr 480 mL/day

A Case of Dehydration
For isonatremic and hyponatremic dehydration
Give HALF of Maintenance and Deficit in first 8 hours and remainder over the next 16 hours (Maintenance + Deficit) Bolus = 1800 mL Therefore: Run 900 mL over 8 hours at 112 mL/hr Then, 900 mL over 16 hours at 56 mL/hr

Hypernatremic Dehydration
Total body water losses in excess of sodium losses Hypernatremia must be corrected SLOWLY
Hyperosmolality causes cells to shrink especially in the CNS Correcting too quickly will cause fluid to be rapidly drawn into brain cells Cerebral edema is BAD

Hypernatremic Dehydration
A Case A 5 kg infant presents with a 5 day history of viral syndrome with fever, vomiting and diarrhea. Signs and symptoms reveal an infant who is 10% dehydrated. Laboratory data reveals a Na of 160.

Hypernatremic Dehydration
Hypernatremic dehydration is corrected EVENLY over 48 hours Bolus 20 mL/kg to restore intravascular volume Maintenance = 100 mL/kg x 5 kg = 500ml/day
48 hours of maintenance = 1000 mL

Deficit = 0.5 kg = 500 mL

500 mL 100 mL (bolus given) = 400 mL remain to be given

Total fluids over a 48 hour period is 1400 mL or 29 mL/hr

Oral Rehydration Therapy

Indications
<10% dehydrated Following initial volume resuscitation

Contraindications
>10% dehydrated/circulatory instability Severe vomiting Abdominal distention/ absent bowel sounds Severe hypo- or hyper- natremia

Oral Rehydration Therapy

Examples Pedialyte, Infalyte, WHO rehydration solution Administration
25 mL/kg/hr of deficit over the first 6 hours Then 10 mL/kg/hr over the next 6 hours (if needed) When repleted then maintenance volumes can be given

ANY QUESTIONS ??