FLUID AND ELECTROLYTE THERAPY IN CHILDREN Steven R. Alexander, M.D. Stanford, California; Michel G. Baum, M.D.

UT Southwe tern at Dalla , Texa I. Distribution of Fluids and Electrol tes Total !od" water con titute #$% of the wei&ht of the term infant and decrea e to two' third of !od" wei&ht after the neonatal (eriod. Two'third of total !od" water i in the intracellular (ace and one'third i in the extracellular fluid (ace. )f the extracellular fluid *+C,-, onl" .$% i intrava cular. Thu , onl" a!out #'/% of total !od" water i intrava cular.

0ote1 The e are a((roximate i2e of !od" com(o ition in #3 4& adult

The com(o ition of the +C, i what we mea ure when we o!tain a et of electrol"te . The odium content of the +C, i a((roximatel" 563 m+78l, and the (ota ium i onl" 6'$ m+78l. The (redominant anion in the extracellular fluid are chloride and !icar!onate. The com(o ition of the intracellular fluid *9C,- i dramaticall" different. :herea there i a ver" mall concentration of (ota ium in the extracellular fluid, the (redominant cation of the intracellular fluid i (ota ium with an intracellular concentration of 563 m+78l. The intracellular chloride concentration i ver" low in mo t cell . The !ul4 of the anion in the intracellular com(artment i made u( of char&e on (rotein and other im(ermeant molecule . II. !asic Fluid and Electrol te T"era# $ %aintenance The &oal of maintenance thera(" i the accurate re(lacement of on&oin& water and electrol"te lo e to maintain 2ero !alance; that i 1 90TA;+ < )UT=UT. 9n ver" un ta!le (atient with a!normal or un(redicta!le lo e , 2ero !alance can !e achieved onl" !" fre7uent re(lacement of (reci el" mea ured lo e . 9n more ta!le (atient , it i clinicall" u eful to !e&in fluid thera(" !" e timatin& normal maintenance re7uirement u in& the e timated caloric ex(enditure method. A. + timated Caloric +x(enditure 0ormal maintenance fluid and electrol"te re7uirement are, in &eneral, determined !" the child> meta!olic rate. :hile numerou method have !een (ro(o ed for e timatin& the meta!olic rate of ho (itali2ed children, the method of ?ollida" and See&ar *?ollida" MA, Se&ar :+1 Pediatrics 5@$#; 5@1/.A- ha &ained wide acce(tance and ha tood the te t of time. 9t i ea " to remem!er, and ha (roven to !e ufficientl" accurate for mo t clinical ituation . ?ollida" and See&ar calculated the rate of caloric ex(enditure *i.e., the meta!olic rate- of ho (itali2ed children and found that it wa (ro(ortional to the child> wei&ht accordin& to the followin&1 5

,or the fir t1 (lu , for1 (lu , for an"1 ,or exam(le1 Child> :ei&ht a. @ ;& !. 5@ ;& c. .@ ;& d. #3 ;&

A ;& to 53 ;& allow1 533 Cal84&8da"; 55 ;& to .3 ;& allow1 $3 Cal84&8da"; B .3 ;& allow1 .3 Cal84&8da". + timated Caloric +x(enditure @33 Cal8da" 5333 C 6$3 < 56$3 Cal8da" 5333 C $33 C 5/3 < 5D/3 Cal8da" 5333 C $33 C 5333 < .$33 Cal8da"

The fir t te( in maintenance fluid calculation i the calculation of the dail" e timated caloric ex(enditure. ,rom thi num!er, all el e follow lo&icall". B. :ater E normal re7uirement 5. 9n en i!le :ater Fo *9:F- E eva(orative lo e from the 4in and lun& which cannot !e directl" mea ured. *Doe not include weatin&-. S4in lo e < A3 cc8533 Cal8da" =ulmonar" lo e < 5$ cc8533 Cal8da" 9:F < 6$ cc8533 Cal8da" *9n actual (ractice, the 9:F of ho (itali2ed children varie from A3 to 6$ cc8533 Cal8da"-. .. Renal :ater Fo E the dail" o!li&ate urinar" water lo i determined !" the renal olute load and the concentratin& a!ilit" of the child> 4idne" . The renal olute load con i t (rimaril" of urea and maGor electrol"te *0a, ;, Cl-; under u ual condition een in ho (itali2ed children thi i a((roximatel" 56.$ m) m8533 Cal. +nou&h water hould !e (rovided for urine formation to avoid the need to either concentrate or dilute the urine, "ieldin& a urine which i nearl" i otonic with (la ma * .@3 m) m8FTherefore o!li&ate renal water lo < normal renal olute load de ired urine concentration < 56.$ m) m8533 Cal .@3 m) m8F $3 cc8533 Cal

A. Stool water lo e E tool water lo e in a! ence of diarrhea are minimal *nl tool water lo < $ cc8533 Cal8da"Remem!er that with diarrhea, tool water lo e increa e dramaticall". Diarr"ea &ater losses 'ust be 'easured and re#laced cc for cc. To ummari2e normal maintenance water re7uirement 1 9:F < 6$ Renal < $3 Stool < $ Total 533 cc8533 Cal8da" Thu , one im(l" calculate child> e timated caloric ex(enditure *?ollida" H See&ar- and (rovide 5 cc85 Cal. +xam(le1 .$ ;& child + timated caloric ex(enditure < 5333 C $33 C 533 < 5D33 Cal8da" Maintenance fluid re7uirement < 5D33 cc8da" < D# cc8hr .

The a((roach li ted a!ove a ume that for ever" hundred 4ilocalorie meta!oli2ed, 533 ml of water i re7uired. 9n truth, the actual water need are a((roximatel" 5.3 ml of water (er ever" 533 4ilocalorie , !ut .3 ml of water i o!tained from the water of oxidation leavin& u to (rovide the additional 533 cc> . C. +lectrol"te + timate of the normal re7uirement for maGor electrol"te are everal time &reater than actual minimum re7uirement ; however, vi&orou l" ana!olic children ma" have even &reater re7uirement . To re(lace normal urinar" electrol"te lo e and (rovide additional electrol"te for &rowth, rou&hl" .'A m+7 of odium and chloride, and . m+7 of (ota ium are re7uired for each 533 4ilocalorie of ener&" ex(ended or 533 cc> of maintenance fluid. Thu , under ordinar" condition where a (atient ha a normal cardiova cular tatu , and normal renal function, ade7uate electrol"te will !e (rovided u in& an intravenou fluid containin& I normal aline *0a < a((rox. A$ m+78l-, with .3 m+7 of (ota ium (er liter. 9t hould !e remem!ered that the e e timate of (ediatric (atient electrol"te re7uirement are !a ed on the electrol"te com(o ition of normal infant feedin& *human !rea t mil4, cow> mil4, etc-. Some authoritie recommend hi&her odium concentration *e&., J normal aline- for older8lar&er children. ?owever, in (ractice, the u e of I normal aline will uffice in mo t ettin& . 9t mu t al o !e remem!ered that to arrive at the e recommendation man" a um(tion are made in term of the (atient> normal renal and cardiova cular tatu . 9t i thu ver" im(ortant that "ou rea e an" (atient receivin& 9K fluid and determine erum electrol"te (eriodicall". D. +ner&"8Calorie A (ediatrician we tr" to (ractice effective (reventive medicine, and the ame a((roach i nece ar" when con iderin& maintenance fluid . )ne a (ect of maintenance fluid which we have not con idered i caloric8ener&" need . :hile the u e of D$ I normal aline (rovide ome calorie in the form of dextro e, onl" .3% of maintenance caloric need are !ein& met thi wa". :henever "ou con ider (rovidin& 9K fluid thera(", "ou need to ma4e a nutritional a e ment a well. 9f the (atient i well nouri hed and will onl" !e on intravenou thera(" for a few da" , the a!ove maintenance fluid are ati factor". ?owever, if the (atient i malnouri hed, or there i a (otential for the (atient to need intravenou fluid for a (rolon&ed (eriod of time, one mu t con ider h"(eralimentation. Thi hould alwa" !e done ooner rather than later, for catch'u( nutritional thera(" doe not wor4 well in the ic4 child. +. LA!normalM E maintenance re7uirement 9n un ta!le (atient with a!normal re7uirement it i alwa" !e t to re(lace mea ured lo e cc for cc and m+7 for m+7. The followin& &uideline ma" !e hel(ful, !ut are onl" a((roximation . 5. ,ever E 9ntermittent tem(erature elevation u uall" do not i&nificantl" increa e caloric ex(enditure. 9f fever i (re ent for a lar&e (art of the da" the e timated caloric ex(enditure i increa ed !"1 5.% for each 5 a!ove A#. +xam(le1 .$ ;& child with avera&e tem(erature of A/.$ C + t. caloric ex(enditure < 5D33 x 5.5/ < 5/// Cal8da" .. Sweat E to normal maintenance the followin& i added1 A

C A3 cc8533 Cal8C B A3.$C am!ient tem( */#,C 3.$ to 5 m+7 0aCl8533 Cal8da" *C .'A m+7 0aCl8533 Cal8da" in c" tic fi!ro i (t .Remem!er E normal 9:F contain no electrol"te . The electrol"te content of weat i al o varia!le accordin& to the de&ree of acclimati2ation of the (atient. A. A!normal Ga trointe tinal lo e a. :ater E re(lace mea ured 0G draina&e, eme i , diarrhea, o tom" lo e , etc. cc for cc. 0o other a((roach will do in the everel" ill (atient. !. +lectrol"te E it i often !e t to directl" mea ure electrol"te content of a!normal G9 lo e . The followin& a((roximation (rovide a (oint at which to !e&in1 Source of Unu ual Fo Ga tric Small Bowel *ileo tom"Diarrhea *non' ecretor"Concentration of +lectrol"te *m+78F0aC ;C Cl' 563 5$ 5$$ 563 5$ 55$ 63 63 63 ?C)A' 3 63 63

6. Che t tu!e draina&e E re(lace cc for cc with $% al!umin or other colloid olution. $. ?"(erventilation E when re (irator" rate increa e , the (ulmonar" com(onent of 9:F increa e (ro(ortionatel". Thu , if RR i 63'$38min, 9:F i increa ed !" 5$'.$ cc8533 Cal8da" to a total of D3'#$ cc8533 Cal8da". D. Mechanical ventilator E The humidified &a e (rovided !" ventilator and hood &reatl" decrea e (ulmonar" water lo . 9n ome ca e the e device actuall" deliver water to the (atient. :hen the difference !etween o! erved and e timated re7uirement defie ex(lanation, varia!le amount of water &ained from the ventilator ma" !e the rea on. III. De" dration A. ,actor (roducin& deh"dration1 Deh"dration or contraction of the !od" fluid com(artment will occur whenever the lo of water and alt exceed the inta4e. ,ever, weatin& and diarrhea (roduce lo e in exce of normal, !ut if inta4e remain &ood, (atient will often !e a!le to com(en ate for the increa ed lo e . Anorexia and8or vomitin& will im(air thi a!ilit" to com(en ate; in fact, due to continuin& o!li&ator" lo e , deh"dration can occur even in the a! ence of a!normal lo e if anorexia i evere or (rolon&ed. B. T"(e of deh"dration will de(end on the relative lo e of alt and water which occur and on the com(o ition and volume of the inta4e received. 5. 9 otonic1 9n thi t"(e of deh"dration, the lo e of water and electrol"te have !een (ro(ortional and the ratio !etween olute and water in the !od" fluid remain normal althou&h the total amount of !oth alt and water are reduced. There are no hift of fluid from 9C, to +C, or vice'ver a. The normal tonicit" of !od" fluid i .#$'.@$ m) m8;&. 9n i otonic deh"dration, the erum odium concentration i !etween 5A3 and 5$3 m+78F. Thi i the mo t common t"(e of deh"dration and the t"(e with the !e t (ro&no i . .. ?"(ertonic1 6

A a re ult of the !alance of inta4e *volume and com(o ition- and out(ut *volume and com(o ition-, the lo e of water exceed the lo e of olute o that the o molarit" of the !od" fluid increa e * erum o molarit" in exce of A33 m) m8;& or erum odium of over 5$3 m+78F-. Thi t"(e of deh"dration i een more commonl" in infant under D month of a&e, u&&e tin& that renal immaturit" ma" !e a factor. A hi tor" of continued inta4e of relativel" hi&h olute fluid uch a undiluted mil4 or concentrated oral electrol"te olution ma" !e o!tained !ut not nece aril" o. There i often a hi tor" of mar4edl" reduced oral inta4e of an" fluid . ,luid lo e ma" !e from !oth +C, and 9C, (ace are u uall" (redominantl" from the intracellular (ace *intracellular deh"dration-. =o i!l" due to the intracellular deh"dration, C0S i&n and "m(tom are common *i.e., tu(or, coma, h"(ertonia, convul ion -. Ka cular volume i u uall" maintained until the de&ree of deh"dration i 7uite evere. A. ?"(otonic1 The lo of alt over a (eriod of time exceed the lo of water *a !alance !etween the volume and com(o ition of inta4e and the volume and com(o ition of renal, G.9. and weat lo e - o that the tonicit" of the !od" fluid dimini he *o molarit" le than .#3 m) m84&; erum odium le than 5A3 m+78F-. Acute h"(otonic deh"dration ma" !e een in older infant and children with the evere diarrhea a ociated with !acterial G.9. infection *i.e., hi&ella, almonella- in which the tool volume ma" !e lar&e and contain a fairl" hi&h concentration of alt. Thi t"(e of deh"dration ma" occur when (atient have received a their onl" inta4e ver" low alt containin& fluid uch a water, rice water, or tea over a (eriod of time and i al o een in malnouri hed and chronicall" ill (atient . ?"(otonic deh"dration i al o een in adrenal in ufficienc". 0ot onl" i fluid lo t to the out ide of the !od" !ut there i al o a hift of fluid from the +C, to the 9C,. Due to the (redominant lo of extracellular fluid in h"(otonic deh"dration, va cular colla( e i een more often and earlier than in the other t"(e of deh"dration. C. + timation of the antecedent deficit *ex(re ed in relation to the !od" wei&ht of the (atient-1 Since accurate wei&ht (rior to on et of illne are not often availa!le, it i nece ar" to e timate the de&ree of wei&ht lo !" careful a((rai al of the (h" ical tatu of the (atient. Si&n and S"m(tom of Kolume De(letion (OLU%E DEPLETION )I*N) AND )Y%PTO%) Mild *A'$% Kolume De(letionThir t, decrea e in urine out(ut, dr" mucou mem!rane. Moderate *D'53% Kolume De(letion=o tural chan&e in !lood (re ure and heart rate, dr" mucou mem!rane , un4en e"e and fontanel, 4in tentin&, li tle ne , tach"cardia. Severe *B53% Kolume De(letion=oor (erfu ion, tach"cardia, h"(oten ion, lethar&" and coma. D. ,luid thera(" of deh"dration1 Isotonic De" dration The lo e of fluid in mo t ca e of deh"dration do not come e7uall" from the intracellular and extracellular fluid volume . Mo t ca e of volume de(letion are due to a lo of extracellular fluid volume. )nl" in ca e of (rolon&ed deh"dration will there !e u! tantial lo e from the intracellular fluid com(artment a well. 9t i thu a((ro(riate to thin4 a!out deh"dration a a hrin4a&e of the extracellular fluid com(artment. Re(letion of tho e lo e hould !e (erformed $

with fluid which re em!le the extracellular fluid com(artment. 9n mo t ca e of deh"dration, the fluid deficit i re(laced with normal aline. Thu , if one calculate the amount of fluid re7uired to re(lace the deficit with normal aline, (lu the maintenance fluid in the form of I normal aline, mo t ca e of i otonic deh"dration will utili2e J normal aline with .3'A3 m+78l of (ota ium a the intravenou fluid. The re(air of a deficit can !e !ro4en down into two (ha e . 9n the initial (ha e of fluid thera(" one need to re tore the intrava cular volume. Thi (ha e hould !e re erved for (atient who are i&nificantl" deh"drated or have an" i&n of va cular in ta!ilit". 9n mo t ca e , the (atient hould receive 5'.% of their !od" wei&ht *53'.3 cc> 84&- of an i otonic fluid in the form of normal aline or Rin&er> lactate. 9f the (atient i h"(oten ive or hoc4", one ma" need to &ive more fluid than thi , and A'$% of their !od" wei&ht in the form of normal aline or lactated Rin&er> can !e &iven in an emer&enc" ituation. 9f the (atient i hoc4" or h"(oten ive, $% al!umin hould al o !e con idered. 9f the (atient i havin& exce ive !lood lo one hould utili2e !lood a well, !ut !" no mean wait for !lood to arrive !efore in titutin& a&&re ive fluid thera(". The econd (ha e of fluid thera(" i to (rovide maintenance (lu deficit re(lacement. 9n the fir t / hour one hould &ive 58A of the normal maintenance (lu re(lacement of J of the e timated deficit. )ne hould re(lace the other $3% of the deficit (lu deliver the re7uired maintenance olution over the next 5D hour . The fluid that hould !e utili2ed durin& the (eriod of deficit re(air i a&ain a com!ination of the i otonic fluid re7uired to re(lete the volume deficit, (lu I normal aline. Thu , one u uall" u e D$ J 0S with .3'A3 m+7 ;8l. The concentration of (ota ium hould not ordinaril" exceed 63 m+78l *6 m+78533 cc> - nor hould the rate of infu ion of (ota ium !e B3.$ m+78;&8hr. =ota ium hould never !e added to 9K fluid thera(" unle one i ure that the (atient i not in renal failure. Thu , one hould have a erum creatinine and !e ure that the (atient i voidin& (rior to the in titution of (ota ium thera(". )nce volume de(letion ha !een corrected one can then &o !ac4 to im(le maintenance fluid a de cri!ed a!ove. H #otonic De" dration Mo t ca e of deh"dration in children and adult are i otonic. ?owever, there are (atient who have either h"(onatremic or h"(ernatremic deh"dration, !ut it mu t !e em(ha i2ed that it i of extreme im(ortance that one determine the etiolo&" of the h"(onatremia or the h"(ernatremia durin& the cour e of the (atient> ho (itali2ation. 9f the (atient ha h"(onatremic deh"dration, one can u e the formula outlined !elow to calculate the amount of odium that would !e nece ar" to increa e the erum odium to the de ired level. Thi odium deficit i in addition to the other deficit outlined a!ove. Nadeficit = (Nadesired Nacurrent) x (0.6) x (Body wt. in Kg) The rate at which the erum odium hould !e corrected had !een under ome de!ate. ?owever, it i now &enerall" a&reed that the erum odium hould !e corrected lowl" to (revent central (ontine m"elinol" i . Thu , the erum odium hould not increa e !" more than 5$ m+78l in a .6' hour (eriod. 9f a (atient ha h"(onatremic deh"dration, the erum odium need to !e mea ured fre7uentl". H #ertonic De" dration$ ?"(ernatremic deh"dration i extremel" unu ual. At the time of (re entation one need to ma4e a determination of the cau e of the h"(ernatremic deh"dration. To re(air the h"(ernatremic deh"dration one ha an additional free water deficit in addition to the deficit outlined a!ove. The D

free water deficit need to !e re(aired lowl". Under no circum tance hould the erum odium decrea e !" more than 5$ m+78l in a .6'hour (eriod. Should thi occur cere!ral edema and death can follow. The e7uation to e timate the free water deficit i hown !elow.

FreeWaterDeficit =

Nao ser!ed x *3.D- x * wt.inKg - *3.D- x * wt.inKg Nadesired

A "ou can ee, the e7uation i im(l" a calculation of the total !od" water time the ratio of the o! erved odium divided !" the de ired odium. Thi will &ive "ou the amount of total !od" water that "ou want "our (atient to have. ,rom thi "ou need to u!tract the amount of total !od" water which "ou have at the time of o! ervation. That difference i the free water deficit. A with h"(otonic deh"dration, it i extremel" im(ortant that the erum electrol"te !e mea ured fre7uentl" durin& the cour e of correction of the h"(ernatremic deh"dration. )ne hould err on the ide of correctin& the h"(ernatremic deh"dration too lowl" rather than too ra(idl". +. +xam(le At thi (oint, a few exam(le will !e (rovided to how "ou an a((roach to calculatin& fluid and electrol"te . 9t i in tructive to !rea4 down each com(onent of fluid and electrol"te individuall" and then come u( with a com(o ite fluid. Fet> ta4e the exam(le of a 5$ 4& child who (re ent with a $% fluid deficit. Thi child will not onl" need hi maintenance 9K fluid , !ut will al o need to have hi deficit re(laced. To determine the amount of volume and the odium com(o ition of that olution to !e admini tered, fi&ure out how much fluid thi child will need, the odium com(o ition in m+78l of each of the e fluid , and then the total amount of odium. ,inall", divide the total odium !" the volume to &et the odium com(o ition of the fluid to !e admini tered. Thi i illu trated in the ta!le !elow. Maintenance8.6 hr Deficit Total :ater *ml5.$3 #$3 .333 or #$ m+78l 0a 0a *m+78FA$ 563 Total 0a *m+766 53$ 56@

The maintenance volume i calculated u in& the tandard formula. )ne u e I normal aline containin& a((roximatel" A$ m+78l, and from our calculation, one need 5.$3 cc> of fluid (er .6 hour . The total amount of odium to !e admini tered in that maintenance fluid i 66 m+7. 0ow, thi child al o ha a $% fluid deficit. Thi will re7uire admini tration of #$3 cc> *$% of thi child> !od" wei&ht- a an i otonic fluid containin& a((roximatel" 563 m+78l of 0a. The total odium that thi child will receive from thi fluid i 53$ m+7. Thu , in total, we are &oin& to &ive 56@ m+7 of odium in .333 ml, or a((roximatel" #$ m+78l odium. )ne would admini ter D$ J 0S with .3 m+7 ;8F *once we are ure that thi child ha normal renal function- at a rate to e7ual .333 ml in the next .6 hour . 9f one re(lace one'half of the deficit in the fir t / hour one would admini ter thi fluid at 533 ml8hr for the fir t / hour and then #$ ml8hr for the next 5D hour . 9f the child i then volume re(lete one can then admini ter maintenance fluid . :ith the econd exam(le, let u a" we have the ame 5$ 4& child who now (re ent with a $% volume deficit, !ut ha a erum odium of 5.3 m+78F. )ne would onl" want to increa e the erum odium !" 5$ m+78F in the next .6 hour . Thi child will till re7uire hi maintenance #

fluid , and will till have a volume deficit Gu t a we have calculated !efore. 9n addition thi child al o ha a odium deficit which i calculated a de cri!ed a!ove. Thi odium deficit i 5A$ m+7 *5$ x 3.D x 5$- and will have to !e added to the total odium that we admini ter to thi (atient, a hown !elow. Maintenance Deficit 0a Deficit Total :ater *ml 5.$3 #$3 .333 or 56. m+78F 0a 0a m+78F A$ 563 Total 0a *m+766 53$ 5A$ ./6

The amount of maintenance fluid and the fluid deficit of i otonic olution ha not chan&ed. :hat we have added at thi (oint i enou&h odium to re(lete an additional odium deficit. :e are now &oin& to admini ter .333 ml> and ./6 m+7 of odium. Thi child will &et D$ 0S with the addition of .3 m+78F of ;Cl when normal renal function i e ta!li hed. 9t i !e t to admini ter the e fluid evenl" over .6 hour to avoid too'ra(id ri e in erum odium concentration durin& the earl" (ha e of thera(". ?owever, (atient with h"(otonic deh"dration ma" have i&nificant cardiova cular in ta!ilit" due to reduction in +C, volume * ee a!ove-. A&&re ive thera(" of hoc4 with i otonic fluid alwa" ta4e (recedence over concern a!out too'ra(id ri e in erum odium concentration. The next (ro!lem i the treatment of h"(ernatremic deh"dration. Thi i conce(tuall" a little !it more difficult to under tand. ,ir t, con ider a im(li tic exam(le1 Fet u ta4e a $ liter !ea4er that ha a odium content of 5D$ m+78l. 9f we would li4e to dro( the odium content to 5$3 m+78l !" addin& more water, we mu t calculate the final volume needed to dro( the odium concentration to 5$3 m+78l and then u!tract the volume that we have. Thi will &ive u the volume of water to !e added. The volume we have in the ca e of our h"ernatremic !ea4er i 7uite im(le. 9t i $ liter . ?ow do we calculate the volume that we wantN Thi i im(l" the ratio of the odium that we have divided !" the odium that we want O*5D$85$3- P $ liter Q a hown in the fi&ure !elow. The volume that we want i $.$ liter . The volume that we have i $ liter . The additional water we need to add to dro( the odium !" 5$ m+7 i 3.$ liter . The ame (rinci(le hold true when one doe thi to a (atient. ?"(ernatremia i extremel" rate, and one mu t determine the rea on for h"(ernatremia in an" (atient. =ro!a!l" the &reate t ri 4 to a (atient with h"(ernatremia i that omeone i &oin& to correct the h"(ernatremia too ra(idl". Ne+er correct " #ernatre'ia b 'ore t"an ,- 'E. in /0 "ours1 ot"er&ise cerebral ede'a &ill ensue. :e are now &oin& to u e the ame (rinci(le that we have learned !efore, to deal with a 5$ 4& (atient who (re ent with a erum odium of 5D$ m+78l. :e are &oin& to want to !rin& thi erum odium down to 5$3 m+78l durin& the fir t .6 hour of fluid thera(". Strictl" (ea4in&, we are not onl" !rin&in& down the erum odium, !ut we are actuall" correctin& the o molarit" of the extracellular fluid com(artment and the intracellular fluid com(artment at the ame time ince water i freel" (ermea!le acro cell mem!rane . Thu , in all of our calculation we u e the (ercenta&e 3.D or the (ercenta&e of our !od" which i made u( of water, a hown !elow. The free water deficit i , once a&ain, the volume of fluid in the !od" that we want, minu the volume of fluid in the !od" that we have. The volume of !od" fluid that we have i 3.D P the /

(atient> wei&ht in 4&. The volume of fluid that we want i that fraction multi(lied !" the ratio of odium that we have divided !" the odium that we want, a hown !elow. ,ree water deficit < 5D$ P *3.D-*5$- ' *3.D-*5$- < 3.@ liter 5$3 To calculate the fluid re7uirement of thi (atient, one ha to a&ain &ive thi child maintenance. The deficit i no lon&er made u( of of normal aline, !ut rather i made u( of the free water deficit that we calculated a!ove. 0ote that the free water deficit *@33 ml- exceed the clinical e timate of $% deh"dration *#$3 ml-. Thi i not uncommon in h"(ernatremic deh"dration where increa ed +C, tonicit" u((ort +C, volume and ma 4 the clinical everit" of deh"dration. The (ortion of the free water deficit to !e re(laced durin& the fir t .6 hour i @33 ml. The T)TAF free water deficit i actuall" 5.D liter R *5D$8563 P 3.D P 5$- E *3.D P 5$-. Maintenance Deficit',ree water Re t of deficit Total :ater *ml5.$3 @33 '' .5$3 or .3 m+78F 0a A "ou can ee in thi ca e we are &oin& to want to admini ter ..5$ liter of D$ 58/ normal aline *with .3 m+7 of ;Cl8F once we are ure that the child ha normal renal function-. 9n the ca e of h"(ernatremic deh"dration, it i e ential to admini ter fluid at an even rate to avoid a!ru(t chan&e in erum odium concentration. )f cour e, "our (atient i not a !ea4er, and man" factor will influence the rate at which the erum odium fall . 9t i e ential to mea ure erum odium concentration at lea t ever" two hour and adGu t thera(" accordin&l". 9t ma" !e ea ier in ome ca e to add a econd 9K of D$: that can !e adGu ted fre7uentl" to fine tune the rate of h"(ernatremia correction. ,inall", the mo t im(ortant thin& to remem!er i that all of what we have di cu ed reflect a((roximation . Sou will need to o! erve "our (atient fre7uentl" to a e their volume tatu and to reevaluate their erum electrol"te to ma4e ure that "our calculation have come clo e to the (atient> re7uirement . ,. +valuation of ade7uac" of thera("1 a- Durin& the fir t da", fluid order hould not !e written for more than 6'D hour in advance. Con tant re'evaluation of fluid e timate i nece ar". !- Clinical im(rovement of the (atient hould occur with reh"dration, (articularl" in re&ard to &eneral a((earance, color, vital i&n , en orium tatu , urine out(ut and activit". c- =atient hould !e wei&hed fre7uentl". :ei&h dia(er . =reci e 9 H ) i e ential. d- The e ta!li hment of ade7uate urinar" out(ut hould !e achieved !" 6 to D hour . e- Beware of on&oin&, undere timated tool lo e or third (ace lo e into the !owel lumen. f- ,ailure of clinical re (on e in D to 53 hour ma" indicate evere meta!olic, renal, adrenal, or (o terior (ituitar" d" function which ma" re7uire (ecific treatment. &- The &uide to fluid thera(" &iven in thi outline can in no wa" u! titute for ound clinical Gud&ment. I(. )odiu' Proble's A. Ba ic con ideration @ 0a m+78F A$ '' 563 0a m+7 Total 66 '' '' 66

Becau e odium i (rimaril" concentrated in the +C,, to which we have read" acce , mo t a!normalitie of odium concentration lend them elve to rational and relia!le thera(". Sodium L!ehave M a if it were di tri!uted evenl" throu&hout the total !od" water. Thu the L odium (ace1 ma" !e e timated im(l"1 :t *;&- P 3.D < L odium (aceM 5. A 53 ;& infant with 4nown :=: i een in the +R for an e(i ode of SKT refractor" to u ual conver ion techni7ue . ?i erum 0a i 5A3 m+78F. A L4ee( o(enM 9K of D$: i tarted in (re(aration for tran fer to the 9CU. )n arrival in the =9CU a!out an hour later the infant ha everal &enerali2ed ei2ure . Durin& the effort to (erform emer&enc" DC cardiover ion it i not reco&ni2ed that a((roximatel" #$3 cc of hi D $: 9K !ottle ha !een infu ed durin& tran fer from the +R. :h" i thi the more li4el" etiolo&" of hi ei2ure than cere!ral h"(oxia from SKTN An wer1 ?i erum 0a i now 55$ m+78F. 53 4& x 3.D < D F L odium (aceM D F x 5A3 m+78F < #/3 m+7 of 0a ,ollowin& #$3 cc D$: infu ed ra(idl", new L odium (aceM i D.#$ F #/3 D.#$ < 55$ m+78F .. A $ 4& infant receive odium !icar!onate durin& C=R. 9f hi erum 0a wa 563 at the time of hi arre t, what do e of odium !icar!onate will it ta4e for hi erum 0a to exceed 5$3 m+78FN An wer1 A3 m+7 or ix 5 m+78;& do e . B. ?"(onatremia1 treatment trate&ie 5. Acute, evere, "m(tomatic, h"(onatremia1 a. U uall" een when erum 0a T 55$ m+78F; develo( ra(idl", in an euvolemic (t. with acce to free water. !. Cere!ral edema can !e evere, rarel" life'threatenin&. c. 9nfant and "oun& children mo t often (re ent with ei2ure ; older (atient more often o!tunded or comato e. d. ?"(erten ion and !rad"cardia are incon i tent findin& , e (eciall" in infant who ma" onl" have h"(erten ion a 9C= ri e econdar" to cere!ral edema. e. Goal of treatment1 5. Control ei2ure with anticonvul ant . .. =rotect airwa", u((ort ventilation. A. Correct erum 0a to 5.$ m+78F in / hour . Do not calculate emer&enc" correction !e"ond 5.$ m+78F. a. ,ir t, calculate odium deficit1 *5.$ E (t.> erum 0a- x :t *;&- x 3.D < m+7 of 0a re7uired. !. Choo e re(air olution 3.@% *0ormal- aline < 5$6 m+78F A% aline < $A3 m+78F $% aline < //6 m+78F c. Rate of re(air de(end on everit" of cere!ral edema. 9n evere ca e &ive J the 0a deficit in the fir t . hour , then remainder in next D hour . Thi ra(id correction i re erved for (t . with "m(tomatic cere!ral edema econdar" to h"(onatremia. d. +xam(le1 Comato e 53 ;&. 9nfant with &enerali2ed ei2ure (oorl" controlled with anticonvul ant ; dilated (u(il ; un ta!le KS1 *B= 5A38@3, ?R 533, re7uirin& 53

ventilator" u((ort for intermittent a(nea-; erum 0a 553 m+78F; 0a deficit < *5.$'553- x *53 ;&- x *3.D- < @3 m+7. Re(air olution 1 3.@% aline < $/6 cc re7uired A% aline < 5#3 cc re7uired $% aline < 53. cc re7uired Rate1 A% aline U 6A cc8hr x . hr , then 56 cc8h for D hr. $% aline U .$ cc8hr x .hr, then @ cc8hr for D hr . Do not u e 3.@3 aline in thi (atient. The volume re7uired for correction i too &reat. 0.B. ?"(ertonic aline cau e a chemical necro i if the 9.K. infiltrate . Durin& h"(ertonic aline infu ion , 9K ite mu t !e chec4ed 75$ min. to a ure (atenc" and a! ence of infiltration. e. Some authoritie recommend Mannitol over h"(ertonic aline in uch (atient . Mannitol i an effective thera(" for cere!ral edema, !ut it will wor en h"(onatremia !" dilution and increa ed urinar" 0a lo e , ma4in& eventual correction of h"(onatremia more difficult. 9f h"(ertonic aline i not readil" availa!le, Mannitol *5 &ram (er 4& of .$% Mannitol olution over 5 hour- i an acce(ta!le alternative in an emer&enc". f. Some authoritie recommend routine u e of a (otent diuretic, uch a ,uro emide, durin& the treatment of h"(onatremia with h"(ertonic or i otonic aline. ,uro emide cau e a net increa e in free water excretion !" 4idne" . ?owever, urinar" odium lo e are al o increa ed to an un(redicta!le de&ree. 9f furo emide i u ed, urinar" odium and water lo e mu t !e (reci el" monitored and re(laced a((ro(riatel". .. Su!acute, chronic, a "m(tomatic h"(onatremia1 a. :hen h"(onatremia develo( lowl", cere!ral edema doe not occur !8c !rain cell volume i maintained !" active de(letion of intracellular olute *0a, ;, Cl, amino acid -. Total !rain water content remain con tant de (ite erum 0a level a low a 533 m+78F when the e level are achieved lowl" *i.e., over everal da" -. !. The a! ence of i&n and "m(tom of cere!ral edema in a (atient with evere h"(onatremia i evidence for a chronic (roce to which the !rain ha ucce full" ada(ted. c. Ra(id correction of evere chronic h"(onatremia i unnece ar" and (otentiall" harmful, !ecau e ra(id correction cau e acute deh"dration of the !rain and ma" re ult in (ermanent !rain inGur". d. ) motic Dem"elination S"ndrome1 Brain inGur" due to too'ra(id correction of chronic h"(onatremia i often a ociated with dela"ed neurolo&ical deterioration *on et of "m(tom 5 to 6 da" after erum 0a i increa ed !" B 5. m+78F in le than .6 hour .e. +xam(le1 A "m(tomatic 53 ;& infant with erum 0a < 553 m+78F Rate of re(air < 3.$ m+78F8hr Re(air olution1 3.@% aline < 5.$6 m+7853 cc < .3 cc8hr x A3 hour )n&oin& urinar" 0a lo e mu t !e mea ured and re(laced m+7 for m+7, u uall" with a e(arate 9K. A. 9f it i not clear whether the individual (atient ha acute or chronic h"(onatremia, correct a if the (atient ha chronic h"(onatremia to avoid the o motic dem"elination "ndrome. (. Potassiu' Proble's A. ,actor affectin& erum O;CQ 55

5- @/% of total !od" (ota ium i intracellular. 9t i therefore im(o i!le to calculate (ota ium deficit or exce e a can !e done with odium. =ota ium !alance i (rimaril" maintained !" the 4idne", lar&el" the di tal tu!ule and collectin& duct where ; i excreted in exchan&e for 0a. Aldo terone (otentiate thi exchan&e a doe an"thin& which increa e di tal 0a deliver". 9n ulin and catecholamine are al o im(ortant in minute to minute re&ulation of +C, (ota ium concentration. .- Common ource of a!normal ;C in(ut1 a- Diet E Starvation often lead to h"(o4alemia. ?i&h dietar" ; inta4e can tran ientl" exceed ecretor" ca(acit" of ver" "oun& infant !ut i not a (ro!lem in older (atient with normal 4idne" function. !- 9K fluid E remem!er the fir t te( in the h"(er4alemic (atient i to remove ; from 9K fluid . c- Salt u! titute are lar&el" ;CF. d- ?emol" i and ti ue trauma relea e va t amount of (ota ium into the +C,. A- Common ource of a!normal ;C out(ut1 a- Renal in ufficienc" *includin& L(re'renalM-. The a!ilit" to excrete ; dro( in (ro(ortion with fall in G,R. !- Mineralcorticoid im!alance. =ota ium wa tin& in h"(eraldo teroni m *5 or .-, Bartter> S"ndrome. =ota ium retention in Addi on> , Con&enital Adrenal ?"(er(la ia. c- 9ncrea ed di tal 0a deliver"1 Diuretic ; o! tructive uro(ath" *after relief of o! truction-; o motic diure i *Dia!ete Mellitu , urea-; non'oli&uric acute renal failure; T"(e 99 *(roximal- RTA; volume ex(an ion. d- Chronic h"(oma&ne emia cau e (ota ium wa tin& e- G9 lo e *diarrhea, eme i , 0G uction, ileo tom" draina&e, etc.6- Alteration in erum O;CQ unrelated to 9 H ) are the re ult of 1 a- Ra(id chan&e in (? LAl4alo i drive ; into cell M LAcido i (ull ; out of cell .M 9n &eneral, a 3.5 unit chan&e in (? "ield a 3.D m+78F chan&e in erum O;CQ. 9f (? ra(idl" ri e from #.. to #.6, erum O;CQ will decrea e 5.. m+78F. !- ?"(er&l"cemia in (re ence of in ulin, drive (ota ium into cell . 9K olution with h"(ertonic dextro e *D53 or &reater- can (roduce h"(o4alemia *and h"(o(ho (hatemia-. c- 9n ulin in 9K fluid (rofoundl" lower erum O;Q. $- Source of (uriou erum O;CQ value 1 a- Too hi&h1 hemol" i of am(le; (ol"c"themia *!lood drawn throu&h T .5 &a. 0eedle!- Too low1 dilutional am(lin& throu&h a line, he(. loc4, etc. B. ?"(o4alemia 5- Dia&no i a- S"m(tom 1 Mu culo 4eletal < wea4ne , cram( , (are the ia , (aral" i ; G9 < nau ea, anorexia, vomitin&, diarrhea; C0S < lethar&", confu ion. !- =h" ical findin& 1 h"(oreflexia c- Fa! findin& 1 low urine (ecific &ravit"; low erum ;C *TA.$ m+78F re7uire thera("-. d- +;G findin& 1 flat or inverted T wave ; ST de(re ion. Fe commonl"1 VT Fon&, wide VRS, U wave. :ith di&itali toxicit"1 all of the a!ove (lu variou AK !loc4 , !rad"cardia , and arrh"thmia of an" t"(e. .- Treatment TR+AT AS 9, T?+R+ 9S A0 +M=TS TA0; 90T) :?9C? S)U CA0>T S++ 5.

a- :hen (atient i "m(tomatic, or on Di&itali , ra(id correction i needed. !- =.). (ota ium thera(" i afe t and hould !e u ed whenever (o i!le. Sou can &ive 5'. me78;&. (o ever" few hour , chec4in& erum ;C 7 6 hr . c- 9K correction when (atient i 0=) for other rea on . 5. 63 me78l. i &enerall" afe at u ual 9K fluid rate . .. D3 me78l. can !e &iven when on cardiac monitor. A. ABS)FUT+ U==+R F9M9T ,)R ;C ADM909STRAT9)0 RAT+1 3.$ me78;&.8hr. T?9S R+VU9R+S ,R+VU+0T S+RUM =)TASS9UM F+K+FS. 6. 0+K+R G9K+ =)TASS9UM AS B)FUS 9K 90W+CT9)0 $. :hen (ota ium level i till dan&erou l" low de (ite alread" &ivin& 9K fluid with ;Cl at D3 me78l., it i (ro!a!l" !etter to &ive intermittent !olu do e no more than 3.$ m+7 ;Cl8;&8hr until the erum ;BA.3. Chec4 erum O;Q7 5'. hour when u in& thi re(lacement a((roach. D. Bac4 off on ;C re(lacement when O;CQ i B A.$. C. ?"(er4alemia 5- Dia&no i a- S"m(tom 1 wea4ne , (aral" i !- =h" ical findin& 1 none (ecific c- Fa!1 erum ;C B $.$ u (ect acido i d- +;G findin& *in a((roximate order of a((earance a ;C ri e -1 (ea4ed, tall T wave =R interval len&then ' 5 heart !loc4 VRS, VT len&then , VRS ma" !lend into T in a di(ha ic curve = widen and flatten R widen and flatten S dee(en +cto(ic rh"thm Kentricular fi!rilation A " tole .- Treatment of ?"(er4alemia a- Sta!ili2e m"ocardium 5. CaCl. E 3.. E 3.A cc8;& of a 53% CaCl. olution ver" low 9K (u h. Mea ure erum Ca after each do e to avoid h"(ercalcemia; erum ioni2ed Ca level i (referred. .. 0a E u uall" accom(li hed when 0a?C)A i &iven. !- Drive ;C into cell 5. 9ncrea e (? if acido i i (re ent a. ?"(erventilation !. 0a?C)A * ee ection on Bicar!onate thera(" for do e calculation or &ive 5 me78;& and re(eat !lood &a e -. c. Do not &ive !icar!onate to (atient who e (? i B #.6. .. Dextro e (lu in ulin E mo t (otent treatment for h"(er4alemia hort of hemodial" i . a. Add D re& in ulin to 533 cc D.$: for a 5 86 &ram dextro e olution; &ive in . cc8;& 9K do e !. ,or infant T D mo . Give a 5 8/ &ram dextro e olution to avoid h"(o&l"cemia. A. Al!uterol E continuou inhalation thera(" a for RAD1 extremel" effective. The 9K al!uterol (re(aration i not availa!le in the U.S. c.- Remove ;C from the (atient 5. ;a"exalate1 0a8; exchan&e re in 5A

a. !. c. d. e.

f.

Give a enema in .3% or!itol or (.o. a (owder mixed in fruit Guice +nema i more effective ince diarrhea it cau e increa e ; lo e . ;a"exalate do e1 5 &m8;& will lower erum ; 3./ me78F Ta(e !uttoc4 to 4ee( 4a"exalate in at lea t J hour Com(lication 1 h"(ocalcemia h"(oma&ne emia odium overload h"(o4alemia :hen &ivin& 4a"exolate (.o. avoid laxative and antacid

A- ?emodial" i E mo t effective treatment of h"(er4alemia 6- =eritoneal dial" i E ma" !e too low in ver" cata!olic (atient $- +xchan&e tran fu ion *neonate onl"- u in& wa hed or ver" fre h (RBC> re' u (ended in $% al!umin or ,,= or aline D- CKK? E not a &ood initial treatment for h"(er4alemia E tart with ?D, then continue with CKK? or CKK?D. (I. Rational Use of )odiu' !icarbonate in t"e Treat'ent of %etabolic Acidosis A. =rinci(le of !icar!onate thera(" 5- Do not &ive a 9K (u h exce(t durin& C=R .- Calculate deficit con ervativel" a follow 1 Goal1 (? . #..$ a- The !lood ?C)A concentration needed to achieve thi (? rarel" exceed 5$ m+78F if (atient i ca(a!le of maintainin& (C). T A$ mm?&. *See acid'!a e nomo&ram-. !- Bicar!onate deficit < *5$ E (la ma O?C)AQ- x :t *4&- x 3.A 0ote that !icar!onate &iven 9K di tri!ute acutel" in onl" a!out J the total !od" water *TB: < :t *4&- x 3.D-. :hile thi calculation undere timate total re(lacement, it i the onl" afe a((roach to acute correction. A- Give calculated deficit SF):FS; ma" &ive J of deficit over 5 t hour if (? T #.5$, remainder over .'A hour . B. Monitor with fre7uent !lood &a e , *venou or ca(illar" will !e a &ood a arterial for acid'!a e tatu monitorin&-. C. Com(lication of !icar!onate thera(" 5- ?"(o4alemia .- ?"(o'ioni2ed'calcemia A- ?"(ernatremia 6- )ver' hoot meta!olic al4alo i $- Cere!ral edema E (aradoxial CS, acido i *ND- 9ncrea in& (C). in (atient with re (irator" failure, re ultin& in wor ened acido i . Do not treat re (irator" acido i with !icar!onate. Remem!er, (roceed cautiou l" and correct lowl" once (? B #.5$. Man" with meta!olic acido i have &enerated lar&e amount of lactic acid which the" will meta!oli2e to !icar!onate once the" are reh"drated and &iven &luco e and ox"&en.

56

5$