Fluid and Electrolyte

Imbalance
Wan Nedra

Introduction to the Principles of Fluid

and Electrolyte Therapy
Important to understand the underlying
physiologic principles of a therapy commonly
employed in pediatrics
Understanding basic principles essential for the
understanding of the management of more
complex disorders such as:
Cholera
Dengue
Pyloric stenosis
Hyperosmotic non-ketotic coma

Crystalloid and Colloid

Crystalloid: Water and electrolyte solution

Does not remain within the intravascular space but
rather distributes to the entire extracellular space
Only impacts on the intracellular space if it causes a
change in extracellular osmolarity
E.g.: 0.9% NaCl, D5 0.3% NaCl
Colloid: Contains large particles which tend to remain within
the blood vessels
Colloid preferentially expands the intravascular space
because the particles exert oncotic force which
retains water within the intravascular space
E.g.: 5% albumin, blood, dextran solution

Isotonic Saline Solution

Isotonic saline solution: Solution such as 0.9% NaCl or
Ringers lactate with a Na concentration similar to that
of plasma water
Crystalloid distributes throughout the extracellular
space
Infusion of crystalloid will cause a fluid shift into or
out of the intracellular space only if it creates an
osmotic gradient between the extracellular and
intracellular space
Isotonic saline does not change the osmolarity of the
extracellular space
Therefore: Isotonic saline solution remains within and
expands the extracellular space and has minimal
effect on the intracellular space

Composition of Fluids
1. D5W (5 g sugar/100 ml): 252 mOsm/L
2. D10W (10 g sugar/100 ml): 505 mOsm/L
3. NS (0.9% NaCl) 154 mEq Na/L: 308 mOsm/L
4. 1/2 NS (0.45% NaCl): 77 mEq Na/L: 154
mOsm/L
5. D5 1/4 NS (34 mEq Na/L): 329 mOsm/L
6. 3% NaCl 513 mEq Na/L: 1027 mOsm/L
7. 10% NaCl 1.7 mEq/cc
8. 20% NaCl 3.4 mEq/cc
9. 8.4% NaHCO3 (1 meq/cc Na & HCO3): 2000
mOsm/L

IV fluids
Lactated Ringers
0-10 gram glucose/100cc
Na 130 meq/L
NaHCO3 28 meq/L as lactate
K 4 meq/L
273 mOsm/L
Amino acid 8.5 %
8.5 gm protein/100 cc
880 mOsm/L
Albumin 25% (salt poor)
25 gm protein/100 cc
Na 100-160 meq/L
300 mOsm/L
Intralipid
2.25 gm lipid/100cc
284 mOsm/L

Requirements of FLUID
Increased requirement :
Fever
Vomiting
Renal failure
Burn
Shock
Tachypnea
Gastroenteritis
Diabetes (Insipidus,
mellitus - DKA)
Cystic fibrosis

Decreased requirement
CHF
Postoperatively
Oliguric ( RF )

Maintenance Fluid and Electrolyte

Requirements
Maintenance: The replacement of normal ongoing losses
Normally serum Na concentration is approximately 140
meq/l and serum K concentration is approximately 4 meq/l
Maintenance solution replaces normal losses
Maintenance solution does not have an electrolyte
concentration equal to serum because the electrolyte
composition of urine and stool is not equal to that of serum
Maintenance fluids commonly provided as a 5% dextrose
solution
Dextrose provides some energy and prevents
hypoglycemia
Spares protein
Cannot meet patients nutritional requirements with 5% (or
10%) dextrose

Maintenance Requirements are a

Function of Caloric Requirements

0-10 kg: 100 kcal/kg

10-20 kg:50 kcal/kg
> 20kg: 20 kcal/kg
Examples:
8 kg: 8 kg X 100 kcal/kg = 800 kcal.
12 kg: 10 kg X 100 kcal/kg + 2 kg X 50 kcal/kg
= 1000 kcal + 100 kcal = 1100 kcal
20 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg
= 1000 kcal + 500 kcal = 1500 kcal
25 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg
+ 5 kg X 20 kcal/kg = 1000 kcal + 500 kcal +
100 kcal = 1600 kcal

Water and Electrolyte Requirements

are Determined by Caloric
Requirements
Requirements per 100 kcal:
100 ml water (provided as a 5% dextrose solution)
2-4 meq Na
2 meq K
2 meq Cl
Plasma: Anion is a balance of Cl and base
(bicarbonate)
Maintenance solution: Can provide some anion as Cl
and some as base (lactate, citrate, phosphate) or
can provide all of it as Cl
But: Providing large volumes of fluid (e.g., in DKA or
hypovolemic shock) with all of the anion as Cl will
promote a hyperchloremic metabolic acidosis

Standard Maintenance Solution

D5W with 20-40 meq/l Na Cl and 20 meq/l KCl (or
KAcetate or KPhosphate) will work well as a
maintenance solution in most pediatric patients
Can use D5 0.2% (or D5 0.3%) NaCl with 20 meq/l KCl (or
KAcetate or KPhosphate) as maintenance solution
Recent article advocated routine use of isotonic saline
solution for pediatric maintenance solution

Some disease states: Another solution might be

appropriate
E.g.: Sickle cell anemia patients may have a relatively
high Na requirement due to high urinary Na losses
0.9% NaCl (without dextrose) in head trauma patients
K should be used with caution or omitted in patients with
renal insufficiency

Water and Electrolyte Requirements

Based on Weight
Water:
0-10 kg: 100 ml/kg
10-20 kg: 1000 ml plus 50 ml/kg
> 20 kg: 1500 ml plus 20 ml/kg
Electrolytes:
Na: 2-3 meq/kg
K: 1-2 meq/kg
Water requirement is the same as with the caloricbased system
Electrolyte requirement is greater than with caloricbased system: Electrolyte requirement is a direct
linear function of weight

Fluids and Electrolytes

Principles
Total body water
(TBW) = Intracellular fluid

(ICF) + Extracellular fluid (ECF)

ECF) = Intravascular fluid (in vessels :
plasma, lymph - IVF) + Interstitial fluid
(between cells - IF)
ECF ( intravascular, interstitial &trancelluler)
Fluid % in child body ( 75%-80%)

Goals:
Maintain appropriate ECF volume,
Maintain appropriate ECF and ICF osmolality
and ionic concentrations

Things to consider:
Normal changes in TBW, ECF

All babies are born with an excess of

TBW, mainly ECF, which needs to be
removed
Adults are 60% water (20% ECF, 40% ICF)
Term neonates are 75% water (40% ECF,
35% ICF) : lose 5-10 % of weight in first week
Preterm neonates have more water (24 wks:
85%, 60% ECF, 25% ICF): lose 5-15% of
weight in first week

Diagnostic Evaluation
1. Anamnesis, Physical, Lab
assessment
2. Type of dehydration

Physical Assessment of FE
status
Skin/Mucosa: Altered skin turgor, sunken AF,
dry mucosa, edema etc are not sensitive
indicators in babies
Cardiovascular:
Tachycardia too much (ECF excess in
CHF) or too little ECF (hypovolemia)
Delayed capillary refill low cardiac output
Hepatomegaly can occur with ECF excess
BP changes very late

Urine output

Lab Assessment of FE status

Serum electrolytes and plasma osmolarity
Urine electrolytes, specific gravity (not very
useful if the baby is on diuretics - lasix etc),
FENa
Blood urea, serum creatinine (values in the first
few days reflect moms values, not babys)
Acid Base (low pH and bicarb may indicate
poor perfusion)

Type of Dehydration
1. Isotonic
(affect ECF ,Na = 135meq /l)
2. Hypotonic
( loss in ECF 2 correct ICF, Na = less
than 135meq/l )
3. Hypertonic
( sever loss in ICF ,Na = more than
150meq/l

Physical Signs of
Dehydration
Signs & sympt.

MILD

Moderate

Severe

General

Thirsty, allert,
restless
Normal rate
Normal
Normal
Pinch retracts
immediately
Normal
Present
Moist
Normal

Thirsty, irritable,
or drowsy
Rapid, weak
Deep
Sunken
Retracts slowly

Drowsy limp,
skin cold / sweaty
Rapid, feeble
Deep & rapid
Very sunken
Poor

Sunken
Absent
Dry
Dark &
decreased

Grossly sunken
Absent
Very dry
Oliguria / anuria

Radial pulse
Respiration
Anterior font.
Skin turgor
Eyes
Tears
Mucous memb.
Urine flow

Pediatric Fluid Therapy Principles

I. Assess water deficit by:
1. weight:
weight loss (Kg) = water loss (L)
OR
2. Estimation of water deficit by
physical exam:
Mild moderate severe
Infants
<5%
%
Older children < 3 %

5 - 10 %
3-6%

>6%

>10

Pediatric Fluid Therapy Principles

II. Maintenance H2O needs:
Weight in Kg

H2O fluid needs

1-10
100cc /kg /day
11-20
1000+50cc/kg/day
> 20
1500 + 20cc/kg/day
Add 12 % for every 0C
Therapeutic management of fluid loss
Oral rehydration therapy
Parenteral fluid therapy
Meet ongoing daily loss
Replace previous deficit
Replace ongoing abnormal losses

Correction of
Dehydration
1. Estimate Fluid Deficit (% :- Mild, Moderate,
Severe).
2. Moderate to severe dehydration:
IV push 10-20 cc / Kg Normal saline, May repeat.
Half deficit over 8 hours, and half over 16 hours.

3.

Find Type of Dehydration

(Isonatremic, Hyponatremic, Hypernatremic).
4. Give daily Maintenance.
5. Give Deficit as follows:
Half volume over 8 hours, half volume over 16
hours
(Exception: in Hypernatremic Dehydration,
replace deficit over 48 hours).

Disturbance of F&E balance

1. Na
2. K
3. Ca
( Na is the primary osmatic farce )
Serum Osmolality
Defined as the number of particles per liter.
May be approximated by:
2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8
Normal range: 275-295 mOsm/L

300-500 cc/M2/day
Less in patients on the ventillator

When administrating I.V fluid

Monitors the response of the

fluids.
Considering the fluid volume.
Content of fluid.
Patient clinical status.

1. Isotonic fluids:
-Have a total osmolality close to that of extra
cellular fluids (ECF) and don't cause RBCs to
shrink or swell.
- 3 L of isotonic solutions are needed to replace
1 L of blood, so pt should be carefully
monitored for signs of fluid overload.
Examples of Isotonic fluids:
D5W: has a serum osmolality of 252 mosm/L.
D5W s mainly used supply water and to correct
an increased serum osmolality

NORMAL SALINE SOLUTION

NS (0.9% Sodium chloride with TO of 308
NS
osmolality
is
contributed
by
electrolytes
- So the solution remains within ECF.
- NS is used to treat ECF deficit.
- Ringer's solutions: Contains Ca, K and
NaCl

2. Hypotonic Fluids
- The purpose of hypotonic fluids is to
replace cellular fluids, because it is
hypotonic as compared with plasma.
- It also used to provide free water for
excretion of body wastes.
- It may used to treat hypernatramia
(hypotonic Na solutions).
Examples of hypotonic solutions:
0.45% Nacl Half-strength saline.

Complications of excessive
use of hypotonic solutions
include:
Intravascular fluid depletion.
Decreased blood pressure.
Cellular edema.
Cell damage

3.Hypertonic Solutions
Hypertonic solutions exert an osmotic
pressure greater than that of ECF
Examples
* High concentrations of dextrose such
as 50% dextrose in water are used to
help meet caloric requirements.
These hypertonic solutions must be
administered into control veins so that
they can be diluted by rapid blood flow.

 Saline solutions are also available in

osmolar pressures greater than that
of ECF and cause cells to shrink.
If administered rapidly or in large
quantities, they may cause an extra
cellular volume excess and cause
circulatory overload and dehydration.

*Management and Nsg Care for

certain fluid and electrolyte
balance disturbances
1-Water depletion
- Provide replacement of fluid.
-Determine and correct cause of water
depletion.
- Measure intake and output.
- Monitor V/S

 2- Water Excess:
- Limit fluid intake.
- Administer diuretics.
- Monitor V/S
- Determine and treat cause.
- Analyze laboratory electrolyte
measurement frequently

 3- Hyponatremia
- Determine and treat cause
- Administer I.V fluids with
appropriate saline concentration
4- Hypernatramia:
-Determine and treat cause.
Administer fluids as prescribed.
-Measure intake and output.
- Monitor lab. Data.

 5- Hypokalemia:
-Determine

and treat cause.

-Monitor V/S and ECG.
- Administer supplemental K.
- Assess for adequate renal output
before administration.
IV: administered slowly.
Oral: after high K fluids and foods.

 6- Hyperkalemia
- Determine and treat cause.
- Monitor V/S and ECG - Administer I.V fluids if prescribed.
- Monitor serum potassium levels.
7- Hypocalcaemia:
- Determine and treat cause.
- Administer calcium supp. as prescribed and administered slowly.
- Monitor serum calcium levels.
- Monitor serum protein level

8- Hypocalcaemia:
- Determine and treat cause.
- Monitor serum Ca levels.
-Monitor ECG.

SODIUM
Na+ are very important for regulating blood and interstitial fluid
pressures as
well as nerve and muscle cell conduction of electrical currents.
Aldosterone causes
retention of Na+.
a. HYPONATREMIA: Vomiting, diarrhea, sweating, and burns cause Na+ loss.
Dehydration, tachycardia
and shock (see above) can result. Intake of plain water worsens
the condition.
Pedialyte is a better fluid to drink. Explain this.
b. HYPERNATREMIA
Severe water deprivation, salt retention or excessive sodium
intake causes this.
Increased Na+ draws water outside of cells, resulting in tissue
dehydration.
Thirst, fatigue and coma result.

CHLORIDE
Cl- anion is necessary for the making
of HCl, hyper polarization of neurons,
regulating proper acid levels, and
balancing osmotic pressures between
compartments.

CHLORIDE
a. HYPOCHLOREMIA
Excessive vomiting causes chloride loss,
resulting in blood and tissue alkalosis, and
a depressed respiration rate.
b. HYPERCLOREMIA
Dehydration or chloride gain can result in
renal failure or acidosis (increases in
Cl- are accompanied by increases in H+).

POTASSIUM
K+ is important in the intracellular fluid.
Aldosterone causes excretion of K+.
a. HYPOKALEMIA
Caused by diarrhea, exhaustion phase of
stress, excessive aldosterone secretions
in adrenal cortical hyperplasia and some
diuretics. K+ loss from cells contributes to
tissue
dehydration and acidosis. Flattened T waves,
bradycardia, muscle spasms, a lengthened
P-R, and mental confusion can also result.

POTASSIUM
b. HYPERKALEMIA
Caused by eating large amounts of
"light salt" (KCl), kidney failure, and
decreased aldosterone secretions in
Addison's Disease; resulting in elevated
T waves and fibrillation of the heart. The
movement of K+ into cells accompanies

tissue alkalosis.

CALCIUM
Calcium Ca++ cations are needed
for bone, muscle contraction, and
synaptic
transmission.

CALCIUM
a. HYPOCALCEMIA
Excessive calcitonin, inadequate PTH,
decreased Vita. D, or reduced Ca++
intake results in muscle cramps, and
convulsions.
b. HYPERCALCEMIA
Increased PTH, Vita. D or calcium intake
can cause kidney stones, bone spurs,
and lethargy.

Child vs. Adult

in medication
administration

1. Water %
2. Body service area
3. Type of food
4. Stomach acidity
(infant much less than adult )
5. Enzyme chains not maturity
6. Rate of break down of drug ( growth
&development rate )
TPN replacement for chronic case

Child vs. Adult in

medication
administration (2)

7. % of protein binding & fat

distributions
8. Drug half life
9. Excretion
10. Gastric empty time
11. Eating habits
12. Exercise pattern
13.sexual development

Steps to give medication

1. Identification the child
2. Oral medication ( infantpreschool
school age)
3. Teach the child how to swallowing
( liqide need hr ,Tablet (1/2-1hr)
* Safe storage of medication
* Determination of the correct dosage