# 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 .

no diarrhea and no fever. She has normal renal function. What would her maintenance fluids be? .Calculating Maintenance Fluids The Holliday-Segar Formula Case #1 An 32 kg girl is admitted for elective surgery and is NPO.

5 ml/hr .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.

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 .

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

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 .

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

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 patient’s needs for next 24 to 48 hours Maintenance + Deficit + On-going losses .

K 3. 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 This infant is ~10% dehydrated given the history and PE findings Na 140.7.

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 .

900 mL over 16 hours at 56 mL/hr .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.

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 .

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

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 .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.

or hyper.natremia .Oral Rehydration Therapy Indications – <10% dehydrated – Following initial volume resuscitation Contraindications – >10% dehydrated/circulatory instability – Severe vomiting – Abdominal distention/ absent bowel sounds – Severe hypo.

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 .Oral Rehydration Therapy Examples – Pedialyte.

ANY QUESTIONS ?? .