Fluids, Electrolytes, and Dehydration

2.1
Mark Davenport and S. H. S. Syed

Appreciation of basic physiology is the key to safe preoperative resusciation enabling

appropriate surgery. Administration of appropriate postoperative fluid regimens
ensures optimal outcome.

2.1.1
Normal Fluid Physiology

Most of us are made up predominantly of water.

~60% of body weight (BW) i.e. total body water ~42L in 70kg man.
This is divisible into two compartments:
(a)Intracellular (~40% BW) high K+, high [proteins]. Regulated by active Na+/K+
pump at cell membrane.
(b) Extracellular (~20% BW) high Na+, high Cl

Plasma Intravascular osmotic pressure maintained by albumin, and regulated by cap-

illary membrane (i.e., Starlings Law oncotic pressure and pore size).
Lymph
Connective tissue, bone water, CSF, etc .
Interstitial (~5%)
N.B. transcellular compartment includes the mythical third-space (<2%).
(NB circulating blood volume (65mL/kg) is made up of not only plasma but red cell
mass as well.)

M. Davenport (*)
Paediatric Surgery Department, Kings College Hospital, London, UK

C. K. Sinha and M. Davenport (eds.), Handbook of Pediatric Surgery, 9

DOI: 10.1007/978-1-84882-132-3_2.1, Springer-Verlag London Limited 2010
10 M. Davenport and S. H. S. Syed

2.1.2
Age-Related Changes

Total body water (80% in neonate vs. 60% in adult)

ECF ICF (almost parity in newborn vs. 3:1 in adult)
Surface area/body mass ratio

2.1.3
Normal Fluid and Electrolyte Requirements

In general, normal neonatal fluid prescription depends on (a) body weight and (b) day of
life (Tables2.1.1 and 2.1.2).

Basic prescription is 100mL/Kg/day (up to 10kg). (Beyond neonatal period.)

Table2.1.1Estimated fluid requirements in childhood

Day of life ml/kg/day

Premature infant 1st 60150

2nd 70150
3rd 90180
>3rd Up to 200
Term infant 1st 6080
2nd 80100
3rd 100140
>3rd Up to 160
Child >4weeks of age, 10kg 100
Child 1020kg 1L+50mL/kg/day for each kg over 10
Child >20kg 1.5L+20mL/kg/day for each kg over 20

Table2.1.2Sample fluid requirements (by body weight)

Body weight Calories required Maintenance Maintenance
(kcal/day) (mL/day) (mL/h)

3 300 300 12
5 500 500 20
10 1,000 1,000 40
20 1,500 1,500 60
45 2,000 2,000 80
70 2,500 2,500 100
2.1 Fluids, Electrolytes, and Dehydration 11

2.1.4
Insensible Fluid Loss

This is an obligate fluid loss, largely from radiation and evaporation related to body sur-
face area and the work of breathing.
~300mL/m2/day

weight(kg) height(m)
Body surface area (m2) = 3,600

2.1.5
Postoperative Fluid Regimens

The composition (if not the volume) of postoperative maintenance fluid prescription has recently
come under scrutiny (at least in the UK), and is changing from one using predominantly low or
no saline solutions (e.g., 5% dextrose, 4% dextrose/0.18% saline, described wrongly as hypo-
tonic) to using high saline solutions (i.e., 0.9% saline, described as isotonic), on the basis that
the former regimens lead to hyponatremia, whereas use of the latter seldom leads to hyperna-
tremia (although it gives far more than normal daily requirement of Na Cl Table2.1.3).
Further, because of the metabolic response to surgery (see Chap. 2.2), there is inap-
propriate secretion of ADH, and many units will prescribe only two-thirds of the calcu-
lated maintenance volume in the first 2448h.
Finally, consider ongoing losses from drains, NG tubes, stomas, and fistulas (Table2.1.4).
In principle, replace Like with Like. In most cases, this is a ml. for ml. replacement with an
isotonic (0.9%) saline solution (20mmol of K+/L).

Table2.1.3Sample electrolyte requirements (by body weight)

Na (mmol/kg) K (mmol/kg)

Neonate (preterm) 46 23
Neonate (term) 10kg 3 2
1020kg 12 12
20Adult 12 1

Table2.1.4Electrolyte content of gastrointestinal secretions

Secretion Na+ (mmol/L) K+ (mmol/L) Cl (mmol/L) HCO3 (mmol/L)

Saliva 44 20 40
Gastric 20120a 10 100
Bile 140 5 100 40
Pancreas 140 5 70 70110
Small intestine 110120 510 90130 2040
Depends on pH and therefore reciprocal with H
a +
12 M. Davenport and S. H. S. Syed

Table2.1.5 illustrates composition of commonly available intravenous fluids.

2.1.6
Dehydration

 Dehydration may be thought of as contraction in predominantly the ECF

compartment because of the relative loss of fluids and sodium.
Is referred to in terms of % body weight loss

One principal cause of dehydration is excess intestinal losses due to diarrheal illness, and
it is a cause of death in >1.5 million children/year. It is important that a pediatric surgeon
has a basic working knowledge of diarrheal illness, as it is so common both in the com-
munity (and therefore on the ward).

Infective Causes Surgical Causes

Viruses Intestinal obstruction

Rotavirus Appendicitis
Calcivirus (incl Norovirus) Intussusception
Astrovirus Fistula losses (also stomas)
Adenovirus
Bacteria
Campylobacter spp
Salmonella spp
E. coli
Clostridium difficle
Shigella spp
Protozoa
Giardia lamblia
Crypotosporidium
Entamoeba histolytica
Table2.1.5Intravenous and oral rehydration solutions
Osmolarity (mOsm/L) Glucose (mmol/L) Na (mmol/L) Cl K HCO3 Notes

Intravenous solutions (crystalloid)

Lactated Ringers1 273 130 110 4 25 Lactate Ca 2+
Hartmanns2 278 131 111 5 29 Lactate, Ca 2+
0.9% NaCl normal saline 308 154 154
Dextrose (5%) 252 300 5g/L=170kcal/L
D5+0.45% NaCl 454 300 77 77
2.1 Fluids, Electrolytes, and Dehydration

D4+0.18% NaCl 284 240 30 30 Not available in UK

Intravenous solutions (Colloids)
Haemaccel 293 145 145 5 Gelatin (35g)
Gelofusine 308 154 125 <0.4 Gelatin (40g)
Hetastarch 310 154 154 Starch (60g)
Pentastarch 326 154 154 Starch (100g)
Albumin (4.5%) 300 <160 136 <2
Oral rehydration solutions
WHOORS 330 110 90 80 20 30
Pedialyte 270 140 45 35 20 30

Dioralyte 90 60 60 20 Common in UK
Electrolade 111 50 40 20
(N.B. CHO=3.4kcal/g, compared with fat 9kcal/g)
1
Sydney Ringer (18361910) British physiologist and physician at University College, London.
2
Alexis Hartmann (18981964) American pediatrician, modified original Ringer solution by the addition of lactate to treat acidosis in children.
13
14 M. Davenport and S. H. S. Syed

2.1.7
Management

In general, the treatment aims to restore normal fluid and electrolyte balance safely without
precipitating complications (e.g., hypernatremic convulsions). The key is to recognize the
degree of dehydration (expressed in terms of % body weight loss i.e., 5% of a 20-kg child
implies a deficit of 1,000mLs. of fluid) (Table2.1.6) and then the type as defined by the
plasma sodium level (Table2.1.7).
Aim for rehydration within 1224 h, unless hypernatremia is documented
(Na >150mmol/L), where the period should be lengthened to ~3648h. In general, oral
rehydration solutions (Tables2.1.5 and 2.1.6) should be used whenever possible (may be
defined as presence of a functioning GI tract). Intravenous resuscitation may well be
required for more severe episodes of dehydration, particularly where there is a shock-like
state and fall in CBV.

Table2.1.6WHO classification of dehydration

No dehydration Mild moderate Severe
Adult <3% 39% >9%
Child 5% 10% 15%
Mental status Alert Restless, listless Lethargic, comatose
Thirst Normal Thirsty Unable to drink
CVS Normal pulse/BP Tachycardia, Tachy/brady,
CRT >2s CRT >>2s
Respiratory Normal Rate Inc rate and volume
Extremities Normal Cool Cold, mottled
Mucous membranes Moist Dry Dry
Skin fold Immediate recoil Delayed (>2s) >2s
Urine output Normal Diminished Absent
Management of nonsurgical dehydration
Encourage normal ORS IV initially
diet and fluids 3080mL/h e.g., 20mL/kg
NaCl (0.9%)
Consider via NG
tube if failing.
REASSESS
CRT capillary refill time
ORS oral rehydration solution (see Table2.1.5)
2.1 Fluids, Electrolytes, and Dehydration 15

Table2.1.7Types of dehydration
Isotonic 130150mmol/L
Hypotonic <130mmol/L
Hypertonic >150mmol/L

2.1.8
Specific Electrolyte Problems

2.1.8.1
Potassium

(Normal 3.55.5mmol/L variability in neonates)

Hyperkalemia 5.5 mmol/L NB-beware factitious result due to hemolysis

Surgical Causes
Dehydration, renal failure, transfusion, tumor lysis syndrome, rhabdomyolysis.
Signs
ECG: tall tented T waves, PR interval QRS complex duration
Treatment
Calcium resonium (oral or rectal) cation exchange resin
Calcium gluconate (100 mg/kg, IV if >7 mmol/L) myocardial membrane
stabilization
Dextrose/Insulin IV
Salbutamol (IV or inhaled)

2.1.8.2
Hypokalemia

Surgical Causes
Fistula, dehydration. Aldosterone-secreting tumors.
Signs
ECG: (less obvious changes) flat T waves, U waves, AV conduction defects.
Treatment
(a)Slow K+replacement (do not exceed KCl 0.51 mmol/kg/h IV, unless on ECG
monitor)
16 M. Davenport and S. H. S. Syed

2.1.8.3
Calcium

(Normal total 2.02.5mmol/L8.510.2mg/dL)

(Normal ionized 1.01.25mmol/L45mg/dL)
Most is stored and relatively fixed in bone. Serum calcium is made up of different com-
ponents (bound to albumin (~40%) and complexed with bicarbonate (<10%) and free ions
(~50%)). Ionized calcium is the active part and is <1% of total. Calcium balance is regu-
lated by parathormone and acid/base balance.

2.1.8.4
Hypocalcemia (always check magnesium levels additionally)

Usually neonates

Surgical causes
Chronic renal failure (e.g., PUV), postthyroidectomy, pancreatitis, malabsorption,
Di George syndrome, and CHARGE syndrome.
Signs tetany,3 i.e., muscle irritability.
Chvostek 4 twitching of facial muscles by tapping facial (VII) nerve.
Trousseau inflation of BP cuff causes carpal spasm (main daccoucheur hand
of the obstetrician/deliverer)
Treatment
Calcium (10%) gluconate (IV)
Calcium supplements (oral)
Vitamin D metabolites
Hypercalcemia
Usually children

Surgical causes
MEN (types I, II), Chronic renal failure, parathyroid tumors, hyperthyroidism,
rhabdomyosarcoma, neuroblastoma, metastatic disease.
Signs
Stones, Bones, Psychic groans, Abdominal moans, i.e., renal calculi, osteoporosis,
bone cysts, psychiatric manifestations, weakness, confusions, pancreatitis, peptic ulcers.
Treatment
Saline rehydration (with furosemide diuresis)
Calcitonin
Bisphosphonates, etc.

3
Frantisek Chvostek (18351884), Austrian physician.
4
Armand Trousseau (18011867) French physician.
2.1 Fluids, Electrolytes, and Dehydration 17

2.1.9
AcidBase Imbalance

2.1.9.1
Concepts

Definition Acid H+ donor Base H+ acceptor

Cation is a +ve ion Anion is a ve ion

pH=log10 [H+]

Neutral pH at 37C=6.8
Normal blood pH=7.4 (H =40nmol/L) (range 7.27.6)
+

Normal intracellular pH=7.0 (H =100nmol/L)+

Anion gap difference between summated anions and cations there is always more of
the latter owing to unmeasured anions (e.g., [protein]). An elevated anion gap is usually
due to an increase in [lactate], [butyrate] and others.
Normal is up to 30mmol/L (but depends on what is being measured),

Key Equations

Henderson5 equation
[H+]+[HCO3] [H2CO3] [CO2] + [H2O]
HendersonHasslebalch6 equation
[HCO3 ]
pH=pK+log
[CO2]

2.1.10
Base Excess (or Deficit)

Definition the quantity of base (acid) required to return the plasma invitro to a normal
pH under standard conditions.
Normal body equilibration is maintained by a series of buffer systems.

(a) Chemical bicarbonate, phosphate, protein

(b) Respiratory elimination of CO2
(c) Renal elimination or retention of bicarbonate

5
Lawrence J. Hendersen (18781942) American biochemist.
6
Karl A. Hasslebalch (18741962) Danish chemist.
18 M. Davenport and S. H. S. Syed

2.1.11
Abnormal AcidBase States

Metabolic Acidosis [H+] [HCO3] [BE]

Multiplicity of causes, but can be subdivided on the basis of change in anion gap.
Thus, the subdivisions are:

Normal anion gap

Loss of base
Renal loss of bicarbonate in renal tubular acidosis.
Fistula loss of bicarbonate (pancreatic)
Increased anion gap
Tissue hypoxia anerobic metabolism [lactate ] + [H ]
+

Ketoacidosis diabetic

2.1.11.1
Treatment

(a) Correct the underlying problem

(b) Sodium bicarbonate (4.2% IV) infused over 30min.
(c) Ensure ventilation adequate to excrete excess CO2

N.B. give half calculated dose repeat blood gas

Metabolic Alkalosis [H+] [HCO3] [BE]

This is much less common in pediatric practice. Causes include

Loss of acid
Vomiting of HCl e.g., pyloric stenosis
Loss of acid stools chronic diarrhea
Loss of chloride
Chronic use of diuretics
Renal perfusion impairment with changes in renin/aldosterone axis.
Dehydration, cirrhosis
Hypokalemia causes hydrogen ion exchange in kidney
Contraction alkalosis as the body fluids are alkali, dehydration causes a fall in total
body water and concentration of electrolytes, hence pH.
2.1 Fluids, Electrolytes, and Dehydration 19

2.1.11.2Treatment

(a) Treat the underlying cause

(b)Often simple correction of fluid and saline deficit will allow restoration of
homeostasis.

Base deficit (mmol/L)body weight (kg)0.3=mmol/L of HCO3 required for full

correction

Further Readings

1. Holliday MA, Ray PE, Friedman AL (2007) Fluid therapy for children: facts, fashions and
questions. Arch Dis Child 92:54650
2. Word Health Organisation (2005) The treatment of diarrhoea: a manual for physicians and
other senior health workers. Geneva, Switzerland, 4th revision
http://www.springer.com/978-1-84882-131-6