Professional Documents
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fluids
Osmolality
– A measure of all solute particles per
weight of solvent, including:
impermeable: Na+, Cl-, mannitol, or glucose
permeable: urea, ethanol
Tonicity
– Measure of the “effective osmols”
(impermeable) in a particular weight of
solvent
– Effective Osm: determined by solutes
that hold water in the ECC: (Na, glucose,
not urea)
– H2O moves across cell membrane from
“low” tonicity to “high” tonicity
ICF & ECF Relationship
K+ 140 meq/L
280 milliosmoles Na+ 150 meq/L
300 milliosmoles/L
Low osmolality outside the cell = swelling
H2O
K+ 140 meq/L
280 milliosmoles/L Na + 120 meq/L
240 milliosmoles/L
Rupture
The Rules of the Road
Cells require adequate circulation (vascular
volume) and a stable isoosmotic milieu to
function
Maintenance fluid has been calculated by
understanding:
– Metabolic rate
– Body size
It assumes:
– All homeostatic mechanisms are intact
– Lungs and kidneys are functional and
there is adequate circulating volume
BUT…
The Rules of the Road…..
2. Deficit
3. Ongoing losses
Concepts
Electrolyte requirements:
– Na+: 2.5-3.0 mEq/100 kCal/day
– K+: 2.0-2.5 mEq/100 kCal/day
– Cl-: 4.5-5.5 mEq/100 kCal/day
Water Electrolytes
1. Maintenance
2. Deficit…..
Deficit Therapy-Approach
Dehydration:
– refers to a negative body water or water
balance
– No definite laboratory test will assess this
Assessing % dehydration depends
upon:
– Bedside examination & clinical findings
– Knowledge of prior “well” weight
– Signs & symptoms
Deficit Therapy
Replacement
Initial IV fluid bolus as needed (NS)
Calculate remaining deficit
– Total deficit- fluid bolus vol
– Replace ½ in first 8 hrs
– Replace remainder in next 16 hrs
– Do not forget to add maintenance
2. Osmolar Disturbance
Not appropriate:
Cola 700 2 0 13 750
Apple juice 690 3 32 0 730
Chicken broth 0 250 8 0 500
Hyponatremia
USUALLY means
Serum osmolality is below normal except for
Hyperlipidemia
Hyperglycemia/mannitol - which adds osmoles
Na+ Lipid measured at
140 meq/L 130 meq/L
because total
Na+ aliquot
140 meq/L is used to divide
even though
Na+ is only
distributed in
the water, not
the lipid
TABLE VIII
body wt
HYPONATREMIA body wt
Wt neutral or slightly
Deficit of total body water Excess total body sodium
and larger deficit of total body Excess total body water and larger excess of total body
sodium water
ECF volume depletion Modest ECF volume excess ECF volume excess
(No edema) (edema)
Urinary sodium Urinary sodium Urinary sodium Urinary sodium Urinary sodium
concentration concentration concentrations concentration concentration
>20 meq/l <10 meq/l >20 meq/l <10 meq/l >20 meq/l
NORMONATREMIA
Berl T,, et al. Kidney Int 10:117, 1976
Hyponatremic dehydration
5% of all dehydration
Usually occurs with a child who has high GI
losses accompanied by water replacement
(Jello/pop, etc.)
Water shifts into the intracellular space to balance
osmoles, so child looks sicker since ECF is
compromised
Causes significant neurological problems as brain
swells Seizures
– If Na <120 meq/L - can cause permanent myelinolysis
If Na is above 120 meq/L
Replace intravascular volume with isotonic
solution
Calculate Na deficit
– desired Na - measured Na X TBW
– (TBW = 0.6 X body wt.)
Use D5 1/2 NaC1 = 75 meq/liter of Na to
replace deficit
– Do not change serum more than 0.5-1 meq/L/hr
– Add in maintenance +/- potassium
Hyponatremia: Correction
Low total body sodium Normal total body sodium Increased total body sodium
Renal losses Extrarenal losses Renal losses Extrarenal losses Primary hyperaldos-
Osmotic diuresis. Excess sweating. Nephrogenic Respiratory and teronism. Cushing’s
Mannitol, glucose, Diarrhea and/or diabetes insipidus. normal insensible Syndrome. Hypertonic
urea vomiting in Central diabetes losses dialysis. Hypertonic
children. insipidus. sodium bicarbonate.
Hypodipsia and Sodium chloride tablets.
partial diabetes
insipidus.
Iso- or Hypotonic Hypertonic urine Hypo-, Iso-, or Hypertonic urine Iso- or Hypertonic
urine (Urinary (Urinary Na+<10 Hypertonic urine (Urinary Na+ urine (Urinary Na+ >20
Na+>20 meq/l) meq/l) (Urinary Na+ variable) variable) meq/l)
Maintenance
Deficit
Ongoing losses….
Ongoing Losses:
Need Replacement
Electrolyte concentration of various body fluids
Fluid Na K C1 Protein
(mEq/l) (mEq/l) (mEq/1) (g/dl)
20-80 5-20 100-150 -
Gastric
Pancreatic 120-140 5-15 40-80 -
Small Bowel 100-140 5-15 90-130 -
Bile 120-140 5-15 80-120 -
Ileostomy 45-136 3-15 30-115 -
Diarrhea 10-90 10-80 10-110 -
Burns 140 5 110 3-5
“Third space”
fluid 140 5 110 Variable
Summary
Cells need adequate circulating volume
to survive: always assess and maintain
adequate vascular volume which is part
of the extracellular space