Pediatrics

OMS III CLINICAL ROTATION

9. Fluid and Electrolyte Management

Reading Assignment: Nelson Essentials of Pediatrics, 8th Edition, Chapters 32 & 33

Learning Objectives:
A. Dehydration
I. Identify clinical manifestations of dehydration and classify it as mild, moderate, or severe based
on history and physical exam findings
II. List the types of dehydration.
III. Explain the appropriate rehydration method for each type of type of dehydration
B. Derive the following based on the child's weight
I. Fluid bolus
II. Volume deficit
III. Daily maintenance needs
IV. Impact of ongoing losses
C. Evaluate the causes, signs and symptoms of the following electrolyte derangements:
I. Hypernatremia
II. Hyponatremia
III. Hyperkalemia
a. Identify classic EKG findings with hyperkalemia.
IV. Hypokalemia
D. List the causes of metabolic acidosis.
Case 1:
A 12-year-old male with Crohn’s disease is admitted to the inpatient unit for a flare. He has had 12-14 large,
loose stools each day for the past 3 days. He has the following electrolyte abnormalities: sodium of 130
mEq/L, potassium of 3.0 mEq/L, and bicarbonate of 15 mEq/L.

1. What is the most likely source of his metabolic acidosis? Diarrhea is the most likely diagnosis.

2. What are other common causes of metabolic acidosis? Other common causes include renal failure,
lactic acidosis and methanol ingestion.

3. What are the next steps in managing this patient’s metabolic acidosis? The patient needs to receive
fluids and bicarbonate.

Case 2:
You are seeing a 2-year-old male in the emergency room for vomiting and diarrhea. He has been sick for
about 4 days. The mother notes that he has no past medical history, and he is up to date on vaccines aside
from Rotavirus. Over the past day, he has refused to take anything to eat or drink, and the last time he
urinated was about 18 hours ago. Over the past few days, stooling has increased and today he has had 10
loose stools. The mother became worried because it seemed like he didn’t want to wake up from his nap and
brought him in to the ER. On exam, his temperature is 100.4 degrees Fahrenheit, his heart rate is 140 bpm,
blood pressure is 70/40 mmHg, respiratory rate is 40 breaths per minute Oxygen saturation is 97% on room
air. His tongue appears dry and his eyes appear sunken. His extremities are cool, his capillary refill is 4-5
seconds, and he stirs minimally when you examine him.

Review the cart below and answer the following questions

 Chart from Dehydration: Isonatremic,
Hyponatremic, and Hypernatremic
Recognition and Management from
Pediatrics in Review

4. What type of dehydration – mild, moderate, or severe - do you think this patient has?
Based on his clinical signs, the patient likely has severe dehydration.

5. You are selecting fluids to give this patient. He is 15-kg.

a. What fluid would you consider giving a bolus of? How much volume would be in that
bolus and how would you calculate it? Give a bolus of 20 mL/kg  (20)(15) so give 300mL

b. What is his volume deficit? >10% of total body water

c. What is his daily maintenance need?

His daily need is 1000 mL/d plus 50 mL/kg/d for each kilogram, so he will need 1750mL/d.

d. What are ways to replace ongoing losses in dehydration?

The patient could start oral rehydration as well.

6. What would the appropriate fluid resuscitation be for each type of dehydration?
Type of Dehydration Fluid Resuscitation
Mild Oral rehydration solution 5mL every 2 min. with the goal 10mL/kg body
weight for each watery stool

Moderate Oral rehydration solution 50-100mL/kg over 2-4 hours, starting with 5mL
 every 5 min.

Severe IV bolus of 20-60 mL, the continuous infusion is dependent on the

weight of the individual. For example if the pt weighs less than 20 kg
give 1000 mL/d plus 50 mL/kg/d for each kilogram between 10 and 20
kg

Case 3:
You are caring for a 14-year-old male who presented to the ER in severe rhabdomyolysis. He is having
diffuse body aches and chest pain. The nurse brings you the EKG you ordered.

Source:
UpToDate.

7. What is the likely etiology of the EKG findings? Hyperkalemia from the rhabdomyolysis

8. What are the next steps in managing this patient? Next steps in management include fluid
resuscitation and electrolyte imbalance correction.

Case 4:
A mother brings her 5-day-old infant into the ER for concerns that he is less active. She was discharged
1. When you draw labs, what metabolic abnormalities may you expect? I may expect hypernatremia,
indicating dehydration.

2. Complete the following chart to evaluate the causes, signs, and symptoms of each metabolic
abnormality.

Causes Signs Symptoms

Dry mucous membranes, High pitched cries,
Hypernatremia Dehydration, diarrhea, decreased skin turgor inconsolable, lack of
vomiting activity

Excessive water intake Hypotension, Confusion, decreased

Hyponatremia or excessive salt wasting tachycardia, head ache cognition

Cola colored urine, Heart flutters, pain in

Hyperkalemia Crush injuries, burns tachycardia, cardiac kidneys
arrest
Muscle weakness, Paralysis
Diarrhea, diabetic hypoactive bowels,
Hypokalemia ketoacidosis, arrhythmias
hypomagnesemia