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Pediatric Fluid and Electrolyte Therapy
Pediatric Fluid and Electrolyte Therapy
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Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Saint Barnabas Medical Center,
Piscataway, New Jersey
Managing fluids and electrolytes in children is an important skill for pharmacists, who can play an important
role in monitoring therapy. Fluid therapy is divided into maintenance, deficit, and replacement requirements.
The Holliday-Segar equation remains the standard method for calculating maintenance fluid requirements.
Accounting for deficits when determining the fluid infusion rate is an important factor in treating dehydrated
patients; deficit fluid is generally administered over the first 24 hours of hospitalization. Maintenance electrolyte
requirements must be taken into account, with particular attention paid to sodium requirements, as recent
evidence suggests that sodium needs in hospitalized children are higher than originally thought. Fluid therapy
can also have an impact on drug therapy. Hydration status can affect the dose needed to achieve therapeutic
concentrations, and dehydrated patients may be at risk for toxicity if standard doses of drugs with high volumes
of distribution are used. Monitoring fluid and electrolyte therapy is an important role of the pediatric pharmacist.
losses. Thus, while the Holliday-Segar method After clinical signs have been observed, the de-
actually estimates kilocalories lost, it is esti- gree (%) of dehydration should be determined.10
mated that a loss of 1 kilocalorie requires 1 mL This is calculated by dividing the difference be-
in replacement, so the kilocalorie estimate is an tween the pre-illness and illness weights by the
efficient target for fluid requirements. pre-illness weight, then multiplying by 100 (Table
Other methods of estimating maintenance fluid 5). For example, a 10-kg patient who has lost 1 kg
requirements exist, including those using body is 10% dehydrated. Every 1 kg of weight lost is
surface area and basal calorie requirements. Gen- equivalent to 1 L of fluid loss. The degree of dehy-
erally these equations involve more calculations, dration calculated should always be compared to
and the basal calorie requirement method requires the clinical signs, which may be better indicators
an indirect calorimeter, which is an expensive of hydration status and are also especially useful
piece of equipment. The Holliday-Segar method when a pre-illness weight is unknown.
is usually preferred due to its ease of calculation; Once the degree of dehydration is established,
however, the other methods are employed in the type of dehydration, defined by serum so-
some instances. The Holliday-Segar method may dium concentrations, needs to be determined.
be simplified by estimating the fluid requirements Most dehydrated patients have an isotonic
in rate required per hour. This equation, also listed dehydration.10 A serum sodium concentration
in Table 2, arrives at similar volumes of fluid as of less than 135 mEq/L is considered hypotonic
the traditional Holliday-Segar equation. dehydration, while greater than 145 mEq/L is
considered hypertonic dehydration.
Deficit Fluids Patients with mild to moderate dehydration
Fluids lost prior to medical care are termed may be rehydrated with oral therapy, even if
“deficit fluids.” Examples of clinical situations diarrhea and vomiting continues.10,11 A volume of
where a patient would present with a deficit fluid 50 mL/kg over 4 hours should be given in small
include gastrointestinal illness with vomiting aliquots for mild dehydration.11 Patients with
and diarrhea, traumatic injuries with significant moderate dehydration should be given 100 mL/
blood loss, and inadequate intake of fluids over kg over 4 hours.11 The oral rehydration solutions
a period of time. available commercially generally have appropri-
Deficit fluids, like maintenance fluids, are most ate amounts of carbohydrates and electrolytes,
easily handled by approaching the needs of the usually about 140 mmol/L of carbohydrate, 45
patient in a systematic manner. Clinical signs of mmol/L (mEq/L) of sodium, and 20 mmol/L
dehydration should be taken into consideration (mEq/L) of potassium.10 Liquids such as milk,
first, as they can provide useful insight into the juice, soda, tea, and sports beverages do not
fluid needs of the patient. One clinical sign of contain appropriate amounts of carbohydrates
dehydration which can be of use is weight loss. and electrolytes to meet the needs of dehydrated
Most young children visit their pediatricians fre- patients, and should not be used for oral rehydra-
quently, and a relatively recent pre-illness weight tion.11 However, infants who are fed human milk
will be on record. Other clinical signs include may continue to breastfeed if they have diarrhea.10
increased thirst, dry mucous membranes, and Patients with hypotonic or isotonic dehydra-
decreased urine output (Table 3).10 Clinical signs tion are given fluids using the same technique to
usually correlate fairly well with the degree of calculate fluid amount and rate (Table 5). Rehy-
dehydration, thus making them an important dration is divided into three phases. In phase I,
part of the physical exam for a dehydrated pa- a bolus of fluid is given in order to restore blood
tient (Table 4). volume to ensure adequate perfusion of critical
organs, such as the brain. Bolus fluids should be fluid shifts, which can result in cerebral edema
isotonic; either normal saline or lactated ringers and convulsions.12 For this reason, serum sodium
solution is used at a volume of 20 mL per kg, should be corrected by no more than 10 mEq/L/
given over 60 minutes.11 Repeat boluses are given day.12 Serum sodium should be checked frequent-
if necessary to maintain adequate perfusion. ly (every 2 to 4 hours) to ensure that rehydration
Isotonic fluids are used because they provide is not occurring so quickly as to cause an overly
rapid volume expansion in the plasma and ex- rapid decrease in serum sodium. The fluid used
tracellular fluid.11 should be hypotonic, such as 5% dextrose with
When determining the amount of fluid to be 0.2% sodium chloride.12
administered in phases II and III, the fluid vol-
ume given during phase I should be subtracted Replacement Fluids
from the deficit fluid. Phase II is given over 8 Replacement fluids are defined as those given
hours.11 The amount of fluid is equivalent to one to meet ongoing losses due to medical treatment.
third of the daily maintenance plus one half of the Examples of clinical situations where replace-
remaining deficit. During phase II, 5% dextrose ment fluids are needed include patients with
with 0.45% sodium chloride should be used, chest tubes in place, uncontrolled vomiting,
with 20–30 mEq/L of potassium chloride added continuing diarrhea, or externalized cerebrospi-
only if the patient has voided. Phase III is given nal fluid shunts. Each of these examples demon-
over 16 hours. The amount of fluid in phase III is strates a situation where there is an ongoing loss
equivalent to two thirds of the daily maintenance which would not be met by administering only
plus the remaining deficit. During phase III, 5% maintenance fluids. Replacement fluids differ
dextrose with 0.2% sodium chloride should be from deficit fluids in that they are ongoing, as
used, again with 20–30 mEq/L of potassium opposed to a loss of fluid that occurred prior to
chloride added only if the patient has voided. receiving medical treatment.
Generally speaking, phases II and III are simply
maintenance fluid plus deficit fluid, given over MAINTENANCE ELECTROLYTES
24 hours, with half of the deficit fluid given in
the first 8 hours, and the second half of the deficit Concentrations of electrolytes are determined
fluid given in the last 16 hours (Table 6). in large part by renal function,7 making con-
The approach to patients with hypertonic de- sideration of the patient’s clinical status vitally
hydration is quite different, due to the hyperos- important when considering electrolyte require-
molar state of their circulating blood. The deficit ments in children. An anuric patient will recycle
fluid volume should be added to the maintenance sodium and potassium, making supplementation
fluid volume needed for 48 hours, and the total generally unnecessary. Any renal dysfunction
should be administered over 48 hours. Admin- requires frequent electrolyte monitoring. Elec-
istering the deficit fluid faster causes osmotic trolyte replacement in intravenous fluids gener-
J Pediatr Pharmacol Ther 2009 Vol. 14 No. 4 • www.jppt.org 207
JPPT Meyers RS
3% 6% 9%
Older child
(30 mL/kg) (60 mL/kg) (90 mL/kg)
5% 10% 15%
Infant
(50 mL/kg) (100 mL/kg) (150 mL/kg)
ally includes sodium, potassium, and chloride. of these cases, symptoms of hyponatremia were
Chloride needs, which are 5 mEq/kg/day,11 are explained as side effects of drugs. The potential
usually met by administering sodium and potas- for hyponatremia or hypernatremia emphasizes
sium as sodium chloride and potassium chloride the need for close monitoring of serum sodium in
salts. Requirements for sodium are 3 mEq/kg/ hospitalized children receiving intravenous fluid
day, while the requirements for potassium are 2 therapy, particularly in the post-operative period.
mEq/kg/day (Table 7).6,11
It is important to consider maintenance electro- ELECTROLYTE ABNORMALITIES
lyte requirements when choosing a maintenance
fluid for a child. For the most part, practitioners Severe Hyponatremia
can choose from commercially available products Patients with a serum sodium of less than 125
to adequately fulfill maintenance needs. mEq/L are at high risk for serious central nervous
For most children, a 5% dextrose solution with system symptoms; lethargy followed by seizures
0.2% sodium chloride provides the estimated is common.16 Due to the emergent nature of this
needs of sodium when used as a maintenance condition, boluses with hypertonic saline, usu-
fluid. However, there has been recent attention ally 3% sodium chloride, are warranted. The
in the literature to the potential for causing hypo- volume of 3% sodium chloride is determined by
natremia when using 0.2% sodium chloride.13,14 the sodium deficit, which is calculated using the
The concern arises from the belief that the 3 mEq/ following equation17:
kg/day of sodium proposed as maintenance by (desired serum sodium concentration – current
Holliday and Segar is only enough for healthy serum sodium concentration) × 0.6 × (weight in kg)
children, and that acutely ill children may have Multiplying the sodium deficit by 2 gives the
higher requirements. 6 Due to this concern, many volume of 3% sodium chloride needed. This is
practitioners use 0.45% sodium chloride in main- generally given over a few hours, with serum
tenance fluids. Some even argue the need for sodium checks done throughout in order to avoid
isotonic fluid.14 hypernatremia. Serum sodium should not be cor-
Recently, two pediatric deaths from hypo- rected faster than 12 mEq/L within 24 hours
natremia have been reported in post-operative
situations.15 In one case, the child received an Hyperkalemia
infusion of 5% dextrose at an incorrect infu- Hyperkalemia is usually defined as a serum
sion rate after an outpatient tonsillectomy and potassium of greater than 6 mEq/L, as this is
adenoidectomy. The subsequent symptoms of where changes in the electrocardiogram are usu-
hyponatremia were mistaken for a dystonic ally seen.18 Before deciding to treat hyperkalemia,
reaction from promethazine, and the child was it is important to discover how the blood was
treated with diphenhydramine. The second case acquired. If the blood came from a heel stick,
involved a patient who had surgery to repair a as is frequently done in infants, cell lysis due to
coarctation of the aorta. The patient became hy- the trauma of the needle can cause intracellular
ponatremic after receiving ethacrynic acid, and potassium to enter the serum locally, leading to
it was unclear whether the patient received the falsely elevated serum potassium.
subsequent order for a sodium chloride infusion. Hyperkalemia can be treated with a variety of
On the second post-operative day, the patient was medications. There are multiple mechanisms for
unarousable, and this was confused for a side ef- decreasing serum potassium, and medications
fect of receiving hydromorphone. Later, seizures are chosen based upon their mechanism and
were misperceived as fidgeting from pain. In both the level of urgency of the clinical situation. In
emergencies, agents which cause a rapid influx may have their fluids decreased and eventually
of potassium intracellularly are useful as they stopped once they tolerate oral hydration.
provide an acute decrease in serum levels. These When monitoring patients who are being
medications include insulin and beta adrenergic treated with maintenance and deficit fluids for
agonists such as albuterol.19 Sodium bicarbonate dehydration, the most important monitoring pa-
is sometimes used to treat hyperkalemia, but its rameters are those which defined the dehydration
mechanism in lowering serum potassium levels in the first place, such as skin turgor, urine output,
is unknown and generally not immediate.19 Other
Table 6. Monitoring Parameters for Parenteral Fluid
medications help by increasing elimination of Therapy
potassium from the body. Sodium polystyrene
sulfonate is an exchange resin which exchanges Oral intake
sodium for potassium in the gut;19 its use is Weight changes
generally for less emergent situations. Diuretics Urine volume and specific gravity
such as furosemide can also be used to increase
Physical signs and symptoms of dehydration (see Table 4)
potassium excretion into the urine, however,
diuretics should be used cautiously, as the re- Serum electrolytes
sultant volume depletion can cause decreased
potassium excretion.19 Calcium is used in symp- and thirst (see Table 4 for a complete list). Monitor-
tomatic patients for cardioprotective effects, as it ing patients’ weights can be especially important,
antagonizes the membrane effects of potassium.19 particularly in infants, as younger patients tend
Frequently, long-term treatments are needed to to present with more significant weight loss when
control the cause of the hyperkalemia. dehydrated. Urine specific gravity can also be
used to assess hydration status.
MONITORING FLUID AND ELECTROLYTE Another monitoring parameter which the phar-
THERAPY macist can impact is the amount of fluid used in
the patient’s medications. For example, if a paren-
Determining an initial fluid rate for children teral antibiotic is being mixed in 100 mL and given
based upon their needs is essential. However, four times per day, this could provide a significant
once therapy is begun, appropriate monitoring is amount of fluid to the patient. Ensuring that the
necessary due to the frequently changing needs patient is not getting an excessive amount of fluids
of a hospitalized patient. The first parameter in medications can help prevent overhydration.
for monitoring is oral intake (Table 6). Gener- The fluid in which the medication is being mixed
ally speaking, the oral route for providing fluid should also be taken into account. A medication
therapy is preferred as soon as it is clinically mixed in a large volume of 5% dextrose could
indicated, as any intravenous administration put the patient at risk for hyponatremia due to
brings with it the risk of infection. Patients who the administration of too much dextrose, which
are not allowed anything by mouth for a short amounts to free water. Monitoring serum elec-
time, such as for an uncomplicated surgery, and trolytes is necessary if the patient has electrolyte
for whom only maintenance fluids are required, abnormalities, but when examining hydration, the