Fluids & Electrolytes

Pediatric Emergency Medicine

Boston Medical Center
Boston University School of Medicine
 Objectives
· To discuss:

¨ Maintenance Fluids and Electrolyte

Requirements
¨ Types of Dehydration
¨ Management of Dehydration
¨ Electrolyte Abnormalities
 Composition of Body
Compartments
· Total Body Water (TBW)= 50-75% of Total
Body Mass
¨ TBW = Intracellular Fluid (ICF) + Extracellular
Fluid (ECF)

· ICF = 2/3 of TBW

· ECF = 1/3 of TBW -- 25% of body weight

¨ ECF = Plasma (intravascular) + Interstitial fluid
 Body Water
Compartments Related to
Age
80
70
60
50 TBW
40 ICF
30 ECF
20
10
0
0 years 1 year 10 years 20 years
 Regulation of Body Fluids
and Electrolytes
· Mechanism to Regulate ECF
volume
¨ Anti-Diuretic Hormone (ADH)
• Kidney = Increase water reabsorption
• ADH secretion is regulated by tonicity of
body fluids
¨ Thirst
• Not physiological stimulated until plasma
osmolality is >290
Regulation of Body Fluids
and Electrolytes
¨ Aldosterone
• Released from the adrenal cortex
– Decrease circulating volume
– Stimulation by Renin-Angiotensin Aldosterone
axis
– Increase plasma K
• Enhanced renal reabsorption of Na in
exchange for K (>Na = expansion of ECF)
¨ Atrial Natriuretic Factor
• Secreated by the cardiac atrium in
response to atrial dilatation (regulates
blood volume)
• Inhibits Renin secretion
 Daily Maintenance
Requirements
Body Weight 0-10 kg 10-20 kg >20 kg

Total Water 100 ml/kg 1000 ml + 50 1500 ml + 20

Volume ml/kg for each ml/kg for each
kg>10 kg Kg > 20kg
Sodium 3 meq/kg 3 meq/kg 3 meq/kg

Potassium 2 meq/kg 2 meq/kg 2 meq/kg

Chloride 5 meq/kg 5 meq/kg 5 meq/kg

 4cc, 2cc, 1cc rule
· 4 cc for the first 10 kg
· 2 cc for the next 10 kg
· 1 cc for each kg after
¨ Example:
• 27 kg child
– 4 cc for the first 10 kg = 40cc
– 2 cc for the next 10 kg = 20cc
– 1 cc for each kg after = 7 cc
67 cc/hr
 Maintenance
Requirements
· Maintenance Fluids: weight
dependent & age dependent:
· (NS =0.9% Saline =154 meq
Na/liter)

¨ age >2 -3 years: D5 0.5 NS + 20

meq KCl/liter
¨ Up to age 2-3 years: D5 0.2 NS + 20
meq KCl/liter

• D5 = 50 gm/liter = 5 g/dl
• Newborns often require D10 = 100
 Dehydration
· Epidemiology:

¨ One of the most common medical

problems
¨ In the U.S. - 10% of all pediatric
admissions
¨ Worldwide, over 3 million children
under 5 years die from dehydration
Estimation of Dehydration
Mild Moderate Severe
Weight Loss 3-5% 6-9% >10%

Blood pressure Normal Orthostatic Shock

Pulse Normal Increase Tachycardic

Behavior Normal Irritable Lethargic

Membranes Moist Dry Parched

Tears Present Decrease Absent

Cap. Refill 2 seconds 2-4 seconds >4 seconds

Urine SG >1.020 >1.030 Oliguria

 Dehydration
· Classification
¨ Isotonic
• Serum Sodium 130-150 mEq

¨ Hypotonic
• Serum Sodium < 130 mEq

¨ Hypertonic
• Serum Sodium >150 mEq
 Management of
Dehydration
· General Principles:

¨ Supply Maintenance Requirements

¨ Correct volume and electrolyte deficit

¨ Replace ongoing abnormal losses

 Management of
Dehydration
· Oral Rehydration:
¨ Effective for mild and some moderate
dehydrations
¨ Child may be able to tolerate PO
intake
¨ Small aliquots as tolerated
• Mild: 50 cc/kg over 4 hours
• Moderate: 100 cc/kg over 4 hours
¨ 2 types of oral solution
• Maintenance
• Rehydration
 Commercial Oral Solutions
Na mEq/L K mEq/L Cl mEq/L Base CHO %

Maintenance

 Reosol 50 20 50 Citrate Glucose 2

 Ricelyte 50 25 45 Citrate Rice syrup 3

 Pedialyte 45 20 35 Citrate Glucose 2.5

Rehydration

 Rehydralyte 75 20 65 Citrate Glucose 2.5

 W.H.O 90 20 80 HCO3 Glucose 2

For cholera use
 Management of
Dehydration: IV
· Replacement of Fluid Deficit Based on %
Dehydration:
¨ Example: 5 kg child who is 6% dehydrated:
5 x 60cc/kg
• fluid deficit (cc) = wt x % dehydration
• fluid deficit (cc) = wt in kg (1000cc/kg) x
(1/100) estimate of dehydration
• fluid deficit (cc) = wt x 10 x estimate of
dehydration
• fluid deficit (cc) = 5 x 10 x 6
• fluid deficit (cc) = 300 cc
 Management of
Dehydration: IV
¨ Initial: NS or LR 20 cc/kg Bolus in first
hour
¨ Then Remainder of Deficit
• In previous example: total fluid deficit =
300cc for 5 kg child who is 6%
dehydrated = 60cc/kg
• Replacement:
– first hour: 20 cc/kg = 20 x 5 = 100 cc
– replace the rest: 40 cc/kg or 300 - 100 = 200
cc
– The type of fluid used and the rate of infusion
depends on the age and Na status of the
 Hyponatremia
· Predisposing Factors
¨ Diabetes mellitus (hyperglycemia)

¨ Cystic fibrosis

¨ CNS disorders ( SIADH)

¨ Gastroenteritis

¨ Excessive water intake (formula

dilution)
¨ Diuretics (thiazides and furosemide)

¨ Renal disease
 Hyponatremia
· Hyponatremic Dehydration
¨ Hypovolemic Hyponatremic

Dehydration
• High urine output and Na excretion
• Increase in atrial natriuretic factor
¨ Euvolemic Hyponatremic Dehydration
• ADH mediated water retention
¨ Hypervolemic Hyponatremic
Dehydration
• Edematous disorder (nephrotic syndrome,
 Hyponatremia
· Acute Hyponatremia (<24 hours)
¨ Early Onset (Serum Sodium <125 meq/L)
• Nausea
• Vomiting
• Headache
¨ Later or Severe (Serum Sodium <120
meq/L)
• Seizure
• Coma
• Respiratory arrest
 Hyponatremia

· Chronic Hyponatremia (>48 hours)

¨ Lethargy
¨ Confusion
¨ Muscle cramps
¨ Neurologic Impairment
 Hyponatremia
· Management
¨ Na Deficit:
• Na Deficit = (Na Desired - Na observed)
x 0.6 x body weight(kg)
¨ Replace half in first 8 hours and the rest in
the following 16 hours
¨ Rise in serum Na should not exceed 2
mEq/L/h to prevent Central Pontine
Myelinolysis (? Existence in children)
¨ In cases of severe hyponatremia (<120
mEq) with CNS symptoms:
• 3% NaCl 3-5 ml/kg IV push for
hyponatremia induced seizures
– 6 ml/kg of NaCl will raise serum Na by 5 mEq/L
 Hypernatremia
· Hypernatremia leads to
hypertonicity
¨ Increase secretion of ADH
¨ Increase thirst
· Patients at risk
¨ Inability to secrete or respond to ADH
¨ No access to water
 Hypernatremia
· Etiology
¨ Pure water depletion
• Diabetes insipidus (Central or Nephrogenic)
¨ Sodium excess
• Salt poisoning (PO or IV)
¨ Water depletion exceeding Na depletion
• Diarrhea, vomiting, decrease fluid intake
¨ Pharmacologic agents
• Lithium, Cyclophosphamide, Cisplatin
 Hypernatremia
· Signs and symptoms
¨ Disturbances of consciousness
• Lethargy or Confusion
¨ Neuromuscular Irritability
• Muscle twitching, hyperreflexia
¨ Convulsions
¨ Hyperthermia
• Skin may feel thick or doughy
 Hypernatremia
· Management
¨ Normal Saline or Ringer lactate to restore volume
¨ Hypotonic solution (D5 1/4 NS) to correct calculated
deficit over 48 hours
• Water Deficit
– Normal body H20 - Current body H20
• Current body water
– 0.6 x body weight (kg) x Normal Na/Observed Na
• Normal Body water
– 0.6 x body weight (kg)
¨ Decrease Na concentration at a rate of 0.5 mEq/hr
or ~ 10 mEq/day: Faster correction can result in
Cerebral Edema
 Potassium

· Most abundant intracellular cation

· Normal serum values 3.5-5.5 mEq

· Abnormalities of serum K are potentially

life-threatening due to effect in cardiac

function
 Hypokalemia
· Diagnosis
¨ Symptoms
• Arrhythmias
• Neuromuscular excitability (hyporreflexia,
paralysis)
• Gastrointestinal (decreased peristalsis or ileus)
¨ Serum K < 3mEq/L
¨ ECG:
• Flat T waves
• Short P-R interval and QRS
• U waves
 Hypokalemia
Nutritional GI Loss Renal Loss
Endocrine
Poor intake Diarrhea Renal tubular acidosis Insulin
therapy
IVF low in K Vomiting Chronic renal disease Glucose
therapy
Anorexia Malabsorbtion Fanconi's syndrome DKA
Intestinal fistula Gentamicin,
Hyperaldosteronism
Laxatives Amphotericin Adrenal
adenomas
Enemas Diuretics
Mineralocorticoids
Bartter's syndrome
 Hypokalemia
· Management:
¨ Cardiac Arrhythmias or Muscle
Weakness
• KCl IV (cardiac monitor)
¨ PO K - Depend of etiology
• Hypophoshatemia = KPO4
• Metabolic acidosis = KCl
• Renal tubular acidosis = K citrate
 Hyperkalemia
· Differential Diagnosis
¨ Pseudohyperkalemia - from blood
hemolysis
¨ Metabolic Acidosis

¨ Chronic Renal Failure

¨ Congenital Adrenal Hyperplasia

• Females = Usually Dx at birth - Ambiguous
Genitalia
• Males = Dehydration, hyponatremia,
hyperkalemia
 Hyperkalemia
· Diagnosis:
¨ Symptoms
• Cardiac Arrhythmias
• Paresthesias
• Muscle weakness or paralysis
¨ ECG
• Peaked T waves
• Short QT interval (K>6 mEq)
• Depressed ST segment
• Wide QRS (K>8 mEq)
 Hyperkalemia
· Management
¨ Close cardiac monitoring
¨ Life -threatening hyperkalmia
• Intravenous Calcium - rapid onset, duration<
30 min
• NaHCO3 or glucose and insulin
¨ Ion exchange resins
• Sodium polystyrene sulfonate (Kayexelate)
– PO or Enema
¨ Hemodyalisis