Student Lecture Presentation, Peds Fluid & Electrolytes, 6-17-20

FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Doctoring 3 2020-2021
Doctoring 3 Didactic Session

Pediatric Fluid & Electrolyte Management
June 17, 2020

Objectives:
1. Learn clinical signs and symptoms which suggest degrees and

types of dehydration.
2. Learn about oral and subcutaneous rehydration fluid therapy
and know indications / risks
3. Learn concepts of intravenous fluid therapy and know
indications / risks and that these are ever changing!
4. Understand principles of maintenance, deficit and
replacement fluids in pediatrics.
5. Understand principles of isotonic dehydration (main focus)
6. Learn importance of monitoring patient response to fluid
therapy, regardless of route.
2
First a Primer
 Look at total body water composition
 Components of extracellular fluid and
relationships
 Water and electrolyte balance - pathways
 Definition of fluid types
 Definition of isonatremic, hyponatremic, and
hypernatremic dehydration
Figure 55-1 Total body water, intracellular fluid, and extracellular fluid as a percentage of body weight and
a function of age. Nelson Textbook of Pediatrics, Edition 20: From Winters RW: Water and electrolyte
regulation. In Winters RW, editor: The body fluids in pediatrics , Boston, 1973, Little, Brown.)
Focus on ECF Components
% Total Body Weight
Age TBW ICF ECF (ISF/IVF)*
Birth 80 35 45 (40 / 5)
3 months 70 40 30 (25 / 5)
1 year 60 35 25 (20 / 5)
10 years 60 40 20 (15 / 5)
TBW = Total Body Water, ICF = Intracellular Fluid, ECF = Extracellular Fluid, 5
ISF = Interstitial Fluid, IVF = Intravascular Fluid (plasma), *ECF = ISF + IVF
Extracellular vs. Intracellular Composition
Figure A
Difference in Distribution of Cations and

Anions between ECF & ICF
Anion difference = intracellular molecules that do not cross
the cell membrane
Cation difference= result of Na+, K+, Adenosine triphosphate

K+ pump (ATPase pump)
• K+ moves fairly freely between ECF and ICF because all

cells express K+ channels and K+ transporters on their
surface membranes
• Na+ does not move freely between compartments
7
Pathways regulating
extracellular fluid
(ECF) volume under
normal conditions.
Note: Hormones may
have additional
effects when the
system is stressed.
CV = cardiovascular.
From: Water and Electrolyte Balance

Lippincott's Illustrated Reviews: Physiology, 1e, 2012
Date of download:
Copyright © Wolters Kluwer
6/7/2016
 24 hour fluid & electrolyte requirements
Maintenance Fluids  Average healthy infant & child with normal ICF /
ECF volumes & electrolyte concentrations
 Combination of insensitive losses = (lungs/skin) +

urine output (stool negligible)
 Giving back fluids that have been lost prior to

Replacement Fluids beginning therapy & have caused dehydration
 Ex: vomiting/diarrhea/excessive sweating, etc.
 Keeping up with fluids that continue to be lost

Ongoing Fluid Loss even after therapy is begun.
 Sources include: ongoing vomiting/diarrhea, G-

Tube losses, surgical drains, etc.
9
Types of Dehydration
Isotonic Na+ : 130-150 mEq/l
(Isonatremic) Water Loss = Solute Loss
(most common and the one covered in today’s session)
Hypotonic Na+: <130 mEq/l

(Hyponatremic) Water Loss < Solute Loss
Hypertonic Na+: >150 mEq/l

(Hypernatremic) Water Loss>Solute Loss
(least common, highest mortality)
10
Composition of Frequently Used IV Fluids

Liquid Carbohydrates Na K+ Cl HCO3
(g/100 mL) (mEq/L) (mEq/L) (mEq/L) (mEq/L)
NS (0.9 % NaCl) 154 154
½ NS (0.45% NaCl) 77 77
¼ NS (0.225% NaCl) 38 38
D5 ¼ NS (0.22% 5 38 38
NaCl)
D5 ½ NS (0.45 5 77 77
NaCL)
Lactated Ringer’s 130 4 109 28
(LR)
D5W 5 0 0 0 0
3% NS 513 0 513
11
Guiding Principles of Fluid Therapy

 Do a thorough history and physical exam.
 Fluid therapy must be individualized.
 Calculating fluid / electrolyte requirements is only
an estimate of needs based on empiric
observations.
 Patient’s response to fluid therapy is best
indicator of success.
 Monitor patient closely and adjust fluid therapy as
needed.
12
Case #1: Mikey and His Tonsils

 Mikey has just arrived to the floor after having
his adenoids out for recurrent sinusitis.
 He is NPO and the ENT caring for him has

consulted you to assist in fluid management.
13
What are appropriate maintenance fluids for Mikey?

Fluid Management in Children
Fluid
Management
Based on Well
Body Weight
Maintenance Replacement Ongoing

losses
**Maintenance = 24 hour fluid & electrolyte requirements of the
average healthy infant & child with normal ICF / ECF volumes & 15
electrolyte concentrations
lo Doctoring 3 2020-2021
Maintenance Fluid and Caloric Expenditure*

Holliday - Segar Method
Body Weight (kg) ML/kg/day ML/kg/hour (4-2-1 rule)
< 10 kg 100 ml/kg/day 4 ml/kg/hr (baseline)

11- 20 kg 1000 ml + 50 ml/kg/day for each 40 ml/hr + 2 ml/kg/hr for each kg
kg from >10 kg - 20 kg from >10 kg - 20 kg
> 20 kg 1500 ml + 20 ml/kg/day for each 60 ml/hr+ 1 ml/kg/hr for each kg

kg >20 kg ** >20 kg
*100 kcal energy expended = 100 ml of exogenous water needed;

therefore, caloric expenditure = fluid needed
** Not suitable x neonates<14 days of age –may not adequately estimate fluid needs
> 65 kg, body weight & water distribution diverge and formula overestimates fluid requirements.
Use adult 2-3 liters/day
Calculations based on NORMAL, HEALTHY infants & children

16
Exercise x Students:
Calculate Maintenance Fluids for Mikey
if he weighs…
 4.5 kg
 17 kg
 But Mikey really weighs 32.5 kg…
17
Maintenance Fluid Calculation Solutions

Wt = 4.5 kg 4.5 kg x 100ml/kg = 450 ml
Wt = 17 kg 10 kg x 100ml/kg = 1000 ml
+ 7 kg x 50ml/kg = 350 ml
Total = 1350 ml
10 kg x 100ml/kg = 1000ml
Wt = 32.5 kg + 10 kg x 50ml/kg = 500ml
+ 12.5 kg x 20ml/kg = 250ml
Total = 1750ml
Maintenance Needs x IV Fluid Therapy
Sodium Child: 154 mEq/l = NS

Neonate: 38 mEq/l =1/4 NS
10-20 mEq/l of IV Fluid

Potassium
Will be taken care of with NaCl
Chloride
Calories given as 5% Solution ≈ 20 % of basal caloric requirement
Dextrose
Final Fluid D5 NS with 20 mEq KCl/l
(Note the electrolyte requirement is per unit of volume)
Composition
The Reason for Sodium Choice………

• D5 ¼ NS + 20 mEq KCL/l of IV solution was preferred maintenance
therapy based on past empiric studies.
• No longer recommended due to many cases of hyponatremia, some
fatal. Exception: neonates
• Different disease states cause ⬆️in Anti-Diuretic Hormone (ADH) release

and results in retention of free H20 & hyponatremia or may cause other
fluid/electrolyte losses
• Use of D5 ¼ NS solution can worsen the situation (See next slide)
• D5 NS + 20 mEq KCL/l = currently the preferred choice for maintenance

fluids in most hospitalized patients.
20
Modification of Maintenance Fluids Requirements

DECREASED NEEDS INCREASED NEEDS
Congestive Heart Failure Hyperventilation
Excessive Diuretic Hormone Burns – (special formulas exist)
(SIADH, CNS problems, post - operative
stress, persistent nausea, positive pressure
ventilation, pain, pulmonary disease
including pneumonia & bronchiolitis, etc)
Oliguria Visibly sweating
(<1 ml/kg/hr)
Anuria High solute loads :
(0 ml/kg/hr- i.e. no urine output) • glucosuria, diabetic ketoacidosis
Hyposthenuric states
•sickle cell anemia, diabetes insipidus
21
Modification of Basal Caloric Expenditure

(Examples)
Increase Decrease
Sustained Fever Hypothermia

12% per° C above 38° C 12% per° C below 36°C
Hypometabolic state
Hypermetabolic state • hypothyroidism
• hyperthyroidism • vegetative state
• thrashing Decrease by 10 - 20%
Increase by 25 - 75%
22
Fluid Management
Based on Well
Body Weight

losses
So Mikey’s Maintenance fluid orders should be…
IV =
23
Case 2: Cynthia and Her Sore Throat

 Cynthia is a 2 year old presenting for sore throat and
fever to 104.
 Her mother states she has had only minimal fluid intake
over the past 2 days.
What historical clues can help you assess her level of

hydration?
24
History – Important Questions to Ask

How illness started Decreased intake
Duration of illness Fever
Underlying disease # of stools / emesis and

characteristics
Weight loss Type of fluids taken / preparation
Urine output Mental status changes
Presence / absence of tears Other factors?

25
Dehydration in Children
• Infants more susceptible to dehydration
• higher metabolic turnover
• renal immaturity
• dependent on caretakers to meet needs
• larger water content
• Children show signs of dehydration earlier than

infants due to less total body water.
26
Cynthia and her sore throat
What clinical clues would you assess

to determine her hydration status?
27
*
*
Powers, K; Dehydration: Isonatremic, Hyponatremic, and Hypernatremic Recognition and Management

28
Pediatrics in Review 2015:36;274 DOI: 10.1542/pir.36-7-274 Accessed 6/22/17 7
Reminder - Types of Dehydration

Isotonic Na+ : 130-150 mEq/l
(Isonatremic) Water Loss = Solute Loss
(most common & one covered in today’s session)
Hypotonic Na+: <130 mEq/l

(Hyponatremic) Water Loss < Solute Loss
Hypertonic Na+: >150 mEq/l

(Hypernatremic) Water Loss>Solute Loss
(least common, highest mortality)
29
Isonatremic and Hyponatremic Dehydration
30
Hypernatremic Dehydration
31
Capillary Refill Time:

<2 seconds = normal
2-3 seconds = moderate
dehydration
>3 seconds = severe
dehydration
32
Mottling
33
34
Laboratory Testing
• Usually not in mild-moderate dehydration due to
acute gastroenteritis
• Indicated in cases with unclear diagnosis
– Test choice depends on clinical indication
• Indicated in severe dehydration
• Moderate dehydration with “doughy” skin
• Prolonged dehydration
35

On physical exam:
 T=104° mildly  RR & HR,
awake, fatigued, warm extremities,
Capillary refill time= 2 sec, normal skin turgor,
mildly decreased tears & dry mucous membranes, mildly decreased urine
output.
What is your assessment of Cynthia’s hydration status?
Her present weight is 11 kg.
How would you manage her fluids?
36
Reminder! – Base Calculations on Well

Weight
Fluid
Management
Based on Well
Body Weight

losses
Replacement Fluids
Giving back fluids that have been lost prior to therapy & have caused
37
dehydration Ex: vomiting/diarrhea/excessive sweating, etc.
"The discovery that sodium transport and glucose transport are coupled in the small intestine so that glucose
accelerates absorption of solute and water (is) potentially the most important medical advance this century."
The Lancet
British Scientific Journal
5th August, 1978
Replacement
Fluid
Management
Oral Subcutaneous
Rehydration Rehydration Intravenous
Oral Rehydration is becoming the first line standard of care in many pediatric
institutions for mild-moderate dehydration due to Acute Gastroenteritis 38
All Fluid Management Begins with

Calculation of Well Body Weight
Well Weight x (100% - % Dehydration) = Sick Weight
Well Weight = Sick Weight

(100% - % Dehydration)
39
Important Facts to Remember

1 liter = 1 kilogram
1 ml = 1 gram
Fluid Deficit (L) = Well Weight (kg) – Sick Weight(kg)
Fluid Deficit (L) = Well Weight (kg) x % dehydration
% Dehydration = (Well Weight – Sick Weight) /Well Wt x 100 %

(or can be determined by clinical evaluation)
40
Now we can calculate Cynthia’s

Well Weight
Sick weight = 11 kg % dehydration= 5%
Well weight= Sick weight/(100%-%dehydration)
Well weight =
So, how do you go about orally rehydrating her?

41
BREAK
42
43
Oral Rehydration - Benefits

• Only 3 - 4% failure rate
• More economical than IV
• Faster to start giving

• Can be given at home if parents are educated in
using ORS
• Comes in liquid, popsicles (flavors)
• Early feeding can resolve diarrhea

• Less nursing and hospital time 44
Indications for Oral Rehydration

 Gastroenteritis (#1 cause of dehydration in children)
 Stomatitis
 Pharyngitis (Cynthia’s problem)
 Febrile illness
 Mild/moderate isonatremic, hypo & hypernatremic
dehydration
 In reality any disease processes that would not
preclude use of the oral route
 Using the enteral route is the safest of all methods –
no rapid fluid/electrolyte shifts
45
ORS Therapy - Downside

• Resistance by medical personnel * but in
pediatric institutions is becoming more the
standard of care
• Resistance by parents – used to high tech
• Labor intensive x parent
• Insurance does not cover cost ORS (at home)
• NG tube may be required * still better than IV
46
Oral Rehydration Solutions (ORS)
Na K CI Base
Glucose Osmol
grams/I mEq/I Mosm
WHO - 1975 20 90 20 80 30 311
WHO - 2002 13.5 75 20 65 30 245
Commercial 16 45 20 35 30 200
(Pedialyte, to to to to to to
Rehydralyte, 40 90 25 65 34 305
Generic CVS,
Walgreens, etc)
Zinc & prebiotics
have been added
to many products
47
APPLE JUICE for Oral Rehydration

 Randomized study in 2016 – in Canada
 323 patients took ½ strength apple juice followed by
preferred fluids; 342 patients took ORS
 Conclusions:
o Fewer treatment failures in ½ strength apple juice followed
by preferred fluids than patients who took ORS
o No deleterious effects
o Dilute apple juice + preferred fluids may be good alternative
in developed countries x pts with minimal dehydration &
mild gastroenteritis
Freedman SB; Willan AR, Boutis K, Schuh S, “Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte
Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis A Randomized Clinical
Trial” JAMA. 2016;315(18):1966-1974 doi:10.1001/jama.2016.5352 accessed online 6/23/2016 .12 48
Guidelines for Oral Rehydration
Degree of Dehydration Rehydration Therapy Replacement of Nutrition

Ongoing losses
Minimal or no Not applicable For each episode of emesis Continue breastfeeding or
dehydration or diarrheal stool based on resume age appropriate diet
body weight after initial hydration
<10kg = 60-100ml ORS including adequate caloric
>10kg = 120-240 ml ORS intake x maintenance **
Mild- Moderate ORS: 50-100 ml/kg body Same Same

dehydration weight over 3-4 hours
Severe dehydration Conventional IV therapy – Conventional replacement Same
(see slides that follow) but IV therapy- (see slides that
once perfusion & mental follow) or once mental status
status improve could switch okay: ORS – same as above.
to ORS 100ml/kg over 4 Can’t drink? Can use
hours Nasogastric tube
**Overly restricted diets should be avoided during acute diarrheal episodes. Breastfeeding should continue ad lib even
during acute rehydration. Infants too weak to eat can be given breast milk or formula through an NG tube. Lactose
containing formulas are usually well tolerated; if lactose malabsorption appears clinically substantial, lactose-fee formula
can be used. Complex carbs, fresh fruits, lean meats, yogurt & vegetables are all recommended. Carbonated drinks or
commercial juices should be avoided.
49
Knowing Cynthia’s well weight,

how would you like to rehydrate her?
50
For Cynthia’s Oral Rehydration

Degree of Dehydration Rehydration Therapy Replacement of Nutrition
Ongoing losses
Minimal or no Not applicable For each episode of emesis Continue breastfeeding or
dehydration or diarrheal stool based on resume age appropriate diet
body weight after initial hydration
<10kg = 60-100ml ORS including adequate caloric
>10kg = 120-240 ml ORS intake x maintenance **
Mild- Moderate ORS: 50-100 ml/kg Same Same

dehydration body weight over 3-4
hours
Severe dehydration Conventional IV therapy – Conventional replacement Same
(see slides that follow) but IV therapy- (see slides that
once perfusion & mental follow) or once mental
status improve could switch status okay: ORS – same as
to ORS 100ml/kg over 4 above. Can’t drink? Can
hours use Nasogastric tube
**Overly restricted diets should be avoided during acute diarrheal episodes. Breastfeeding should continue ad lib even
during acute rehydration. Infants too weak to eat can be given breast milk or formula through an NG tube. Lactose
containing formulas are usually well tolerated; if lactose malabsoprtion appears clinically substantial, lactose-fee
formula can be used. Complex carbs, fresh fruits, lean meats, yogurt & vegetables are all recommended. Carbonated
drinks or commercial juices should be avoided. 51
Calculations of Cynthia’s Oral Rehydration

Well weight = 11.58 kg
Oral Rehydration =
Choice of ORS = any commercially available
Orders:
52
Practical Way to Estimate ORS Replacement & How to Give
Powers, K; Dehydration: Isonatremic, Hyponatremic, and Hypernatremic Recognition and 53

Management Pediatrics in Review 2015:36;274 DOI: 10.1542/pir.36-7-274 Accessed 6/22/17
Another Method of Stool & Emesis Replacement

Using ORS
Powers, K; Dehydration: Isonatremic, Hyponatremic, and Hypernatremic Recognition and

Management Pediatrics in Review 2015:36;274 DOI: 10.1542/pir.36-7-274 Accessed 6/22/17 7
54
Adjunct Therapy for ORS

Ondansetron (Zofran)
 Off label use for emesis due to acute gastroenteritis (*LOE 1
& 2)
 ↓need for IV fluids & hospitalizations (but may↑ diarrhea x
up to 48 hrs)
Dosing – (0rally dissolving tablets) ONE DOSE but repeat once if

emesis occurs within 15 minutes of taking
 Not indicated in children <8kg
 2mg (8-15 kg)
 4 mg (15-30 kg)
 8 mg (>30 kg)
*LOE = Level of Evidence 55
Cynthia refused ORT
Cynthia refused the ORT and Mom refused an NG

tube to rehydrate Cynthia
What can you try next?
56
Replacement
Fluid
Management
Oral Subcutaneous
Rehydration Intravenous
Rehydration
**Currently Gaining Much Popularity with Pediatric

Hospitalists 57
Subcutaneous Rehydration (SCRT)

Advantages & Uses Limitations
Healthy child with uncomplicated mild- Unfamiliar – resistance by
moderate dehydration personnel/parents
Only x straightforward cases of mild-
Less invasive/painful than IV moderate dehydration
2nd line after trying ORS Rate & number of boluses limited
Use of hyaluronidase (150 Units Limited meds can be given

Subcutaneous) –faster administration
No venous access
Fewer sticks needed to place
Can cause local
irritation/swelling/erythema/bruising/
Safe – no skilled monitoring needed extravasation
No known secondary bacterial infection
58
Representative interscapular infusion site before infusion (A), 4 minutes after initiation of infusion (B), and 44
minutes after initiation of infusion (C).
Sites, tools, fluids to use

 Locations: (anywhere you can pinch skin) abdomen,
thigh, upper chest, upper arm & especially
interscapular area
 Use 24 angiocath or 25 butterfly needle between skin
& muscle
 Use NS or Lactated Ringers x bolus, then glucose
containing fluids
Coburn H. Allen et al. Pediatrics 2009;124:e858-e867
©2009 by American Academy of Pediatrics

Case #3: Harold and his Diarrhea

 Harold is a 1y.o. who you are seeing in the E.R. for vomiting and
diarrhea x 2 days. You estimate him to be 8% dehydrated. Your
attending instructed you to try rapid IV rehydration followed by ORT if
he responds.
 Vitals: wt. 10 kg, T 99.4, RR 32, HR 112
 What would you expect his Blood Pressure to be?
What is next?
60
Replacement
Fluid
Management
Oral Subcutaneous
Rehydration Intravenous
Rehydration
61
Indications for Intravenous Therapy for

Hypovolemia due to Dehydration
 Shock – “is a condition in which tissue perfusion of nutrients
and 02 is inadequate to meet the metabolic demands of the
body.”” * Compensated Shock (BP maintained)
Decompensated Shock (BP is low)
 Mental status changes
 Suboptimal response to oral rehydration & /or SCRT
 Surgical abdomen, bowel obstruction, intussusception

 Ileus
62
IV Therapy – Downside (examples)

 Phlebitis, extravasation of fluids
 multiple IV sticks, hematomas
 Risk of over hydration
 Rapid rise / fall in sodium levels

 Errors in rate, wrong fluids
 Morbidity from hospitalization
63
Airway
Breathing
Circulation –Shock due to any form of dehydration (isonatremic,

hyponatremic, hypernatremic)
• Normal Saline or Lactated Ringers – May need to use interosseous route
• 10 ml/kg (neonates); 20 ml/kg (all others)
• rapid boluses (each over 5-10 minutes) up to
total 30 ml/kg (neonates) & 60 ml/kg (all others)
• Revaluate x response after each bolus. After 3 boluses, no/poor response –
you need to look for another cause. This is not “standard” dehydration
• Reassess History, Physical, Diagnosis
64
Rescue IV Rehydration- in Shock due to Dehydration
Response evaluated with each bolus

Assessments for Improvement
Heart Rate, Respirations
Blood Pressure –( especially for
decompensated shock )
Mental Status
Capillary Refill
Urine output
Once stabilized -replacement of remaining fluid
deficit by IV until patient is stable enough for ORS
65
Rapid IV Rehydration
Used in patients with uncomplicated dehydration
from gastroenteritis
o Example 40-60 ml/kg NS given IV over 3-4 hours
• If patient responds well switch to ORT for remainder
of deficit replacement
• If suboptimal response, or if it fails admit for
extended duration of rehydration
*There is no ”fixed formula” – different institutions have established their

own protocols or algorithms for fluid amounts given and over timeframe 66
Harold and his diarrhea
Write E.R. orders for rapid hydration for Harold
67

 Well weight = Sick wt/(100%-%dehydration)
So Harold’s Well Weight is

 Rapid I.V. rehydration: You choose to give
So Harold’s orders should read:
68

 Harold receives his rapid rehydration fluids but
continues to vomit and can’t tolerate any oral fluids.
 You give him a dose of Zofran, but you decide he
needs to be admitted.
At this point, since there is variation from one institution to
another in managing IV maintenance and replacement
fluids, it would be best to follow the guidelines of your
particular institution for the numerical calculations.
*The following slides will just give you some general
guidelines & do the basic calculations of Harold’s
needs
69
Looking at Final Fluid Composition
Fluid
Management
Based on Well
Body Weight

(M) (R) losses (O)
70
Informational : Patterns of Water and Solute Loss

Duration of the illness determines the pattern of water and solute
loss (i.e. deficits)
< 2 days 80% ECF 20% ICF
3 - 7 days 60% ECF 40% ICF

> 7 days 50% ECF 50% ICF
ECF [Na+ ] = 140 mEq/l ICF Na+ = negligible
ECF K+ = negligible ICF [K+] =150 mEq/l
Total Na+ Deficit =Fluid Deficit in L x %Na+ ECF x [Na+] mEq/L ECF
Total K+ Deficit = Fluid Deficit in L x %K+ICF x [K+] mEq/L ICF

71
Harold’s Maintenance Calculations

 Harold’s Well Weight =
 Maintenance fluids:
100 ml/kg for the first 10 kg = 1000 ml
+ 50 ml/kg for next 10 kg = 50 ml/kg x 0.87 kg = 44 ml
• Rate =
Total volume divided over 24 hours =
72
Important Facts to Remember

1 liter = 1 kilogram
1 ml = 1 gram
Fluid Deficit (L) = Well Weight (kg) – Sick Weight(kg)
Fluid Deficit (L) = Well Weight (kg) x % dehydration
% Dehydration = (Well Wt - Sick Wt)/ Well Weight x100%

(or can be determined by clinical evaluation)
73
What is Harold’s Fluid Deficit ? (i.e. fluid that needs to be replaced)

His Well Weight =
His Sick Weight =
Fluid Deficit =
Well Weight – Sick Weight =
74
Harold and his Bolus Fluids

• But Harold received during his rapid rehydration
• Harold’s replacement fluids should be based on his
deficit of
• He received ml of NS during his rapid rehydration,
therefore:
This is all that remains of his fluid deficit & only this amount
will need to be replaced
75
How quickly to Complete IV rehydration

Na+
 The concentration of Na+ & rate varies from institution to
institution.
 It is more practical to combine maintenance + deficit
fluids/electrolytes into one IV fluid solution and give over 24 hours
K+ is infused at a constant rate

 K+ > 0.5 meq/kg/hr requires EKG monitoring AND infusion rate
should never exceed 1 mEq/kg/hour & should not be started until
patient urinates
 Generally, KCL can be given as 20 mEq/l of I IV fluids unless there is laboratory
confirmation of hypokalemia. There are exceptions to this rule.
76
But what about ongoing losses?

Fluid
Management
Based on Well
Body Weight
Ongoing
Maintenance
Replacement losses
Ongoing Losses: Keeping up with fluids that continue to be lost

even after therapy is begun. 77
Ongoing Losses – IV therapy

 Vomiting and diarrhea
 Nasogastric losses
 Surgical drainage losses
78
Ongoing Losses – IV therapy Replacement

Example Method
• Measure electrolyte concentration of fluids lost
- or –
use tables with standard electrolyte composition of different
fluids
• Choose a starting point and measure the losses over each

subsequent 4 hour period
• Use a piggyback IV fluid with appropriate electrolyte

concentrations and give back the volume lost during the prior 4
hours ml for ml & repeat measuring loss and replacement over
each 4 hour period until the loss is negligible
79
The Patient should be assessed frequently

• Fluid intake and urine output (I’s and O’s) - urine output
should be 1-2ml/kg/hr or about 2/3 maintenance x 24
hrs
• Overall status of patient
• Vital signs, physical findings, weight
• Serum electrolytes (only if indicated by situation)
• Urine specific gravity
• You cannot just calculate the fluids & let them run to
completion – you must frequently re-evaluate
80
Outcome?
If the patient does not have the anticipated
outcome of fluid therapy:
─ recheck patient
─ recheck fluid calculations
─ check to be certain patient received prescribed
fluids
─ re-think diagnosis
81
Informational Slide Only

 Hyponatremic Dehydration
 Calculations same as isotonic dehydration but need to also
include calculations for excess Na+ loss
 Excess Na deficit = 0.6 x Weight x (desired Na level- serum Na)
(0.6 = volume of distribution of Na in total body water)
• Simplified fluids: 5% glucose in 0.9% saline with 20 mEq/l KCl
given over 12 h followed by 5% dextrose water in 0.9% saline
with 20 mEq/l KCl given over the next 24 h
 Hypernatremic Dehydration
 Free water deficit given over 48 hours-72 hours + maintenance
fluids depending on severity of hypernatremia
 Free water deficit = 4 ml / kg x wt in kg x (serum Na -150 mEq/l)
82

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FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE

Doctoring 3 Didactic Session

June 17, 2020

1. Learn clinical signs and symptoms which suggest degrees and

Difference in Distribution of Cations and

Cation difference= result of Na+, K+, Adenosine triphosphate

• K+ moves fairly freely between ECF and ICF because all

From: Water and Electrolyte Balance

 Combination of insensitive losses = (lungs/skin) +

 Giving back fluids that have been lost prior to

 Ex: vomiting/diarrhea/excessive sweating, etc.

 Keeping up with fluids that continue to be lost

 Sources include: ongoing vomiting/diarrhea, G-

Hypotonic Na+: <130 mEq/l

Hypertonic Na+: >150 mEq/l

Composition of Frequently Used IV Fluids

Guiding Principles of Fluid Therapy

Case #1: Mikey and His Tonsils

 He is NPO and the ENT caring for him has

What are appropriate maintenance fluids for Mikey?

Fluid Management in Children

Maintenance Replacement Ongoing

Maintenance Fluid and Caloric Expenditure*

< 10 kg 100 ml/kg/day 4 ml/kg/hr (baseline)

> 20 kg 1500 ml + 20 ml/kg/day for each 60 ml/hr+ 1 ml/kg/hr for each kg

*100 kcal energy expended = 100 ml of exogenous water needed;

Calculations based on NORMAL, HEALTHY infants & children

Maintenance Fluid Calculation Solutions

Sodium Child: 154 mEq/l = NS

10-20 mEq/l of IV Fluid

The Reason for Sodium Choice………

• Different disease states cause ⬆️in Anti-Diuretic Hormone (ADH) release

• D5 NS + 20 mEq KCL/l = currently the preferred choice for maintenance

Modification of Maintenance Fluids Requirements

Modification of Basal Caloric Expenditure

Sustained Fever Hypothermia

Maintenance Replacement Ongoing

So Mikey’s Maintenance fluid orders should be…

Case 2: Cynthia and Her Sore Throat

What historical clues can help you assess her level of

History – Important Questions to Ask

Duration of illness Fever

Underlying disease # of stools / emesis and

Urine output Mental status changes

Presence / absence of tears Other factors?

• Children show signs of dehydration earlier than

Cynthia and her sore throat

What clinical clues would you assess

Powers, K; Dehydration: Isonatremic, Hyponatremic, and Hypernatremic Recognition and Management

Reminder - Types of Dehydration

Hypotonic Na+: <130 mEq/l

Hypertonic Na+: >150 mEq/l

Isonatremic and Hyponatremic Dehydration

Capillary Refill Time:

Cynthia and her sore throat

What is your assessment of Cynthia’s hydration status?

Her present weight is 11 kg.

How would you manage her fluids?

Reminder! – Base Calculations on Well

Maintenance Replacement Ongoing

All Fluid Management Begins with

Well Weight x (100% - % Dehydration) = Sick Weight

Well Weight = Sick Weight