Fluid & Electrolytes

Parenteral Fluid Therapy

Introduction
 Clinicians who care for inpatients must be able to
assess the need for parenteral fluid therapy and to
specify the composition of the fluid and rate of
administration.
 The goal is to normalize the intracellular & extra
cellular chemical environments that optimize cell
and organ function.
 Fluid composition (maintenance need , deficit ,
and ongoing losses).
Maintenance [Fluid]
Maintenance [Fluid]
Maintenance [Fluid]

 Because it is difficult to remember basal

metabolic rates for various ages & sizes
during childhood
[relate maintenance needs to body weight]
Maintenance [Fluid] (theories)
 The Surface Area method (requires a table to
determine surfece area ,the patient’s height
& weight).
 The Basal Calorie Method (requires a table).
 The Holliday-Segar System (most frequently
used because of the ease of the formula).
Maintenance [Fluid]
Maintenance [Fluid]
( holliday-segar theory)
 For each 100 kcal expended , approximately
50 ml of fluid is required to for skin , for
respiratory tract , and basal stool losses , and
55-65 ml of fluid is required for the kidneys
to excrete an ultrafiltrate of plasma at 300
mosm/l , a S.G. of 1.010 without having to
conc. The urine
 the sum is rounded to 100 ml of fluid/100
kcal.
 Are maintenance fluid and
electrolytes all that children at
bed rest in the hospital need?

 Fever.
 Catabolic State (additional solute).
 Nutrition (includes additional osmoles).
 Inflammation (fluid sequestration).
 In the absence of disease,should
intake & output be equal, or
should u.o.p. always equal half of
what is taken in?
Maintenance [Electrolytes]
 Insensible loss contains virtually no
electrolytes.
 All electrolytes loss can be considered to
be urinary.
 Insensible water loss increase with activity ,
fever [ i.e. 12% increase for each 1ْ C rise in
body temperature ].
Maintenance [Electrolytes]
 Pulmonary insensible water loss increase
with hyperventilation , as in asthma &
D.K.A. , & decrease with exposure to highly
humidified atmospheres or humidified
ventilator systems.
 Cutaneous losses may be especially high in
low birth weight & VLBW infants with a
large surface area & decreased skin
thickness.
Should the sodium concentration
of maintenance fluids provided to
adolescent and adults differ from
that generally provided to infants
and children?
Maintenance [Electrolytes]

 Both the amount of lytes. & the amount

water for maintenance needs are based on
metabolic rate , not on the body weight.
 The lytes.-water ratio is fixed,so the
composition of maintenance fluids should
remain constant [G/S 0.2% + 20 meq/l KCl]
Maintenance [Electrolytes]

 Adolescents & adults frequently are

provided G/S 0.45% based on a need for
sodium of 3 meq/kg , when the actual need
is 3 meq/100 kcal.
Maintenance [Electrolytes]
 The error of calculating sodium based on
weight results in a linearly increasing
amount with increasing weight , when fluid
needs actually decrease with advancing
weight .
 This results in adults generally being
provided more sodium than neede for
maintenance support.
Deficit [Fluid]
Deficit [Fluid]
 If signs of hypovolemia are present
(tachycardia & hypotension) , a rapid
infusion of fluid (bolus) is indicated .
 The amount generally administrated in a
single bolus is 20 ml/kg (equivalent to 2%
of body weight) for infants & children & 10
ml/kg for teenagers.
Deficit [Electrolytes]
 Normal saline OR ringer lactate is used
when a bolus of fluid is administrated
(sodium concentration is compatable to
serum , so intravascular volume is bolstered
without fluid shift).
 The total sodium loss is approximately
80 - 100 meq/l.
Deficit [Electrolytes]
 Particularly when a bolus of N/S or ringer
lactate has been provided , the remaining
deficit is approximated by HALF normal
saline ( G/S 0.45% ).
 Once u.o.p. is assured , 20 meq/l KCl is
added to replacement solutions. & if
hypokalemia is concered,KCl supplement
can increase.
Ongoing losses [Fluid]
 Include (continued diarrhea or vomiting ,
aspirates from a NGT attached to suction ,
or the polyuria of an osmotic diuresis)
 can be measured directly.
 Other losses (abnormal internal collections
with an ileus , peritonitis or edema) which
are difficult to estimate.
Ongoing Losses [electrolytes]

 Gastrointestinal losses can be replaced by

half N/S.
 Transudates reflect the composition of the
intravascular space & have the higher
sodium content of N/S or ringer lactate .
 Radiant losses are sodium free.
Laboratory Evaluation
 Na conc. : defines the type of dehydration ,
reflects the relative losses of water& lytes ,
not of total body sodium stores.
 Serum K : hyperkalemia [reflects acidosis
&diminished renal function] , hypokalemia
[reflects significant stool losses ; with
gastric losses ass. with alkalosis (pyloric
stenosis) .
Laboratory Evaluation

 Serum HCO3 : detecting metabolic acidosis

or alkalosis.
 BUN & serum creatinine : elevated in
severe dehydration because of decreased
glomerular filtration rate.
Parenteral Rehydration Without
a Calculator of a Moderately
Dehydrated Infant

 An initial bolus of 20 ml/kg is provided to

restore normal hemodynamics.
 20 ml/kg represents 2% of body weight .
 If the initial deficit was estimated to be 10%
, the reminder after the bolus is 8%.
Parenteral Rehydration Methods
Hypertonic Dehydration

 Fluids is drawn into the intravascular space

from the intracellular space .
 The rapid administration of fluid , as
recommended for isotonic states , can create
fluid shifts that result in cerebral edema &
intracranial bleedings.
Hypertonic Dehydration

 The calculated deficit fluid and electrolyte

needs are added to 2 days [48 hrs.] worth of
maintenance fluid and electrolyte
requirements ; the sum is divided by 48 and
administrated at constant hourly rate for 48
hours.
Hypotonic Dehydration
 The extra sodium loss can be calculated
from the formula:
[Na deficit =desired Na –actual Na ×0.6 × wt]
 If seizures developed , intravenous
administration of a 3% solution of NaCl at a
rate of 1 ml/minute to a max. of 12 ml/kg.
 Na correction must not exceed an increase
of serum Na of 10 mEq/24 hrs.
Monitoring the Effectiveness of
Parenteral Fluid & Electrolyte
Therapy.
Thank you