PHARMACOLOGY

FLUID AND ELECTROLYTES

FLUID AND ELECTROLYTE ADMINISTRATION IN

CHILDREN
DR. ICBAN (AUGUST 25, 2016)
BODY WATER CONTENT
Average:
Healthy males: 40 Liters of fluid makes up 60%
Body Weight
Healthy females: 40 Liters of fluid makes up
50% Body Weight
Infants: have low body fats, low bone mass and
are 80% or more water
Total water content decline throughout life
Body consist of lean tissue, fat and water
Lean portion is primarily muscle mass has about
75% water
Fat tissue is essential anhydrous

Difference Male vs Female:

Higher body fat
Smaller amount of skeletal muscle
Of the 40 liters: 25L are intracellular fluids
Factors that affect the amount of Total body water
a. Relative amount of muscle and fat Mass
(Obesity)
b. Gender
c. Age
Before you administer any IV fluid, it is important
yet that we review basic physiology of the water
composition of your body. So on average person
there is 40L of fluid which makes up to 60% of the
body weight. So if the patient is weighing 50 kilos
how many liters does that 50 kilos person gram
contain water. 30 Liters.
Body water composition would vary depending on
the body fats, skeletal muscle and intracellular
fluids
Infants have lower body fat thats why they contain
more fluid/ total body water. Thats why the TBW
among infants is higher compared to adults.
Because the body fat is anhydrous, so they would
occupy the space reducing the total body water
composition. Total body content decline throughout
life.

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Body consists of lean tissue, fat and water. And
the lean portion is composed of muscle mass
and is about 75% of water. Fat tissue is
anhydrous. This explains the higher body water
in infants to adults or females compared to
male.
TBW varies between gender, age and relative
amount of muscle and fat mass.

COMPOSITION OF TOTAL BODY WATER

It is important to identify and recognize the
composition of your body fluids
60:40:20:5 Rule
o 60% TBW
o 40% ICF (37% adult)
o 20% ECF
o 5% Plasma
(%) x kg BW
e.g 50kg
TBW

60%

30L

ICF

40%

20L

ECF

20%

10L

Plasma

5%

2.5L

40(ICF)
60 (TBW)

15 (Interstitial)
20 (ECF)
5 (plasma)
Your body fluid is present in two major compartments:
ECF and ICF.
A. Intracellular Fluid
makes up about 37% of the adult weight and
40% childs weight.
source of protein, potassium and phosphate
B. Extracellular Fluid
ECF is further divided into two compartments
o Intravascular (plasma)
o Interstitial (fluid in between the cells).

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PHARMACOLOGY
FLUID AND ELECTROLYTES
DR. ICBAN
AUGUST 25,2016
CLINICAL ASSESSMENT OF CHANGES IN FLUID
COMPARTMENTS
How would you asses whether the patient needs fluid in
the interstitial, extracellular or plasma. Heres the
parameters.
PLASMA COMPARTMENT
Fixed compartment with continuous circulation
composed of:
o Forward circulation (afterload) e.g Pulse
and blood pressure
o Backward circulation (preload) e.g
Venous pressure
INTERSTITAL COMPARTMENT
Can be assessed by the presence of the
following:
o Edema
o Skin elasticity/skin turgor (assessed in
pediatric patients in the abdomen
o Dryness of mucous membrane
o Tension of anterior fontanel (sunken or
depressed anterior fontanel means
decreased fluid in interstitial
compartment)
INTRACELLULAR COMPARTMENT
Assessed indirectly:
E.g for Brain assess:
o Headache
o Confusion
o Seizure
CHECKPOINT #1
1. A patient came diaphoretic with a blood pressure of
70/50 (hypotensive). There is a decrease in body water
in which compartment?
A. Plasma
C. ICF
B. ECF
D. NOTA
2. If the patient has seizure, the compartment that is
deranged is:
A. Plasma
C. ICF
B. ECF
D. NOTA
3. The patient present with edema and sunken
fontanels. In which compartment does the patient have
derange body fluid level?
A. Plasma
C. ICF
B. ECF
D. NOTA
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LEVEL OF DEHYDRATION
It is important for patients suffering from
gastroenteritis, diarrhea and vomiting to classify their
levels of dehydration. (Mild, Moderate, Severe)
CLASSIFICATION OF SOLUTES
Solutes are classified as electrolytes and NonElectrolytes

Electrolyes are inorganic salts: sodium,

potassium, calcium acid and bases (usually
expressed in meq/L or mmol/L)
Non-electrolytes: Mannitol, Glucose, Lipids,
Creatinine and Urea

TONICITY
Describes the relative levels of electrolytes
(osmotic pressure) on both sides of a
semipermeable membrane
Refers to effect osmolality of solution
It is important that when we discuss different IV
fluid, we should be familiar with tonicity. This
describes the level of electrolytes on both sides
of the semi-permeable membrane.

TYPES OF IV SOLUTIONS (TONICITY) AND

DEHYDRATION
Isotonic (Isonatremic)
Hypotonic (Hyponatremic)
Hypertonic (Hypernatremic)
HYPOTONIC
D5 Water
SOLUTIONS
ISOTONIC SOLUTIONS 0.90 NSS
Plain LRS
HYPERTONIC
D5 LRS
SOLUTIONS
D5 NSS
D5 0.45
D5 0.225
ISOTONIC SOLUTION
Ideally, you give a fluid that is iso-osmotic with
your plasma
Have similar electrolyte concentration and
therefore same osmotic pressure as ECF
normal plasma osmolality is between 285-295.
Close to 285 mOSM/L
Example is plain NSS. This is an isotonic fluid because
when you compute for the osmality for PNSS (0.9%

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PHARMACOLOGY
FLUID AND ELECTROLYTES
NaCl)contains 154 meqs/L of sodium. Multiply the level
of sodium by 2 (the easiest way to get the osmolality of
a fluid).
Computation for Isotonic Fluids:
1. OSM of PNSS= 154 x 2 (0.93)= 286 meq/L
0.93 is the osmotic coefficient
This is almost similar to plasma osmolality thats why its
considered as an isotonic fluid.

Fluid
PLRS
D5 IMB
D5 0.45
D5 0.3
D5 water

Color
Blue
Violet
Light
Blue
Red

Sodium Content
147 meq/L
25 meq/L (20->K)
77 meq/L
51 meq/L

ISOTONIC ALTERATIONS
Disorder that WILL NOT MAKE cell either swell
or shrink.
Same effective osmolality as body fluids E.g
PNSS
This alteration occurs when osmotic pressure
equal between intra and extracellular
Example: Blood loss from penetration trauma or
expansion fluid volume when patient receives
too much NSS
HYPOTONIC SOLUTION
Lower levels than normal level of some
essential electrolyte
E.g D5 IMB, D5 Water, D5 0.45 and D5 0.30 and
also ENERGY DRINK (Gatorade)
*according to Dr. Icban which different from
her table
Why are they considered as hypotonic?
OSM D5 0.45= 77 x 2 = 154
OSM D5 0.30= 51 x 2 = 102
OSM D5 IMB= 25 x 2= 50
Plasma OSM = 285-295 mmol/L
HYPOTONIC ALTERATION:
Overhydration/ Excess body fluid administration
e.g. If the weight of the patient is 10 kg and the patient
is not dehydrated and you forgot the formula to
compute for the maintenance and you regulated the IV
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fluid to 100 cc/hr. The cause of hypotonic alteration is
overhyration. Causing hyponatremia in patient.
What fluid is best given to patients with penetrating
trauma? NSS or LRS (if blood is not available)
Patients suffering from gastroenteritis you give ORS not
energy drink.
HYPERTONIC SOLUTION
Greater than normal level of some essential
electrolytes.
Contain more solute
Cause cell shrinkage
May contain electrolytes or non-electrolytes
(e.g Mannitol which exerts osmotic effect
because it diffuse across biological membrane

HYPERTONIC ALTERATION
Occurs when give hypertonic solution like NSS
Severe dehydration that cause hypernatremia
Renal disease that causes sodium retention

CLASSIFICATION OF IV SOLUTIONS
Crystalloids
o commonly used
o contain electrolytes and may contain
glucose (osmotic diuretic)
o e.g D5 NSS, D5 LRS, D5 IMB)
Note that
Colloids (dextran)
Blood and blood products
Lipids
CHECKPOINT #2
1. If the patient is hypertensive BP=80/50, what is
compartment is deranged in the patient?
A. Plasma
C. ICF
B. ECF
D. NOTA
2. In the above case, what type of fluid is
contraindicated?
A. Plain LRS
C. Plain NSS
B. D5 LRS
D. NOTA
*check your answer in the following discussion below

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PHARMACOLOGY
FLUID AND ELECTROLYTES
OSMOLARITY
1. Electrolytes
Sodium=dominant ECF electrolyte
Has attracting power for water
Can cross capillary membrane
Cannot cross cell membrane
2. Glucose (attracts water)
Is an osmotic diuretic
In cases of overflow renal excretion of
sugar (Glucosuria in case of
hyperglycemia), water will be
eliminated
Glucose containing fluids should not be
given in hypotensive patients
3. Plasma proteins (albumin)
Are the main negatively charged
intravascular fluid anions
Balance the positive charge of sodium
in osmolarity
Pulls water into the vascular space and
keeps it there
Plasma proteins create a pulling power
for water which affects fluid balance in
the body
For secondary management of Dengue
cases
In the latest management guideline for Dengue:
1. After IV bolus 20ml/K or NSS or PLRS.
2. If the patient is not responding they would
recommend administration of albumin (colloids)
Because they want to prevent congestion or fluid
overload
REGULATION ECF VOLUME and OSMOLALITY
The body is equipped with mechanism that
allows precise regulation of the volume and
amount of sodium
Two components of ECF determines its
osmolality
Osmoreceptors are present in the kidney that
will affect ADH secretion to maintain normal
osmolality
ECF
HIGH (too
LOW (too low Na)
Osmolality
much Na)
ADH Secretion Increases
Decreases
Water
Retained (to Lost
dilute
(to concentrate Na)
sodium)
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It is important to note that CHANGES IN
VOLUME OVERRIDE CHANGES IN TONICITY
Decrease in ECF volume would always stimulate
ADH secretion to restore normal volume level,
regardless of the tonicity
ECF VOLUME
LOW
ADH SECRETION

INCREASED

WATER

RETAINED

CHECKPOINT #3
1. The concentration of the which of the following
accurately reflects the osmolality of body fluids?
A. K
C. Na
B. Proteins
D. Glucose
2. Compute for the plasma osmolality if Na= 130, BUN=
14 mg/dl and glucose= 90 mg/dl

VOLUME REGULATION
Sodium and its accompanying anions, Chiefly Cl,
are effectively confined to the ECF
By their osmotic effect within the ECF, they
determine the volume of that compartment
Thus, the amount of Na in the extracellular fluid
determines the volume of the compartment

MAINTENANCE FLUID
is the amount of fluid the body needs for the
replacement of the usual daily losses from normal
functions of the respiratory system, the skin
(insensible), the kidney (obligatory urine volume)
and the GIT.
Computation using Holliday-Segar Method
o (Fluid requirement based on caloric
expenditure)
o More specific
Ludans is based on age and weight (with range)
Holliday-Segar Method
Weight
Daily Requirement
(Kg)
0-10
100 ml/kg
11-20
1000ml + 50ml/kg for each kg >10
>20
1500 ml +20 ml/kg for each kg >20

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PHARMACOLOGY
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Examples:
1. Patient weighing 10 kg, the formula for
maintenance IV fluid is 100 ml/kg in first 10 kg.
a. Fluid Requirement per day:
10kg x 100 ml/day = 1000ml/day
b. Regulation per hour
1000 ml = 41.6 cc / hour
24 hours
c. Doctors Order:
Maintenance fluid D5 IMB IVF 500 cc at 41-42 cc/hour
or 41-42 microdrops/ minute
2. Patient weighing 15 kg.
a. Fluid requirement per day:
First 10 kg = 1000ml
5kg left (50ml each)= 5x50ml = 250ml
Total: 1000ml + 250ml = 1250 ml/day
b. Regulation per hour
1250 ml
= 52.08 cc/ hour
24 hours
3. Patient weight 25 kg
a. Fluid requirement per day:
First 10 kg = 1000ml (10x 100ml)
Second 10kg= 500ml (10x50ml)
5 kg left= 5 x 20 ml= 100ml
Total: 1000+500+100ml= 1600 ml/day
b. Regulation per hour:
1600 ml
=
66.67 cc/hour
24 hours
4. Patient weighing 30 kg
First 10 kg = 1000ml (10x 100ml)
Second 10kg= 500ml (10x50ml)
10 kg left= 10 x 20 ml= 200ml
Total: 1000+500+100ml= 1700 ml/day
a. Regulation per hour:
1700 ml
=
70 cc/hour
24 hours
All of this applies: If patient is admitted, dehydrated
with normal BP, plasma and interstitial and extracellular
compartment are normal. You just want to administer
IV medication.
HOW DO WE KNOW IF THE PATIENT NEEDS BOLUS OR
MAINTENANCE?
If a patient suffering from pneumonia, with cough,
without insensible water loss, no vomiting, with good
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appetite and you want to administer the medication
through IV. You can start the patient on maintenance
fluid.
But if the patient have signs of dehydration, you do not
give maintenance fluid, instead you give fluid that
contains Na or K (electrolytes), depending on the need
of the patient
INDICATIONS FOR IV FLUIDS
a. Maintenance fluid therapy to replace estimated
normal physiologic urine output and insensible
losses; patients with reduced or no oral intake;
b. Bolus fluid therapy to expand the circulating
volume; children with hypovolemia or shock
during dehydration or hypotension
c. Fluid therapy to replace abnormal losses from
the GI tract and other body cavities
If the patient is dehydrated and BP is below normal it is
recommended to give bolus fluid therapy which is given
at 20 ml/kg
E.g. 1 year old infant with dengue shock, fever of 5 days
duration, accompanied with vomiting, loss of appetite,
HCT= 50(elevated), platelet =60, HR=140, weighing 10
kg has BP palpatory 70. How would you order IV fluid?
What kind of fluid is given? Isotonic
D5 containing or plain?
- Plain LRS (for the risk
of hypokalemia)
Should be given bolus= 20 ml/kg (because patient
is dehydrated / in shock)
Total fluid should be given in bolus= 20ml/kg x 10
kg= 200ml/hour
After 15-30 minutes, The blood pressure is reassessed
and BP becomes 80/50
Lower limit is age in years x 70 +2 =72 systolic
80/50 therefore is acceptable
How do we regulated the body fluid now?-Give
maintenance fluid now:
Fluid Requirement per day:
10kg x 100 ml/day = 1000ml/day
Regulation per hour
1000 ml = 41.6 cc / hour
24 hours
Or for dengue it can be computed as 2-3 or 3-5
cc/kg/hour
2.

Same patient, at the ward after admission,

patient experience several episodes of
projectile vomiting around 6 times approx~ 100
cc / vomitus.

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PHARMACOLOGY
FLUID AND ELECTROLYTES
DR. ICBAN
AUGUST 25,2016

The replacement of ongoing fluid loss

should be done cc by cc.
If vomitus is 100cc. Give 100cc or PNSS or
PLRS (fast drip or for 1 hour)
Goal is to restore fluid compartment while
avoiding fluid congestion as well
For every intervention that you do you
assess and reassess the patient (CR, pulses,
Peripheral pressure, signs of edema,
capillary refill time, skin elasticity,
headache, seizure

COMPOSITION OF MAINTENANCE FLUIDS

Composed of water, glucose, Na and K
Usually contain 5% dextrose = 17cal/dl
o Prevents ketone production
o Minimize protein degradation
Goals
o Prevent dehydration
o Prevent electrolyte disorders
o Prevent ketoacidosis
o Prevent protein degradation
Adult patients: D5 NS +20 meq/L KCL
Children: D5 0.2 NS +20 meq/L KCL
o Children weighing is <10 kg
o Higher water needs
o Usually for children <10 kg, D5 IMB is
used
o D5 0.2 Contains around 20 meq/L
o D5 IMB Contains around 25 meq/L
GENERAL PRINCIPLES
Any hospitalized child requiring IV fluid should
be considered at risk of nonphysiological
(inappropriate) ADH secretion
Groups particularly as risk identified in
published case series include:
o Children undergoing surgery and those
with acute medical illness including
meningitis, encephalitis, brochiolitis and
pneumonia
o In the absence of a need to correct a
fluid deficit in the patients, IV fluid
should be administered at the rate of
60-70% of the usual calculation for
normal maintenance requirement and
in the form of isotonic saline or Ringers
Lactate
CONDITIONS WHEN YOU DONT GIVE THE FULL
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MAINTENANCE
E.g 2 year old patient weighing 15 kg, admitted due to
pneumonia, with no signs of dehydration.
Patient weighing 15 kg.
o Fluid requirement per day:
First 10 kg = 1000ml
5kg left (50ml each)= 5x50ml = 250ml
Total: 1000ml + 250ml = 1250 ml/day

However
for
pneumonia,
brochiolitis,
meningitis, encephalitis they are at risk of
developing inappropriate ADH secretion
o Should only administer 60-70% of total
fluid
o 1250 x 0.60 = 750 ml /day
o Regulation per hour
750 ml = 31.25 cc/ hour
24 hours

GENERAL PRINCIPLES (continuation)

Oral fluid intake should be included in
estimation of fluid requirement to prevent fluid
overload
Both the volume and concentration of sodium
in IV and oral are important contributors of
Hyponatremia
You should quantify the lots of water to you
patients- this could cause Iatrogenic
hyponatremia secondary to fluid overload- you
should consider this before attempt to compute
for maintenance
Proprietay enteral fluid preparation and TPN
solutions are low in sodium (<40 mmol/L) and
maybe a substantial source of electrolyte-free
water
Patients in long term TPN and who are not
acutely ill are not at increased risk for
development of acute hyponatremia
Infant and young children have limited glycogen
stores and what is usually give is DEXTROSE
CONTAINING
SOLUTIONSto
prevent
hypoglycemia and ketosis
Children with cardiac failure, renal failure and
hepatic failure with ascites have chronically low
Plasma Sodium Values because of water
retention and/or abnormality of RAAS
mechanism
o These
patient
have
CHRONIC
HYPONATREMIA and are NOT at risk for
development of cerebral edema

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PHARMACOLOGY
FLUID AND ELECTROLYTES
DR. ICBAN
AUGUST 25,2016

Before starting any IV fluids, baseline serum

electrolytes and non-electrolytes (Na, K,
glucose, urea, creatinine) should be measured
Patients undergoing day surgery where the IV is
discontinued at the end of the case do not need
their electrolyte measured
Patient with elective surgery tomorrow at 8am. When
would you administer the IV fluid?
Ideally start the IV fluid when patient is NPO
Elective surgery- do not need to request
electrolyte post-op
CLASSIFICATION OF IV SOLUTIONS (continuation)
CRYSTALLOIDS
Primary fluid used for prehospital IV therapy
Contain electrolytes but lack large proteins and
molecules found colloid
Come in many preparation and are classified
according to their tonicity
E.g PNSS and PLRS
COLLOIDS (DEXTRAN)
Contain large proteins or other similarly sized
molecules
Given to patients not responding to fluid bolus
Remain the blood vessels for long periods of
time and can significantly increase the
intravascular volume
Have the ability to attract water from the cells
into the blood vessels
Useful in maintaining blood volume
Expensive and have specific storage
requirements amd have short shelf life
Commonly used colloids: Plasma protein
fraction, salt poor albumin, dextran and
hetastarch
BLOOD AND BLOOD PRODUCTS
Blood and blood products (platelets and PRBC,
plasma) are the most desirable fluids for
replacement
Not only is the intravascular volume increase,
but the fluid administered can also transport O2
to the cells
The universal compatibility of O-negative blood
makes it the ideal choice for administration in
emergent situations
LIPIDS (not included in discussion)
Usually used for TPN

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COMPOSITION OF IV SOLUTIONS

IV FLUID ADMINITRATION
IV fluid boluses should only be used in children
with significant ECF contraction or impending
shock and only in the follow or PNSS or PLRS
(Isotonic Fluids)
Excessive use of IV bolus will transiently overexpand the ECF compartment and result in an
increase in the renal sodium excretion
IV fluid therapy to replace from the GI tract
should be by PNSS or PLRS (Isotonic Fluids)
Solutions with added dextrose may be required
based on patient age and blood glucose levels
Until serum electrolyte values are known, when
starting IV maintenance fluids PNSS or PLRS are
recommended
This solution should be adjusted when serum
electrolyte results become available
MONITORING
Patients receiving >50% of maintenance fluids
by IV route should have at least daily
measurements of serum electrolytes and
glucose
All children receiving IV fluids have an accurate
daily intake and output record kept and when
feasible, daily weight measurement

POTASSIUM

NV: 3.5-5.0 meq/L

Potassium is the dominant intracellular
electrolyte
Primary buffer in the cell
Depending on the pH of body fluids, K+ and H+
can compete with each other for elimination in
the kidney tubules
K+ and H+ can also be exchanged at the cell
level in acidosis and alkalosis
If H is greater that K, the kidney tubules will
secrete H istead of K. Serum K will Rise
The opposite is true if H level drops
o ACIDOSIS = Hyperkalemia
o ALKALOSIS= Hypokalemia
Increased
potassium
elvels
stimulate
aldosterone release from the adrenal gland,
which promotes K loss in the urine

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PHARMACOLOGY
FLUID AND ELECTROLYTES
DR. ICBAN
AUGUST 25,2016

Potassium like other electrolytes, moves

constantly among cells, blood, urine, GI fluids,
sweat and saliva
This movement of potassium is influenced by:
o Changes in pH (acidosis=increase; vv)
o Insulin (entry of K)
o Adrenal Hormones (aldosterone)
o Changes in serum sodium

REGULATORY
BALANCE
o
o
o

MECHANISM

OF

POTASSIUM

Insulin
Cathecolamines (increase RA leads to
increased aldosterone)
Aldosterone (promotes potassium
excretion) affect distribution between
ECF and ICF

ROUTES OF ELIMINATION OF POTASSIUM

o
o
o

SIGNS AND SYMPTOMS OF HYPOKALEMIA

Kidney (80%)
Bowel
Skin

HYPOKALEMIA <3.5 meq/L

o Causes:
1. Hypokalemia without K deficit (shift from
extracellular
fluid)
or
Redistribution
Hypokalemia
a. Insulin
b. Cathecolamines
c. Alkalosis
d. Famililal hypokalemia periodic paralysis
2. Hypokalemia with K deficit
a. Decrease Intake
b. Extrarenal losses (vomiting, diarrhea,
laxative abuse)
c. Renal losses (tubular disease, diuretic
abuse,
RTA,
DKA,
excess
mineralocoricoid effect)
Hypokalemia with K Best treatment: K
deficit
replacement
Hypokalemia without Identify the cause
K deficit

THERAPY FOR HYPOKALEMIA

o

Mild hypokalemia occurring asymptomatic

persons may not require specific therapy (e.g
adult K=3.2 mmol/L asymptomatic, no
treatment required)
o Replace may be given by oral route done
(Kalium durule 10 meq/tablet) slowly and
started once urine flow is confirmed
o If the K deficit is severe and causing cardiac
arrhythmias, rhabdomyolysis , extreme
weakess, IV replacement is necessary
o Guidelines on IV administration
Peripheral vein
Max 60 mmol/L
Central vein
Max 80 mmol/L
Rate
0.2 to 0.3 mmol/kg/hr
Metabolic Alkalosis
Use KCl
Metabolic Acidosis
Use KHCO3
o The child with symptomatic hypokalemia and
potassium less that 3 mmol/L should be
admitted

Example # 1
Patient Weight= 10 kilos
Patient Potassium = 3 meq/L
Patient Rate = 50 cc/hour
1. Maintenance
(2-3meq /kg)

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2 meq x 10 kg = 20 meq
kg

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2. Deficit= 3.5actual) x wt x
50(constant)
x 0.05
3. Total
K
requirement
=
Maintenance
+ Deficit
4. Potassium
Infusion Rate
(KIR)

=(3.5-3) x 10kg x 50 x 0.05

=12.5 meq

=20 meq + 12.5 meq= 32.5

meq/day

Notes
o For peripheral max is 6
meq/100ml or 60 meq/L;
central
max
is
8
meq/100ml
o For infants: give it at
4meq/100 ml because of
risk of phlebitis
o For rapid correction=6
meq/100
ml
(with
monitoring of heart rate)
for risk of arrhythmia
If the infusion = 4/100 x 20 = 0.08
rate is given at
10
4meq/100ml,
*This is acceptable (0.30)
and infusion rate
of
20cc/hour @10
kilogram
weight;
what would be maintenance is 41 cc/hour;
the KIR?
potassium replacement rate
should
not
exceed
maintenance fluid rate (e.g
Potassium is 20 cc/hour,
Maintenance is 21 cc/hour)
Preparation of 4 meq/100ml to run @20
KCl drip
cc/hour
Doctors Order

If you want to
increase the rate
@ 30
How
much
potassium
is
given for 24
hours at this rate
(20cc/hour)?

Start KCl drip 4meq of KCl in

100 ml diluents to run @ 20
cc/hour as side drip
=4/100 x 30 = 0.12
10
*This is acceptable (0.30)
=4meq x 24 hours x 20 cc
100cc
hr
=19.2 meq/day

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DR. ICBAN
AUGUST 25,2016
Correction time
=Total Requirement x 24
Total K in 24 hours
=32.5 x 24 hours
19.2
=40.63 hours
If this is given at Correction time is 20 hours
40
cc/hour, =4meq x 24 hours x 40 cc
correction time
100cc
hr
would be?
=38.4 meq/day
=32.5 x 24 hours
38.4
=20.32 hours
If this is given at Correction time is 30 hours
30
cc/hour, =4meq x 24 hours x30 cc
correction time
100cc
hr
would be?
=28.8 meq/day
=32.5 x 24 hours
28.8
=27.08 hours
*actually its not 30

Example # 2
Patient Weight= 28.5 kilos
Patient Potassium = 2.3 meq/L
Rate= 50 cc/kg/hour
1. Maintenance
(2-3meq /kg)

2 meq x 28.5 kg = 57 meq

kg

2. Deficit= 3.5actual) x wt x
50(constant)
x 0.05
3. Total
K
requirement
=
Maintenance
+ Deficit
4. Potassium
Infusion Rate
(KIR)
=meq x IVF rate
Wt

=(3.5-2.3) x 28.5kg x 50 x
0.05
=85.5 meq
=57 meq + 85.5 meq= 142.5
meq/day

Peripheral:
meq=6meq/100ml
= 6/100 x 50 = 0.10
28.5
Should not exceed 0.30 (risk
for phlebitis

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PHARMACOLOGY
FLUID AND ELECTROLYTES
DR. ICBAN
AUGUST 25,2016
5. Total K in 24 =6meq x 24 hours x 50 cc
hours
100cc
hr
=72 meq/day
6. Correction
time

=Total Requirement x 24
Total K in 24 hours
=142.5 x 24 hours
72
=47.5 hours

POTASSIUM SUPPLEMENTS
o

Dosage:
o PO 20 meq in 1-2 divided doses
o Kalium Durule (10 meqs/durule)
o IV 20-40 meq diluted in 1L IV solution

Adults patient: If can tolerate oral, Give Kalium

durule
o

Pharmacokinetics
o Absorption: PO rapidly absorbed, 95 in
the body fluids
o Distribution: Unknown (for durule)
o Metabolism: Unknown (for durule)
o Excretion: 80-90% in urine, 10% feces
Pharmacodynamics
o PO: onset 30 minutes
o PO: Peak: 1-2 hours
o IV: Onset:rapid
o IV: Peak: 1-1.5 hours
Adverse effects: Nausea, vomiting, diarrhea,
abdominal cramps, irritability, rashes, phlebitis
with IV administration

If patient is receiving K-sparing diuretics, shift

diuretics to furosemide or thiazide
Sodium bicarbonate: Giving base, allows
shifting potassium to cell
10% ca gluconate: does not correct
hyperkalemia, but reduce irritability of
myocardium from hyperkalemia
Insulin: increase entry in potassium
Kayexelate: catio exchange for severe cases

SODIUM

HYPERKALEMIA >5 meq/L

Pseudohyperkalemia=prolonged tourniquet or
probing

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PHARMACOLOGY
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DR. ICBAN
AUGUST 25,2016

HYPONATREMIA: THERAPY

HYPONATREMIA <135 MMOL/L

HYPERNATREMIA >150 MEQ/L

THERAPY: (SEE NEXT PAGE)

Most common manifestation: Neurologic

(seizure) due to cerebral edema and altered
nerve conduction
For correction, should identify the cause

What fluid is given in hyponatremia? Isotonic

solutions. PNSS and PLRS

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PHARMACOLOGY
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AUGUST 25,2016

THERAPY: HYPERNATREMIA

THERAPY: HYPERNATREMIC DEHYDRATION

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PHARMACOLOGY
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SUMMARY MAINTENANCE AND BOLUS
1. 2 year old child
Admitting diagnosis
12kg.
What IV fluid would be
given?

with fever and cough.

is pneumonia. Weight is

Fluid Requirement per

day (12 kg)

10x 100ml +
2 x 50ml
=1100 ml/day

Maintenance Fluid
(D5-IMB)
R: patient is not
dehydrated

Just use 60% to prevent 1100 ml x 0.60

inappropriate
ADH =660 ml/day
secretion
Regulation of IV fluid
660 ml/24 hours
=27.5 ml/hour or
27.5
microdrops/min
Doctors Order

D5 IMB, 500cc @
27.5 cc/hour or 27.5
microdrops/minute

On the second hospital day, patient complains of

loss of appetite, vomiting (post-tussive) for 10
episodes and loose watery stools. Pertinent PE
findings: Slightly sunken eye-ball, dry lips, BP
90/60, CR: 120. Nurse called you for fluid to
follow:
What would be the
fluid to follow?

Do we need to give IV
bolus?

PNSS or PLRS
R: the patient is
dehydrated
No. because this is
not an impending
shock

Note: For dehydration the rehydrating fluid volume depends

whether it is mild, ,moderate severe
Less than 10 kilos:
Mild 50ml/kg;
Moderate-Severe 100ml/kg

More than 10 kilos:

Mild 30 ml/kg;
Moderate: 50 mg/kg

DR. ICBAN
AUGUST 25,2016
If the patient is 12 kg x 30 ml/kg
weighing 12 kg (Mild 360 ml for 6(or 8)hrs
dehydration)
=60 ml/ hour
Doctors Order

Plain LRS 500cc @

60cc/hour for 6
hours, then reassess
hydration status

If this was given at 12mn and at 6am, the

nurse called for to-follow fluid. Would you give a
new fluid?
Would you give a new No. because the
fluid?
previous
fluid
(500cc) is not used
up yet because in 6
hours only 360cc has
been used up. 140cc
is still remaining
What is the appropriate Regulate IV fluid if
action?
the patient is not
dehydrated anymore
at maintenance rate
(27.5 cc/hour)

@ 8am, patient complains severe abdominal pain

with abdominal distention (ileus)
What
cause Ileus secondary to
abdominal distention hypokalemia
in patient?
Appropriate action
Check
for
bowel
sounds and check for
electrolytes

Note:

For adults, the fluid regulation, avoid fluid

regulation, the maximum is usually 120 cc to
150 cc/hour.
For young obese patients, should not give the
full 50 kilos requirement.
e.g: 50 kilos= 2.1 L (not exceeding 3L)
You should not exceed 3L/day for maintenance
fluids

For the patient, 12 kg the rehydration fluid is at 30 ml/kg

that should be given for 6-8 hours

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