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Disorders of sodium and fluids Patrick D Brophy, MD, MHCDS Director Pediatric Nephrology Professor The
Disorders of sodium and
fluids
Patrick D Brophy, MD, MHCDS
Director Pediatric Nephrology
Professor
The University of Iowa
Objectives
Objectives
1. Understand cellular fluid shifts. 2. Understand maintenance/deficit fluids and calculations. 3. Understand
1. Understand cellular fluid shifts.
2. Understand maintenance/deficit fluids and
calculations.
3. Understand hyponatremic, isonatremic
hypernatremic dehydration and therapy.
TBW changes with Age
TBW changes with Age
TBW changes with Age
TBW changes with Age
Total Body Water
Total Body Water
Total Body Water  % Total body water (TBW)  ’ s with  age –

% Total body water (TBW) s with age

– Preterm infants: 80% – Neonates & infants: 70-80% – Toddlers & young children: 60-70%
– Preterm infants: 80%
– Neonates & infants: 70-80%
– Toddlers & young children: 60-70%
– Older children & adults: 60%
 calculate TBW: 0.6 x weight(kg) in adults
 calculate TBW: 0.6 x weight(kg) in adults
Total Body Water
Total Body Water
 Two main fluid compartments – Intracellular space – Extracellular space  Maintained through water
 Two main fluid compartments
– Intracellular space
– Extracellular space
 Maintained through water and sodium
balance
Extracellular Fluid (ECF)
Extracellular Fluid (ECF)
Extracellular Fluid (ECF)  Fluid outside of cells 1/3 of TBW   ’ s with


Fluid outside of cells 1/3 of TBW s with age ECF divided into 2 sub-compartments


 ’ s with age ECF divided into 2 sub-compartments  – interstitium  15-20% of
– interstitium  15-20% of TBW – vascular space  5-10 % of TBW
– interstitium
 15-20% of TBW
– vascular space
 5-10 % of TBW

Extracellular Fluid- Components
Extracellular Fluid-
Components
 Na + is principal cation in the ECF  Cl - & HCO 3
 Na + is principal cation in the ECF
 Cl - & HCO 3 - are principal anions in the
ECF
 Regulation of ECF is primarily related
to Na + balance
– Total body Na + affects ECF status
Intracellular Fluid
Intracellular Fluid
 ICF consists of fluid w/in cells  True ICF is difficult to calculate 
 ICF consists of fluid w/in cells
 True ICF is difficult to calculate
 K + is principal cation in ICF
 HPO 4 -2 & proteins are principal anions
in the ICF
 Regulation of ICF: through regulation
of plasma osmolality through changes
in water balance
Osmolality
Osmolality
 Osmolality – A measure of all solute particles per weight of solvent, including: 
 Osmolality
– A measure of all solute particles per
weight of solvent, including:
 impermeable: Na + , Cl - , mannitol, or glucose
 permeable: urea, ethanol
– Calc. Osmolality = 2x [Na + ](mEq/L) +
BUN(mg/dL)/2.8 + Glucose(mg/dL)/18
– Normal osmolality= 280-295 mOsm/kg
Tonicity
Tonicity
 Tonicity – Measure of the “effective osmols” (impermeable) in a particular weight of solvent
 Tonicity
– Measure of the “effective osmols”
(impermeable) in a particular weight of
solvent
– Effective Osm: determined by solutes
that hold water in the ECC: (Na, glucose,
not urea)
– H 2 O moves across cell membrane from
“low” tonicity to “high” tonicity
ICF & ECF Relationship
ICF & ECF Relationship
 ICF separated from ECF by cell membrane – Cell membrane highly permeable to H
 ICF separated from ECF by cell
membrane
– Cell membrane highly permeable to H 2 O
– Cell membrane impermeable to solutes
 Osmolality at equilibrium b/w ICF &
ECF
Osmotic Forces
Osmotic Forces
osmotic gradient K+140 meq/L 280 milliosmoles/L Na + 140 meq/L 280 milliosmoles/L
osmotic gradient
K+140 meq/L
280 milliosmoles/L
Na + 140 meq/L
280 milliosmoles/L

H 2 O moves passively across the cell membrane according to the

High osmolality outside the cell = shrinkage
High osmolality outside the cell =
shrinkage
K+ 140 meq/L 280 milliosmoles
K+ 140 meq/L
280 milliosmoles

Na + 150 meq/L 300 milliosmoles/L

Low osmolality outside the cell = swelling
Low osmolality outside the cell = swelling
H 2 O K+ 140 meq/L 280 milliosmoles/L
H 2 O
K+ 140 meq/L
280 milliosmoles/L

Na + 120 meq/L

240 milliosmoles/L

cell = swelling H 2 O K+ 140 meq/L 280 milliosmoles/L N a + 1 2

Rupture

The Rules of the Road
The Rules of the Road
 Cells require adequate circulation (vascular volume) and a stable isoosmotic milieu to function 
 Cells require adequate circulation (vascular
volume) and a stable isoosmotic milieu to
function
 Maintenance fluid has been calculated by
understanding:
– Metabolic rate
– Body size
 It assumes:
– All homeostatic mechanisms are intact
Lungs and kidneys are functional and
there is adequate circulating volume
BUT…
The Rules of the Road…
The Rules of the Road…
 If these assumptions are not met (ie Renal failure), you must: – Calculate insensible
 If these assumptions are not met (ie Renal
failure), you must:
– Calculate insensible losses
– Calculate fluid and electrolyte loss
– Calculate fluid rate based on above
TABLE 1
TABLE 1
INSENSIBLE WATER CALCULATIONS Basal Calorie Expenditure for Infants and Children* = water loss
INSENSIBLE WATER CALCULATIONS
Basal Calorie Expenditure for Infants and
Children* = water loss

Age

Weight

Surface

H

2 O

 

Area

Expenditure

 

(kg)

(M 2 )

(cc/kg/24 hr)

Newborn

2.5-4

0.2-0.23

50

1

week-

3-8

0.2-0.35

65-70

6

months

6-12 months

8-12

0.35-0.45

50-60

1-2 years

10-15

0.45-0.55

45-50

2-5 years

15-20

0.6-0.7

45

5-10 years

20-35

0.7-1.1

40-45

10-16 years

35-60

1.5-1.7

25-40

Adult

70

1.75

15-20

*Water expenditure equals 1 ml/cal.

Calculation of Insensible Losses
Calculation of Insensible
Losses
 Insensibles=500 ml/m 2  To calculate m 2 :  BSA (m 2 )=
 Insensibles=500 ml/m 2
 To calculate m 2 :
 BSA (m 2 )=
sq root of [height (cm) x

weight (kg)/3600] Alternatively based on wt:

2 )= sq root of [height (cm) x weight (kg)/3600]  Alternatively based on wt: –
2 )= sq root of [height (cm) x weight (kg)/3600]  Alternatively based on wt: –
2 )= sq root of [height (cm) x weight (kg)/3600]  Alternatively based on wt: –

BSA= 4 x wt (kg) + 7/ 90 + wt (kg)

Approach to Fluid Calculations
Approach to Fluid
Calculations
 Calculate….  1. Maintenance  2. Deficit  3. Ongoing losses
 Calculate….
 1. Maintenance
2. Deficit
3. Ongoing losses
Concepts
Concepts
 Fluids are DRUGS!!  We wouldn’t prescribe morphine without checking the dose or thinking
 Fluids are DRUGS!!
 We wouldn’t prescribe morphine
without checking the dose or thinking
it through (side effects, allergies etc.)
 Why do we do this with fluids?
Maintenance Fluids
Maintenance Fluids
 Based upon usual losses of H 2 O & solutes under normal conditions 
 Based upon usual losses of H 2 O &
solutes under normal conditions
 Fluid requirements may be calculated
by:
– –
 Fluid requirements may be calculated by: – – – Metabolic requirements (Holliday-Segar) Body surface

Metabolic requirements (Holliday-Segar) Body surface area (BSA) Body weight

may be calculated by: – – – Metabolic requirements (Holliday-Segar) Body surface area (BSA) Body weight
may be calculated by: – – – Metabolic requirements (Holliday-Segar) Body surface area (BSA) Body weight
Holiday & Segar (1957)
Holiday & Segar (1957)
 Based on studies of normal, healthy infants and children – 100 mL/100 kCal/day fluid
 Based on studies of normal, healthy
infants and children
– 100 mL/100 kCal/day fluid requirement = 1 mL/1
kCal/day:
 IV fluids are calculated based on weight
and metabolic req’ts:
– 0-10 kg: 100 mL/kg/day
– 10-20 kg: 1000 mL plus 50 mL/kg/day
– >20 kg: 1500 mL plus 20 mL/kg/day
– Max 2500cc/24 hr
Maintenance Electrolytes
Maintenance Electrolytes
 Electrolyte requirements: – Na + : 2.5-3.0 mEq/100 kCal/day – K + : 2.0-2.5
 Electrolyte requirements:
– Na + : 2.5-3.0 mEq/100 kCal/day
– K + : 2.0-2.5 mEq/100 kCal/day
– Cl - : 4.5-5.5 mEq/100 kCal/day
 Based on these calculations, all
children receive hypotonic fluids
TABLE II Holliday Segar calculation of maintenance fluids and electrolytes
TABLE II
Holliday Segar calculation of maintenance fluids and
electrolytes
 

Water

Electrolytes

 

(cc/kg)

(per 100 cc H 2 O)

1 st 10 kg body weight

100

Na

3mEq

2 nd 10 kg body weight

50

C1

2mEq

Each additional kg

20

K

2mEq

through 70 kgm

EX: Therefore in a 22 kg 4-year-old, the maintenance fluid could be calculated by:

10 kg x 100 cc/kg = 1,000 cc 100 kg x 50 cc/kg = 500 cc 2 kg x 20 cc/kg = 40 Total H 2 0 - 1,540 cc

Na=3 meq/100 cc = 45 meq in 1.5 liters = 30 meq/Liter K=2 meq/100 cc = 30 meq in 1.5 liters = 20 meq/Liter

These calculations can be made with a maximum weight of 70 kg or a total volume of 2,500 cc/24 hr.

In order to utilize prepared IV solutions, you round off the electrolyte requirements to the
In order to utilize prepared IV solutions, you round
off the electrolyte requirements to the closest
solution available. All orders must be written
with the quantities “per liter” as a standard.
This makes it easy to compare the IV solution to
what you know is in plasma water. You know
D5.2NaC1 contains 38 meq of NaC1 per liter,
so this is an effective fluid to use.
For the 22 kg boy, your order would read:
D5.2 NaCl with 20 meq/KCl/liter @ 64 cc/hr.
Maintenance Concepts
Maintenance Concepts
 The Holliday Segar calculation was derived at a very different time in the history
 The Holliday Segar calculation was derived
at a very different time in the history of
caring for children:
– The severity of illness of kids has changed
– We understand more about hormonal (ADH)
control water and electrolyte homeostasis
– This formulation has stood the test of time and
is still useful for general treatment of well
children
Maintenance Calories
Maintenance Calories
 Caloric requirements (to prevent severe ketosis & tissue catabolism): – 20% of daily caloric
 Caloric requirements (to prevent
severe ketosis & tissue catabolism):
– 20% of daily caloric requirements
sufficient
– 5 gm dextrose  20 kCal
– Each 100 mL of maintenance fluid should
contain 20 kCal (5 gm dextrose)/100 mL
– D 5 W (50 gm dextrose/1 Liter)
Composition of Standard IVF
Composition of Standard
IVF

Solution

Na +

           

HCO 3

-

 

Osmolality

 

K +

Cl -

 
 

(mEq/L)

(mEq/L)

(mEq/L)

(mEq/L)

(mOsm/kg)

5% Dextrose in

0

0

0

0

 

278

2 O (D 5 W)

H

Isotonic Saline (0.9% NSS)

154

 

0

154

0

 

308

5 W w/ 0.45%

D

77

0

77

0

432

Saline

5 W w/ 0.225%

D

38.5

 

0

38.5

0

 

355

Saline

Lactated Ringers

130

 

4

109

28

272

Abnormal Maintenance
Abnormal Maintenance
Increased Maintenance fluid requirement:
Increased Maintenance fluid requirement:
–
Maintenance Increased Maintenance fluid requirement: – Fever (12.5% per degree > 38C) Increased sweating

Fever (12.5% per degree > 38C) Increased sweating

– Fever (12.5% per degree > 38C) Increased sweating Hyperpnea Vomiting Diarrhea High environmental temperature
Hyperpnea Vomiting
Hyperpnea
Vomiting

Diarrhea High environmental temperature Hyperosmolar states (dehydration, DKA)

temperature Hyperosmolar states (dehydration, DKA) Hyperventilation (asthma, RSV) Decreased maintenance fluid
temperature Hyperosmolar states (dehydration, DKA) Hyperventilation (asthma, RSV) Decreased maintenance fluid
Hyperventilation (asthma, RSV)
Hyperventilation (asthma, RSV)
Decreased maintenance fluid requirements:
Decreased maintenance fluid requirements:
–
(asthma, RSV) Decreased maintenance fluid requirements: – Decreased renal function Increased environmental humidity

Decreased renal function Increased environmental humidity Hypothermia

fluid requirements: – Decreased renal function Increased environmental humidity Hypothermia Hypometabolic states
fluid requirements: – Decreased renal function Increased environmental humidity Hypothermia Hypometabolic states
Hypometabolic states
Hypometabolic states
fluid requirements: – Decreased renal function Increased environmental humidity Hypothermia Hypometabolic states
Approach to Fluids con’td
Approach to Fluids con’td
 1. Maintenance  2. Deficit…
1. Maintenance
2. Deficit…
Deficit Therapy-Approach
Deficit Therapy-Approach
 Before correcting a fluid deficit, one must answer the following: 1. Does a significant
 Before correcting a fluid deficit, one
must answer the following:
1. Does a significant volume deficit exist?

If so, how much? Does an osmolar disturbance exist? Does an acid-base disturbance exist? Does a disturbance of K + exist?

2. 3. 4.
2.
3.
4.
5. What is the state of renal function?
5. What is the state of renal function?
1. Volume Deficit
1. Volume Deficit
 Dehydration: – refers to a negative body water or water balance – No definite
 Dehydration:
– refers to a negative body water or water
balance
– No definite laboratory test will assess this
 Assessing % dehydration depends
upon:
– Bedside examination & clinical findings
– Knowledge of prior “well” weight
– Signs & symptoms
Deficit Therapy
Deficit Therapy
 When treating deficits, remember: – Deficits are dynamic – Account for both maintenance &
When treating deficits, remember:
– Deficits are dynamic
– Account for both maintenance & deficit
fluids
 Deficit assumed to be due to a
decrease in ECF
1. Volume Deficit- Estimation
1. Volume Deficit-
Estimation
 Severity of dehydration (estimates): – Mild: 5% (3% for older child) – Moderate: 10%
Severity of dehydration (estimates):
– Mild: 5% (3% for older child)
– Moderate: 10% (6% for older child)
– Severe: 15% (9% for older child)
– Shock: inadequate tissue perfusion
 “Well” wt - “Ill” wt = fluid deficit (kg)
1. Volume Deficit- Estimation
1. Volume Deficit-
Estimation
 Mild Dehydration (3-5%) – Normal BP, HR, pulses, fontanel, skin turgor, slightly dry mucous
 Mild Dehydration (3-5%)
– Normal BP, HR, pulses, fontanel, skin turgor, slightly dry
mucous membranes,  UOP
 Moderate Dehydration (6-10%)
– Normal BP, increased HR,  pulses, sunken fontanel,
depressed MS,  skin turgor,  UOP, dry mucous
membranes
 Severe Dehydration (9-15%)
– Normal to  BP,  pulses, sunken fontanel, depressed MS,
 skin turgor, oliguria/anuria, dry mucous membranes
 Shock (> 10-15%)
– Sign  BP/pulses, impaired organ perfusion/failure,
decreased mentation
1. Volume Deficit- Calculation
1. Volume Deficit-
Calculation
Severity of dehydration (calculation):
Severity of dehydration (calculation):
Deficit- Calculation Severity of dehydration (calculation):  – Requires prior knowledge of “ well ” weight


Requires prior knowledge of well

weight – % dehydration = [(“well” weight- “ill” weight)/”well” weight] x 100%
weight
– % dehydration = [(“well” weight- “ill”
weight)/”well” weight] x 100%
weight- “ill” weight)/”well” weight] x 100% ie 12 kg child with current wit 10.8kg  12-10.8/12

ie 12 kg child with current wit 10.8kg 12-10.8/12 x 100%= 10% deficit


Volume Deficit: Replacement
Volume Deficit:
Replacement
 Severe dehydration of signs of decreased perfusion
 Severe dehydration of signs of
decreased perfusion
 Severe dehydration of signs of decreased perfusion – Appropriate therapy is the administer 10- 20cc/kg

Appropriate therapy is the administer 10-

20cc/kg NS bolus and reassess – Note: Hypotension is a late sign in children
20cc/kg NS bolus and reassess
– Note: Hypotension is a late sign in
children
Volume Deficit
Volume Deficit
Volume Deficit  Replacement Initial IV fluid bolus as needed (NS) Calculate remaining deficit  


Replacement Initial IV fluid bolus as needed (NS) Calculate remaining deficit

IV fluid bolus as needed (NS) Calculate remaining deficit   – Total deficit- fluid bolus
  – Total deficit- fluid bolus vol – Replace ½ in first 8 hrs
– Total deficit- fluid bolus vol
– Replace ½ in first 8 hrs
– Replace remainder in next 16 hrs
– Do not forget to add maintenance
2. Osmolar Disturbance
2. Osmolar Disturbance
 Measuring serum Na + : – Severe hypotonic: < 120 mEq/L – Hypotonic (hyponatremic):
 Measuring serum Na + :
– Severe hypotonic: < 120 mEq/L
– Hypotonic (hyponatremic): 120-130
mEq/L
– Isotonic (eunatremic): 130-150 mEq/L
– Hypertonic (hypernatremic): > 150
mEq/L
 Not always necessary to measure
serum osmolality

mgm/dl mgm/dl

Serum osmolality = serum Na + X 2 + BUN + glucose

2.8

18

Urea - moves passively across the cell and therefore does not cause an osmotic

gradient

Glucose - in diabetes cannot move intracellularly and therefore is an osmotic gradient and dilutesthe sodium effect

Types of Dehydration
Types of Dehydration
 Isonatremic - cells neutral  Hypernatremic - cells shrunken and can have rebound 
 Isonatremic - cells neutral
 Hypernatremic - cells shrunken and
can have rebound
 Hyponatremic - cells swollen
Types
Types
 Isonatremic – 80% of all dehydration – Proportional loss of salt and water –
Isonatremic
– 80% of all dehydration
– Proportional loss of salt and water
– Treatment
 Calculate deficit from decreased weight
 Replace intravascular volume with isotonic
solution such as lactated ringer’s
 Calculate maintenance
 From tables calculate estimate of water,
sodium and potassium deficit
Orders Standard  Isotonic rehydration 10-20 cc/kgm (more important to restore vascular volume)  Calculate

Orders Standard

 Isotonic rehydration 10-20 cc/kgm (more important to restore vascular volume)  Calculate deficit –
 Isotonic rehydration 10-20 cc/kgm (more
important to restore vascular volume)
 Calculate deficit
– Give ½ over 8 hours
– Give ½ over 16 hours
 Calculate maintenance
– Run piggyback
 Calculate ongoing losses
– Replace hourly
Orders In Reality
Orders In Reality
 Emergency Room - isotonic rehydration 10-20 cc/kg or until looks better  Home on
 Emergency Room - isotonic rehydration
10-20 cc/kg or until looks better
 Home on oral rehydration solution
5cc/minute = 300 cc/hour
 Key is to restore intravascular volume
Oral Rehydration Therapy
Oral Rehydration Therapy
 Preferred for mild/moderate dehydration  Recommended by the AAP, WHO, CDC  Advantages of
 Preferred for mild/moderate dehydration
 Recommended by the AAP, WHO, CDC
 Advantages of ORT:
– Less expensive/fewer complications than IV therapy
– Applicable in any patient care setting
 Contraindications to ORT:
– Severe dehydration, intractable vomiting shock, impending
shock
– Lack of personnel to administer ORT
ORT Failure
ORT Failure
 Indications of ORT failure
Indications of ORT failure
ORT Failure  Indications of ORT failure – Clinical deterioration – Failure to rehydrate in 8
ORT Failure  Indications of ORT failure – Clinical deterioration – Failure to rehydrate in 8

Clinical deterioration

 Indications of ORT failure – Clinical deterioration – Failure to rehydrate in 8 hours –

Failure to rehydrate in 8 hours

Clinical deterioration – Failure to rehydrate in 8 hours – Intractable vomiting/high purging rate Institute IV

Intractable vomiting/high purging rate

Institute IV therapy
Institute IV therapy
  Use of IV therapy does not preclude resumption of ORT after rehydrated
 Use of IV therapy does not preclude
resumption of ORT after rehydrated
Appropriate Fluids
Appropriate Fluids
CHO/mmol/L Na K Base Osmo WHO formula 140 45 20 48 265 Pedialyte 140 45
CHO/mmol/L Na
K
Base
Osmo
WHO formula
140
45
20
48
265
Pedialyte
140
45
20
30
250
Not appropriate:
Cola
Apple juice
Chicken broth
700
2
0
13
750
690
3
32
0
730
0
250
8
0
500
Hyponatremia
Hyponatremia
Hyponatremia  USUALLY means Serum osmolality is below normal except for  Hyperlipidemia 

USUALLY means

Serum osmolality is below normal except for  Hyperlipidemia  Hyperglycemia/mannitol - which adds osmoles
Serum osmolality is below normal except for
 Hyperlipidemia
 Hyperglycemia/mannitol - which adds osmoles

Na

+

140 meq/L

Lipid

Na + 140 meq/L Lipid Na + 140 meq/L measured at 130 meq/L because total aliquot
Na + 140 meq/L
Na +
140 meq/L

measured at 130 meq/L because total aliquot

is used to divide

even though

Na + is only distributed in

the water, not the lipid

TABLE VIII

body wt

TABLE VIII  body wt Deficit of total body water and larger deficit of total body

Deficit of total body water

and larger deficit of total body sodium

of total body water and larger deficit of total body sodium ECF volume depletion HYPONATREMIA 

ECF volume depletion

and larger deficit of total body sodium ECF volume depletion HYPONATREMIA  body wt Wt neutral
and larger deficit of total body sodium ECF volume depletion HYPONATREMIA  body wt Wt neutral

HYPONATREMIA

of total body sodium ECF volume depletion HYPONATREMIA  body wt Wt neutral or slightly 

body wt

Wt neutral or slightly

Excess total body sodium

and larger excess of total body water

Excess total body water

larger excess of total body water Excess total body water Modest ECF volume excess (No edema)

Modest ECF volume excess (No edema)

ECF volume excess (edema)

ECF volume excess (No edema) ECF volume excess (edema) Renal losses Diuretic excess. Mineralo- corticoid
ECF volume excess (No edema) ECF volume excess (edema) Renal losses Diuretic excess. Mineralo- corticoid

Renal losses Diuretic excess. Mineralo- corticoid deficiency. Salt- losing nephritis. Bicarbonaturia (renal tubular acidosis. Metabolic alkalosis). Ketonuria, osmotic diuresis (glucose, urea, Mannitol)

Extrarenal losses Vomiting. Diarrhea. third spaceburns. Pancreatitis. traumatized muscle

1.Glucocorticoid

Nephrotic syndrome.

Acute and

deficiency. 2 Hypothyroidism. 3. Syndrome of Inappropriate ADH secretion.

chronic renal

Cirrhosis. Cardiac failure.

failure

Urinary sodium

Urinary sodium

Urinary sodium

Urinary sodium

Urinary sodium

concentration

>20 meq/l

concentration

<10 meq/l

concentration >20 meq/l concentration <10 meq/l Isotonic saline

Isotonic saline

concentrations

>20 meq/l

Water restriction

concentration

<10 meq/l

concentration

>20 meq/l

concentration <10 meq/l concentration >20 meq/l Water restriction

Water restriction

<10 meq/l concentration >20 meq/l Water restriction NORMONATREMIA Berl T,, et al. Kidney Int 10:117, 1976
<10 meq/l concentration >20 meq/l Water restriction NORMONATREMIA Berl T,, et al. Kidney Int 10:117, 1976

NORMONATREMIA

Berl T,, et al. Kidney Int 10:117, 1976

Hyponatremic dehydration
Hyponatremic dehydration
 5% of all dehydration  Usually occurs with a child who has high GI
 5% of all dehydration
 Usually occurs with a child who has high GI
losses accompanied by water replacement
(Jello/pop, etc.)
 Water shifts into the intracellular space to balance
osmoles, so child looks sicker since ECF is
compromised
 Causes significant neurological problems as brain
swells  Seizures
– If Na <120 meq/L - can cause permanent myelinolysis
If Na is above 120 meq/L
If Na is above 120 meq/L
 Replace intravascular volume with isotonic solution  Calculate Na deficit – desired Na -
 Replace intravascular volume with isotonic
solution
 Calculate Na deficit
– desired Na - measured Na X TBW
– (TBW = 0.6 X body wt.)
 Use D5 1/2 NaC1 = 75 meq/liter of Na to
replace deficit
– Do not change serum more than 0.5-1 meq/L/hr
– Add in maintenance +/- potassium
Hyponatremia: Correction
Hyponatremia: Correction


Ex: Na 120, in 15 kg child want to correct to 135 Calculate Na deficit (135-120) x .6 (15) = 135 meq D5W.45 = 75meq/L =1.8L Correct total 15 meq over 24 hrs

meq D5W.45 = 75meq/L =1.8L Correct total 15 meq over 24 hrs    –
 
 – Run at 75cc/hr + maintenance – Check Na q2-4 Hr and MAKE ADJUSTMENTS
– Run at 75cc/hr + maintenance
– Check Na q2-4 Hr and MAKE ADJUSTMENTS
If Na<120 meq/L, assess hydration very carefully
If Na<120 meq/L, assess
hydration very carefully
 If dry, give 20 cc/kgm of Isotonic solution  You may use hypertonic saline
 If dry, give 20 cc/kgm of Isotonic solution
 You may use hypertonic saline if CNS
signs are evident = 3% NaCl
– 514 meq/liter = 1028 mosm/L or
– 0.5 meq NaCL per cc
 Risk of seizures

Calculate deficit of sodium to

get you to 120
get you to 120
 In a 10 kg child with a sodium of 110 – (CD-CA) X 0.6
 In a 10 kg child with a sodium of 110
– (CD-CA) X 0.6 wt/kg
– (120-110) X .6 X 10
– 10 X .6 X 10 = 60 meq
 60 meq NaC1 = 120 cc of 3% NaCl
 Give over 1-2 hours rechecking Na+ every
30 minutes
Hypernatremia (Na > 150 meq/L)
Hypernatremia (Na > 150
meq/L)
 ALWAYS means Serum osmolality is above normal
ALWAYS means
Serum osmolality is above normal

TABLE VII

HYPERNATREMIA body wt body wt
HYPERNATREMIA
body wt
body wt

Na+ + H20 losses

TABLE VII HYPERNATREMIA body wt body wt Na+ + H20 losses H20 losses Low total body

H20 losses

Low total body sodium

Normal total body sodium

H20 losses Low total body sodium Normal total body sodium body wt Na+ addition Increased total
H20 losses Low total body sodium Normal total body sodium body wt Na+ addition Increased total
body wt Na+ addition
body wt
Na+ addition

Increased total body sodium

Renal losses Osmotic diuresis. Mannitol, glucose, urea

Extrarenal losses Excess sweating. Diarrhea and/or vomiting in children.

Renal losses Nephrogenic diabetes insipidus. Central diabetes insipidus.

Extrarenal losses Respiratory and normal insensible losses

Primary hyperaldos- teronism. Cushings Syndrome. Hypertonic dialysis. Hypertonic sodium bicarbonate.

 

Hypodipsia and

Sodium chloride tablets.

partial diabetes

insipidus.

Iso- or Hypotonic urine (Urinary Na+>20 meq/l)

Iso- or Hypotonic urine (Urinary Na+>20 meq/l) Hypertonic urine (Urinary Na+<10 meq/l) Hypo-, Iso-, or

Hypertonic urine (Urinary Na+<10 meq/l)

Hypo-, Iso-, or Hypertonic urine (Urinary Na+ variable)

Hypo-, Iso-, or Hypertonic urine (Urinary Na+ variable) Hypertonic urine (Urinary Na+ variable) Hypotonic saline or

Hypertonic urine (Urinary Na+ variable)

Na+ variable) Hypertonic urine (Urinary Na+ variable) Hypotonic saline or isotonic saline depending on

Hypotonic saline or isotonic saline depending on intravascular volume

saline or isotonic saline depending on intravascular volume Water replacement NORMONATREMIA Iso- or Hypertonic urine

Water replacement

NORMONATREMIA

Iso- or Hypertonic urine (Urinary Na+ >20 meq/l)

diuretics and water replacement

or Hypertonic urine (Urinary Na+ >20 meq/l) diuretics and water replacement Berl T, et al. Kidney

Berl T, et al. Kidney Int 10:117, 1976

Hypernatremic dehydration
Hypernatremic dehydration
 15% of all dehydration  Seen in children with deprivation of water – Breast-feeding
 15% of all dehydration
 Seen in children with deprivation of water
– Breast-feeding failure
– Children with losses replaced by high sodium foods
(broth, etc.)
 Water moves out of the intracellular space and the ICF is
compromised
 Na + > 160 meq/L causes CNS effects
 With shrinking of the brain there can be tearing of
bridging blood vessels causing subarachnoid or subdural
bleeds.
Treatment -- SLOW!!!
Treatment -- SLOW!!!
 If child is stable and hypernatremic and got that way over weeks, you may
 If child is stable and hypernatremic and got that way
over weeks, you may take a week to correct
 If child is in shock, give isotonic solution 10-20 cc/kg
to get out of shock
 Calculate water deficit
– 4 cc/kg for every meq that serum Na exceeds 145
– i.e. Na 160 in 10 kg child
 4X 10 X 15 = 650 cc water or 1300 cc of 1/2 NaCl
 Correct no faster than 0.5-1 meq/hr
 Run as 1/2 NaCl over 30 hrs = 1300 cc = 43 cc/hr

30

Deficit Replacement- Hypertonic
Deficit Replacement-
Hypertonic
 Hypernatremic dehydration – Clinically, the most difficult & dangerous to tx – Treat shock
 Hypernatremic dehydration
– Clinically, the most difficult & dangerous
to tx
– Treat shock w/ 0.9% NSS (20 mL/kg) IVB
over 1/2-1 hr
– Then, D 5 0.45% NSS w/ 20-40 mEq/ L
KCL
Deficit Replacement- Hypertonic
Deficit Replacement-
Hypertonic
 Duration of correction based on serum Na: – Serum Na + 150-170 mEq/L :
 Duration of correction based on serum
Na:
– Serum Na + 150-170 mEq/L : correct over 48 hrs
– Serum Na + > 170 mEq/L : correct over 72 hrs
– Serum Na + > 200 mEq/L: dialysis
Deficit Replacement- Hypertonic
Deficit Replacement-
Hypertonic
 Hypernatremic dehydration – Complications:  Cerebral swelling/brainstem herniation  Hyperglycemia: unclear
 Hypernatremic dehydration
– Complications:
 Cerebral swelling/brainstem herniation
 Hyperglycemia: unclear why, decrease
dextrose to 2.5%
 Hypocalcemia: unclear why, supplement Ca
Gluconate to IVF
Approach to fluids cont’d
Approach to fluids cont’d
 Maintenance  Deficit
Maintenance
Deficit
Approach to fluids cont’d  Maintenance  Deficit  Ongoing losses….
Approach to fluids cont’d  Maintenance  Deficit  Ongoing losses….

Ongoing losses….

Ongoing Losses:

Need Replacement
Need Replacement
Electrolyte concentration of various body fluids
Electrolyte concentration of various body fluids

Fluid

Na

K

C1

Protein

(mEq/l)

(mEq/l)

(mEq/1)

(g/dl)

20-80

5-20

100-150

-

Gastric

 

Pancreatic

120-140

5-15

40-80

-

Small Bowel

100-140

5-15

90-130

-

Bile

120-140

5-15

80-120

-

Ileostomy

45-136

3-15

30-115

-

Diarrhea

10-90

10-80

10-110

-

Burns

140

5

110

3-5

“Third space”

 

fluid

140

5

110

Variable

Summary
Summary
 Cells need adequate circulating volume to survive: always assess and maintain adequate vascular volume
 Cells need adequate circulating volume
to survive: always assess and maintain
adequate vascular volume which is part
of the extracellular space
 Cells are at risk with rapid shifts in
osmolality. Rapid fluid expansion
should always occur with isotonic fluid
Additional References  Finberg L, Kravath ER, Hellerstein S, editors. Water and Electrolytes in Pediatrics:
Additional References
 Finberg L, Kravath ER, Hellerstein S, editors. Water and Electrolytes
in Pediatrics: physiology, pathophysiology, and treatment. 2nd ed.
Philadelphia: W.B. Saunders Company; 1993.
 Feld LG, Kaskel FJ, Schoeneman MJ. The Approach to Fluid and
Electrolyte Therapy in Pediatrics. Adv Pediatr 1988;35:497-536.
 Chesney RW, Batisky DL. Fluid and Electrolyte Therapy in Infants
and Children. In: Arieff AI, DeFronzo RA, editors. 2nd ed. New York:
Churchill Livingstone; 1995. p. 877-904.
 Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte
Disorders. 5th ed. New York: McGraw-Hill; 2001.
 Winters RW. Principles of Pediatric Fluid Therapy. Chicago: Abbott
Laboratories.
 THANKS to Kevin McBryde MD -Children’s National Medical Center-
for the use of some of his slides and cases