CLINICAL PHARMACOLOGY – Fluids and Electrolytes

Lecturer: Dr. Icban

Date: January 29, 2019
Transcribed by: OOZMA KAPPA

COMPOSITION OF TOTAL BODY WATER

OUTLINE
 60:40:20:5 Rule
1. Body Water Content
2. Evaluation of Dehydration o 60% total body water
3. Indications for IV o 40% intracellular fluid
4. Maintenance Fluid o 20% extracellular fluid
a. 3 Methods for Computation of Maintenance o 5% plasma
Fluid
i. Modified Darrow (Ludan)
ii. Holliday-Segar Caloric Expenditure
Method
iii. Crawford Body Surface Area Method
b. Selection
c. General Principles
d. Assessment
e. Prescription EVALUATION OF DEHYDRATION
f. Administration
g. Monitoring
5. Potassium
a. Hypokalemia
i. Causes
ii. Manifestations
iii. Therapy
iv. Cases
b. Hyperkalemia
i. Causes
ii. Manifestations
iii. Therapy
6. Sodium
a. Hyponatremia
i. Causes
ii. Manifestations
iii. Treatment
iv. Key Points
v. Cases
b. Hypernatremia Other modifying factor to be considered before giving
i. Causes maintenance fluids:
ii. Signs and Symtoms  Fever – increase maintenance fluid about 12% for every
iii. Treatment 1⁰C rise from 37.5⁰C
Black – ppt; Blue – recording; Italicized – Batch 2019 Trans Example: 40⁰C
BODY WATER CONTENT (40-37.5) x 12% = 30%
 Average: 40 liters (40,000 mL) of fluid which make up 60%
of the body weight for healthy males; healthy females are  Hyperventilation – increase 50% of maintenance
around 50%  Presence of edema – reduce maintenance fluid by 50% of
the required maintenance
TOTAL BODY WATER
 60% water by weight
 Factors that affect the amount of TBW:
o Obesity
o Gender
o Age

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

Example: 1 y/o patient, acidotic (there is hyperventilation), Example: 3 y/o child


diarrheic, and febrile  Estimated wt= 14 kg
 Wt= 10kg  DWR(Daily water requirement)= 75ml/kg
 Maintenance: 10kg x 100 ml/kg = 1000mL  75ml/kg x 14kg = 1,050/24hrs= 43cc/hr
 Fluid to be given: 500mL This is only used in healthy individuals adult and children.
 Febrile: WEECH’S FORMULA (For weight estimation)
o (40 – 37.5) x 12% = 30%  3-12 months
o 0.30 x 1000ml = 300 ml Expected weight (kg) = (age in months + 9) / 2
 Hyperventilating: 50% (1000ml)= 500ml  1-6 years
 Total fluid requirement Expected weight (kg) = (age in years x 2) + 8
o maintenance + febrile + hyperventilation  7-12 years
o 1000ml + 300ml + 500ml = 1, 800ml/day Expected weight = (age in years x 7) - 5
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INDICATIONS FOR IV FLUID
 Maintenance fluid therapy to replace estimated normal Holiday-Segar Caloric Expenditure Method
physiologic urine output and insensible losses; patients WEIGHT (kg) DAILY WATER REQUIREMENT
with reduced or no oral intake; 3-10 100ml/kg
 Bolus fluid therapy to expand the circulating volume; 11-20 1000 + 50 ml for each kg >10
children with hypovolemia or shock > 21 1500 + 20 ml for each kg > 20
 during dehydration or hypotension
Example: 3 y/o, 14kg
 given at 20ml/kg for 3doses
Maintenance Fluid Requirement = 1,200 ml/kg
 Fluid therapy to replace abnormal losses from the GI tract
24 hrs
and other body cavities
= 50 cc/hr
 In the latest management guideline for Dengue:
o IV bolus 20ml/K or NSS or PLRS. Then recheck BP.  Most commonly used 

o If still hypotensive, administer blous again. Recheck  More accurate than Ludan 

BP.  Calculates the rate of caloric expenditure to 
hospitalized
o If the patient is not responding they would children 

recommend administration of albumin (colloids) to  It is proportional to the child’s weight with the needs for
prevent congestion or fluid overload water estimated at 100ml/100cal 

 Not suitable for: 

MAINTENANCE FLUID
o Newborn < 14 days old
 It is the amount of fluid the body needs for the
o GI or abnormal urine conditions

replacement of the usual daily losses from normal
o Obese children

functions of the respiratory system, the skin (insensible),
o Increased metabolism in patients with infections
the kidney (obligatory urine volume) and the GIT.
 Requirement is directly proportional to the caloric Crawford Body Surface Area Method
expenditure in the absence of renal impairment and other  Used in patients whose requirements cannot be measured
insensible losses. using Holliday-Segar’s method.
 Daily water requirement= 1500ml/m2 BSA
3 METHODS FOR COMPUTATION OF MAINTENANCE FLUIDS
 Caloric expenditure is proportional to surface area 

Modified Darrow (Ludan Method)
 Accurate for children >10kg and can be used in 
diseases
WEIGHT (kg) DAILY WATER REQUIREMENT (ml/kg)
with abnormal losses 

Newborn 75
 More accurate in complicated patients 

3-10 100
 Most precise and should be applied to the ff: 

10-20 75
o ICU patients with oliguria secondary to acute kidney
20-30 50-60
injury
30-60 40-50
o Children with insensible losses (diarrhea, burn,etc)
>60 40
 Body Surface Area (BSA)
 Estimate daily water requirement based on expenditure o BSA= SQR [BW(kg) x ht (cm) / 3600]
of energy among healthy children and adult. o *SQR (square root)
 Ludan simplified Darrow’s data and formulated the above Newborn 0.25 m2
table with the assumption that the needs for water are Child 2 yrs old 0.5 m2
estimated at 150ml/100cal to include changes in dynamic Child 10 yrs old 1.14 m2
activity, growth, body temperature, and respiration. Adult Women 1.6 m2
 Maintenance depends on caloric expenditure. Adult Men 1.9 m2

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

SELECTION ASSESSMENT
 D5 ½ NS (D5 0.45 NS) + 20 mEq/L KCl  Before starting IV fluids, baseline serum electrolytes (Na,
 D5 0.2 NS + 20 mEq/L KCl K, glucose, urea, creatinine) should be measured.
o For children weighing < 10kg  Patients undergoing day surgery where the IV is
o Higher water needs discontinued at the end of the case do not need their
 But the available in the country is D5 .9 NS electrolytes measured.
o Dilute D5 .9 NaCl with water to prepare for D5 ½ NS o Elective cholecystectomy (managed as
o For every 100ml solution of D5 ½ NS: 50ml of PNSS (or outpatient)- no need for post op electrolytes
0.9 NS) + 50 ml D5 water o Ruptured appendicitis- needs post op elec
 For the current guideline does not recommend D5 IMB
anymore, D5 ½ NS and D% 0.2 NS are recommended PRESCRIPTION OF IV FLUID THERAPY
instead.  5% Dextrose in water
o A carbohydrate solution that uses glucose(sugar) as
Example: if the maintenance fluid for a 10kg child is D5 ½
the solute dissolved in sterile water. Five percent
NS, how would you prepare it?
dextrose in water is packed as an isotonic solution but
becomes hypotonic once in the body because the
 For every 100ml solution of D5 ½ NS:
glucose (solute) dissolved in sterile water is
50ml of PNSS (or 0.9 NS) + 50 ml D5 water
metabolized rapidly by the body’s cells.
 Colloid solutions
GENERAL PRINCIPLES
o IV fluids containing large proteins and molecules that
 Any hospitalized child requiring IV fluids should be
tend to stay within the vascular space (blood vessels).
considered at risk of non-physiological (inappropriate)
o Commonly used colloid solutions include plasma
ADH secretion.
protein fraction, salt poor albumin, dextran, and
 Groups particularly at risk identified in published case hetastarch.
series include : o D5 water
o Children undergoing surgery and those with acute
 Crystalloid solutions (LRS, NSS, D5 IMB, D5 NM)
medical illnesses including meningitis, encephalitis,
o Are the primary fluid used for prehospital IV therapy.
bronchiolitis and pneumonia
o Crystalloids contain electrolytes (e.g., sodium,
 In the absence of a need to correct a fluid deficit in these potassium, calcium, chloride) but lack the large
patients, IV fluids should be administered at the rate of proteins and molecules found in colloids.
60-70% of the usual calculation for normal maintenance o Crystalloids come in many preparations and are
requirements and in the form of isotonic saline or Ringer's classified according to their “tonicity.”
Lactate. o Crystalloid’s tonicity describes the concentration of
 Proprietary enteral fluid preparations and TPN solutions electrolytes (solutes) dissolved in the water, as
are low in sodium (<40 mmol/L) and maybe a substantial compared with that of body plasma (fluid surrounding
source of electrolyte free water. the cells).
 Patients on long term TPN and who are not acutely ill are  Isotonic
not at increased risk for the development of acute  Hypotonic
hyponatremia.  Hypertonic
 Infants and young children have limited glycogen stores  Lactated Ringer’s
and saline solutions with added dextrose are required to o An isotonic crystalloid solution containing the solutes
prevent hypoglycemia and ketosis. sodium chloride, potassium chloride, calcium chloride,
 Children with cardiac failure, renal failure and hepatic and sodium lactate, dissolved in sterile water
failure with ascites have chronically low PNa values (solvent).
because of water retention and/or abnormalities of the  Normal saline solution
renin/angiotensin mechanism. o An isotonic crystalloid solution that contains sodium
 These patients have chronic hyponatremia and are not at chloride (salt) as the solute, dissolved in sterile water
risk for the development of cerebral edema. (solvent).
 Patients who are at increased risk for cerebral edema are o The specific concentration for normal saline solution
those with acute hyponatremia (symptoms occurring is 0.9%.
<48hrs).
FLUID Na Cl (mEq) K (mEq) Ca Lactate
Example: 3 y/o child with pneumonia. How will you (mEq) (mEq)
regulate the fluid of this patient using Holliday-Segar NSS 154 154
method? 0.45% NaCl 77 77
 Requirement= 1200ml/day 0.2% Normal 34 34
 Because of the presence of an acute medical illness: Saline
1200ml x (.60) = 720ml should only be given Ringer’s 130 109 4 3 28
Lactate

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IV FLUID ADMINISTRATION
 IV fluid boluses should only be used in children with
significant ECF contraction or impending shock and only in
the form of isotonic saline (0.9% NaCl or Ringers Lactate).
 Solutions containing glucose (D5 containing) are not used
because glucose is a osmotic diuretic.
 The injudicious use of IV bolus therapy will transiently over
expand the ECF compartment and result in an increase in
the renal sodium excretion.
 IV fluid therapy to replace losses from the GI tract should
only be in the form of isotonic saline (0.9% NaCl or Ringers
Lactate).
 Solutions with added dextrose may be required based on
the patient age and the blood glucose level
 Until serum electrolyte values are known, when starting IV
maintenance fluids, 0.9% NaCl or Ringers Lactate are
recommended.
MONITORING
 Patients receiving >50% of maintenance fluids by the 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 (K)
 Normal value: 3.5-5.0 mEq/L 
 by:
 Potassium is the dominant intracellular electrolyte
 It is the 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 
 o Poor dietary intake
 If H+ is greater than K+, the kidney will secrete H+ instead
of K+. The serum K+ will rise. The opposite is true if the H+
level drops. This is important to remember in acid-base
disorders.
 Increased potassium levels stimulate aldosterone release
from the adrenal gland, which promotes K+ loss in the
urine.
 K is 98% intracellular
 The serum K does not decline significantly until there is
substantial total body K deficit and/or shift of K from the
ECF to the ICF
 There is no accurate method to calculate the absolute
amount of K deficit in a patient
 Potassium, like other electrolytes, moves constantly
among cells, the blood, urine, gastrointestinal fluids,
sweat and saliva. This movement of potassium is
influenced by:
o Changes in pH
o Insulin
 Managed with:
o Adrenal hormones
  K supplement
o Changes in serum sodium
CLINICAL PHARMACOLOGY – Fluids and Electrolytes
 Important functions include:
o Neuromuscular irritability, the ability of nerve and
muscle cells fire (depolarize)

 hypoK→ there is prolonged repolarization →
diminished action potential → if hypoK
progresses, Na channels may open →
hypereactive state → arrhythmia
o Cardiac impulse conduction and muscle contractility
o ICF osmolarity (cell osmotic pressure)
o Regulation of acid-base balance
o Activation of enzyme reactions
o Influencing kidney function
 Regulatory Mechanisms of Potassium Balance
o Insulin
o Catecholamines (increased renin angiotensin leads to
increased aldosterone)
o Aldosterone (promotes potassium excretion) affects
the distribution between ECF and ICF
 Route of Elimination of Potassium
o Kidneys excrete about 80% of potassium
o Bowel
o Skin
HYPOKALEMIA (<3.5 mEq/L)
Causes
 Hypokalemia without K deficit (shift from extracellular to
intracellular fluid or redistribution hypokalemia) caused
o Insulin

o Catecholamines
o Alkalosis
o Familial hypokalemia periodic paralysis
 Hypokalemia with K deficit caused by:
o Extrarenal losses (vomiting, diarrhea, laxative abuse)
o Renal losses (tubular disease, diuretic abuse, RTA,
DKA, excess mineralocorticoid effect)
Bartter syndrome represents a set of closely related,
autosomal recessive renal tubular disorders characterized
by:
 Hypokalemia
 Hypochloremia
 Metabolic Alkalosis
 Hyperreninemia
 Normal Blood Pressure
The underlying renal abnormality results in excessive
urinary losses of sodium, chloride, and potassium.
In response to this, the body will increase the release of
aldosterone (↑Na reabsorption, ↓ K levels). Hence the
hypokalemia in these patients. (hypokalemia with K deficit)
 ACEi
 Aldosterone antagonist
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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

Signs and Symptoms Correction Time mEq K x total K in 24 hours

 Neuromuscular: most important clinical manifestation 24 hrs X
o Ileus, muscle weakness, areflexia, tetany
 Cardiac: Arrythmias Example 1:
o ECG changes, flattened T waves, U waves and ST Weight = 28.5 kg
segment depression Rate = 50cc/kg/hr
 Renal: K = 2.3 mEq
o Polydipsia, polyuria, edema, Na retention, increased Maintenance 2mEq x 28.5kg = 57
ammonia production Deficit (3.5 – 2.3) x 28.5 x 50 x 0.05 = 85.8
 Rhabdomyolysis

 Vasoconstriction
 In calculating the deficit, 0.05 will
 Hormonal: Increased aldosterone secretion, decreased actually depend on the level of
insulin resistance
 potassium. For exam purposes, you
 Metabolic: Hyperglycemia (impaired insulin release)
 can use 0.05.
 Neuropsychiatric: Depression, apathy, confusional state Total K Requirement 57 + 85.5 = 142.5
KIR 6 mEq/100 x 50 = 0.10
Therapy *Peripheral line: 28.5
 Mild hypokalemia occurring in asymptomatic person may 6mEq/100ml
not require specific therapy. *Central vein upto KIR for this is patient is 0.10 which is
o Treat only when patient is symptomatic. 8mEq/100ml acceptable. KIR should not be > 0.3
 Replacement may be given by the oral route, done slowly bec. it will cause phlebitis. It is is
and started once urine flow is confirmed >0.3, you can reduce the potassium
o 40-60 mEq K p.o → increase plasma K by 1-1.5 mEq/L drip to ¾.
 If the K deficit is severe and causing cardiac arrhythmias, Total K delivered in 6 mEq x 24 x 50/100 = 72mEq/day
rhabdomyolosis, extreme weakness, IV replacement is 24 hours
necessary (the only indication for IV of K) Correction Time 72 mEq x 142.5 = 47.5 hrs
 Oral is still the best because of risk of hyperkalemia with 24 hrs X
IV route.
o If the patient is symptomatic, give Parenteral. Example 2: A 5 yr old child with acute Gastroenterirtis
 Rapid IV bolus administration of potassium is usually presented with fever. For symptomatic children, K is less
contraindicated because of phlebitis. than 3. Ideally you correct it through parenteral
 The body has limited ability to rapidly absorb potassium Weight = 20kg
and lethal cardiac rhythm disturbances may result. K = 3 mEq/L
 Can be given in 2 methods:
 Na = 145
o Continuous infusion – usually as side drip Maintenance 2mEq x 20kg = 40mEq/kg
o Intermittent infusion Deficit (3.5 – 3) x 20kg x 50 x 0.05 = 25
 Not recommended to be given as maintenance Total K Requirement 25 + 40 = 65mEq
 Guidelines on IV administration

o Peripheral vein: max 60 mmol or mEq/L KIR 6 mEq/100 x 50 = 0.15
o Cental vein: max 80 mmol/L
 20
o Rate: 0.2-0.3 mmol/kg/hr

o K Salt 0.15 is acceptable (KIR should not
 KCl in cases of alkalosis be > 0.3)
 KHCO3 in cases of metabolic acidosis Total K delivered in 6 mEq x 24 x 50/100 = 72mEq/day
 The child with symptomatic hypokalemia and K less than 3 24 hours
mmol/L should be admitted. (How may K is given
o Ideally if the patient is on parenteral therapy, there for 24hrs if the rate
should be cardiac monitoring because on adverse is 50cc/hr?)
effect of iatrogenic hyperkalemia. Correction Time 72 mEq x 65 = 21.67 hrs
(If 72 mEq is given in 24 hrs X
COMPUTATION FOR HYPOKALEMIA CORRECTION 24 hrs, how many
Maintenance 2-3 mEq/kg hours is needed to
Deficit (desired – actual) x weight x 50 x0.05 correct the
Total K Requirement maintenance + deficit potassium or obtain
KIR (K Infusion Rate) mEq x IVF rate
the total K
weight/100
requirement?)
Total K Delivered in 24 mEq x total K in 24 hours
Hours 100 24 x 50

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

Potassium Supplements  Vomiting → loss of H and Cl in gastric fluid → raise in

Dosage bicarbonate → Metabolic alkalosis → decrease in Cl loss
 PO 20 mEq in 1-2 divided doses, TID → hypochloremia
o Onset: within 30mins  Volume depletion due to vomiting → RAAS → renal
 IV 20-40 mEq diluted in 1 L IV solution potassium loss and Na resorption and the K loss from
o Onset: very rapid vomiting will aggravate the cond
 Kalium Durule: contain 10 mEq K per tablet, TID  There is greater renal K loss in vomiting compared to
diarrhea due to obligate loss of K secondary to
Adverse Effects bicarbonaturia resulting from the metabolic alkalosis
 Nausea  Most common cause of HPS: Erythromycin (protein
 Vomiting synthesis inhibitor)
o Metabolic Alkalosis  Treatment: SURGICAL then treat elec imbalance
o Loss of H+ and Cl- in gastric fluid raises plasma  Initial IV: give pottassium containing plain LRS for px
HCO3- w/vomitting
o Dehydration and potassium loss lead to renal
HCO3-retention which exaberates the alkalosis HYPERKALEMIA (> 5 mEq/L )
 Diarrhea Causes
 Abdominal cramps  Pseudoyperkalemia –shift of intrcellular pottassium
 Irritability o Improper collection and handling of blood
 Rashes o Leukocytosis or thrombocytosis
 Phlebitis with IV administration  Increased K load due to correction
o Oral/IV supplementation
Pharmacokinetics o Blood transmission
 Absorption: PO rapidly absorbed,95% in body fluids  Decreased renal excretion
 Distribution: unknown o Acute or chronic renal failure
 Metabolism: unknown o Mineralocorticoid deficiency
 Excretion: 80-90% in urine,10% in feces o K-paring diuretics
 Shift from intracellular to extracellular fluid
Cases o Metabolic/respiratory acidosis
Case 1 o Drug-induced
A 6 yr old is brought in for generalized weakness. She had o Mineralocorticoid and insulin deficiency
a previous episode of self-limiting non-profuse diarrhea 2 days
ago. For the past 2 weeks, she had been waking up 2-3x a Clinical Manifestations
night to urinate. Serum K is 3 mEq/L. Weight is 15 kg.  Neuromuscular: parasthesia, weakness, paralysis
1. What is the best way to correct her hypokalemia?
 ECG changes: tall, peaked T wave, widened QRS,
a. 10 mEq oral KCl TID
prolonged PR interval, disappearance of P wave
b. 10 mEq KCl IV bolus
 Hormonal effects: stimulates release of aldosterone,
c. 10 mEq IV infusion via soluset
insulin and epinephrine
2. Total Potassium requirement = 48.7mEq
3. Correction time (if 10mEq oral KCl is given 3x a day)
Therapy
30 mEq x 48.75 mEq = 39 hours
 Always treat underlying cause first
24 hr X
 Most common adverse effect of over supplementation of
 Repeat K measurement after 48 hours. Best way is still
K- iatrogenic hyperkalemia
oral. You will only give parenteral if the patient cannot
 K restriction –normally effective
tolerate. She doesn’t have vomiting, only diarrhea so we
can give oral. Risk for Hyperkalemia is lower when given  Na bicarbonate –by elevating the PH,K moves back into
orally. the cell,lowering K level
 10% Ca gluconate- decreases the irritability of the
Case 2 myocardium because the MC manifestation is arrythmia
A two week old male came in due to projectile from hyperkalemia
vomiting for days. On PE, weight is 2.6kg, had deep fontanel,  Insulin and glucose- moves K back into the cell
sunken eyeball, jaundice with palpable olive mass on the right  Kayexalate Na- non-absorbed, cation exchange polymer
epigastrium. Ultrasound result is hypertrophic pyloric stenosis. that increases fecal potassium excretion through binding
What electrolyte/ acid-base abnormalities would you expect? of potassium in the lumen of the gastrointestinal tract.Is a
a. Hypokalemia cation exchange polymer for severe hyperkalemia and can
b. Hypochloremia be administered orally and rectally.
c. Metabolic alkalosis
d. All of the above

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

SODIUM (Na) Manifestations

 Normal serum level: 135-145 mEq/L  Neurological symptoms are due to cerebral edema and
 Main electrolyte in the ECF. altered nerve conduction
 Na+ affects the fluid volume of the ECF and is  Seizure – most common
 Regulated, in part, by:
o Aldosterone Treatment
o Renal blood flow  For ECF volume depletion
o Renin secretion o Correct shock by giving PNSS depending on the level
o ADH due to its effect on water of Na
o Estrogens o If symptomatic: give 3% NaCl solution
o Carbonic anhydrase enzyme  Modest ECF volume excess, no edema:
 Routes of elimination of sodium o Water restriction
o Urine  ECF volume excess, edema:
o Feces o Water restriction + specific replacement therapy
o Perspiration
 Sodium excretion occurs in stool and sweat, but the
kidney regulates sodium balance and is a principle site of
sodium excretion.
 There is some sodium loss in stool, but it is minimal unless
diarrhea is present. Normally, sweat has 5-40mEq/L of
sodium
 Sweat sodium concentration is increased in children with
cystic fibrosis, aldosterone deficiency or
psudohypoaldosteronism
 The highest sweat losses in these conditions may cause or
contribute to sodium depletion
 Factors regulating sodium levels
o Thirst Mechanism Key Points
o Glomerular filtration  Na deficit independent of volume deficit
o RAAS o Na required to normalize serum Na without replacing
o Atrial natriuretic peptide volume loss
o Osmotic pressure Na deficit= (desired Na- current Na) x weight x 0.6
o ADH *0.6 - from 60% Total Body Water
o Aldosterone
o Na-K pump  Na deficit associated with volume loss
o Na concentration of deficit volume in isonatremic
HYPONATREMIA (<135 mEq/L ) dehydration is 140 mEq/L
Causes Maintenance Na = weight x 3 mEq
 Deficit of total body water and larger deficit of total body *Maintenance Na is 3-5mEq/kg
Na (ECF volume depletion)
o Renal losses: diuretic use  For all cases of hypotonic hyponatremia, the correction
o GI losses: vomiting, diarrhea rate is limited to 10 mEq/L in the 1st 24hrs and 18 mEq/L
 Excess total body water with normal total body Na in the 1st 48hrs
(modest ECF volume excess, no edema) - Dilutional o If more excessive than this, there is increase in risk of
Hyponatremia pontine myelinolysis
o SIADHs  Acute hyponatremia may be corrected faster initially (1-2
o Water intoxication (IV therapy, psychogenic water mEq/L/hr); a rise of 5 mEq/L is usually sufficient to
drinking) improve symptoms and treat cerebral edema
o Hypothyroidism  Correction of hyponatremia depends if the Na is
 Excess total body Na and larger excess of total body dangerously low (<125 mEq/L) and the patient is
 water (ECF volume excess, edema) symptomatic – 3% NaCl is given
o Renal: Nephrotic syndrome, ARF  Hypertonic saline (3% NaCl = 513 mEq/L) should never be
o Cardiac: CHF mistaken for 0.3 NaCl (51 mEq/L)
 3% NaCl is given as slow infusion rate over an hour. To
prepare a 100ml 3% NaCl solution:
o Incorporate 80ml sterile water in 20ml 14.6% (2.5
mEq/ml) NaCl injection vial

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

 Overcorrection and autocorrection should be anticipated COMPUTATION FOR HYPONATREMIA CORRECTION

during treatment with hypertonic or isotonic saline thus, Maintenance  Ludan – Healthy Patient
there is a need to repeat serum Na ideally every 3-4hrs Fluid  Holliday-Segar
for appropriate revision of IVF.  Crawford - <14 days, etc.
 Hypovolemia and dehydration are not necessarily the Maintenance 4 x wt
same. Na
Water Fluid (wt x % dehydration) x 1000
 Volume depletion is usually due to sodium and water loss.
Deficit
 Dehydration is primarily free water deficit ECF Na Loss Total fluid in ml x % fluid deficit from ECF x 145)
disproportionate to loss of sodium. 1000
 Rapid replacement is generally for hypovolemic children. Excess Na (desired Na – actual Na) x 0.60 x wt
 Slow and careful infusion of water should be done in Deficit *0.60 = total body water
dehydration. Total Na Maintenance + ECF Na loss + excess Na deficit
 In managing hyponatremia, you should resuscitate Requirement
rapidly. Then, reassess and replace regularly. Every Correct ½ Deficit over 8 hours, then ½ deficit over 16 hours.
replacement, you should also reassess the patient to *wt = pre-illness weight
avoid fluid overload. *Na requirement: 2-4 mEq/kg/day
 For computation in managing hyponatremia, first, PERCENT FLUID DEFICIT AS RELATED TO DURATION OF ILLNESS
determine the pre-illness weight. Duration % fluid deficit from % fluid deficit
ECF from ICF
Pre illness weight = (current weight x 100) <3 days 80 20
100 – % dehydration >3 days 60 40
Example 1:
10% dehydration, Current wt= 10kg Cases
Case 1
Pre illness weight: (10kg x 100) = 11.1kg A 3 yr old child with pneumonia had been vomiting for 3
100 – 10 days. She has been drinking tap water most of the time.
Examination shows sunken eyes and marked tenting of the
Example 2: skin but the child is not in shock. The serum Na is 125 mmol/L.
A 3 y/o, with several episodes of vomiting and diarrhea for The weight is 14 kg. You estimate the deficit is 6%. What is her
1 week. The child presents with sunken eyeball, dry lips, computed Na requirement for 24 hrs?
poor skin turgor, CRT >2secs, BP 70/80, wt is 13 kg. What is a) 170 mmol
the child’s pre illness weight? (Refer to table 57-1 for b) 220 mmol
degree of dehydration) c) 230 mmol
Degree of dehydration is 10%. d) 440 mmol

Pre illness weight: (13kg x 100) = 14.4kg  Diagnosis: Pneumonia with Dehydration
100 – 10 o Signs of dehydration: Sunken eyes and marked
tenting of the skin (poor skin turgor)
o Since the patient is not in shock, no need to give IV
bolus.
o Patient also has hyponatremia due to dehydration.
Pre-illness (14kg x 100) = 14.9kg
Weight 100 – 6
Maintenance Holliday-Segar Method:
Fluid 1000 + (50ml x 4.9) = 1245ml
Maintenance Na 4 x 14.9 = 60
Water Fluid (14.9 x 6% dehydration) x 1000ml =
Deficit 894ml
*0.06 = 6% dehydration
*1000 is constant because it is 1L
ECF Na Loss 894 ml x 0.60 x 145) = 78
1000
*0.60 = 60% fluid deficit from ECF
because the duration of illness is 3 days
(refer to table about “percent fluid
deficit as related to duration of
illness”).

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 CLINICAL PHARMACOLOGY – Fluids and Electrolytes

Excess Na Deficit (135 – 125) x 0.60 x 14.9 = 89.4 NEXT 16 HOURS

*0.60 = total body water Water (ml) Na (mmol) K (mmol)
Total Na 60ml + 78 + 89.4 = 227.4 Maintenance 830 40 30
Requirement Deficit 447 84 27
Correct ½ Deficit over 8 hours, then ½ deficit over 16 hours. Free Water
Initial Bolus 1277 124 57
TOTAL 24 HOURS 16-hr total Per 1000ml 97 4
Water (ml) Na (mmol) K (mmol) (needed)
Maintenance 1245 60 45 Suggested Fluid therapy: to run at 80 ml/hr
Deficit 894 78 54 D5 0.3 NSS + 46 mmol/L Na + 45 mmol/L K
Excess Na deficit 89
 Maintenance Water
24-hr total 2139 227 99
o 1245 – 415 = 830
o (1245/3) x 2 = 830
FIRST 8 HOURS
 Initial Bolus of Water: 830 + 447 = 1277 to be given in 16
Water (ml) Na (mmol) K (mmol)
hours
Maintenance 415 20 15  Maintenance Na: 60 – 20 = 40
Deficit 447 84 27
 Initial Bolus of Na: 40 + 84 = 124
Initial Bolus
 How many Na is given per liter?
8-hr total 862 104 42 o Cross multiply:
Needed Per 1000ml 120 49 → 1277_ = 124
Suggested Fluid therapy: to run at 108ml/hr 1000ml X
D5 LR + 45 mmol/L K → 1277 X = 124 (1000ml)
 Maintenance Water: 1277 1277
o 1245/24hrs = 51.87ml/hr x 8hrs= 415 → X = 97: For every 1000ml or 1L, the fluid
o 1245/3 = 415 should contain 97 mEq of sodium.
 Divided by 3 because it is given for the 1st 8  Which among the IVF fluids contain approximately 97
hours mEq of sodium?
 Deficit Water: 894/2 [1/2 over 8hrs] = 447 o For the choice of fluid, it should not exceed the
o Divided by 2 bec ½ is given for the 1st 8hrs required but it can be lower from the required value.
 8hr total water: 415 + 447 = 862 o D5 0.3 NSS (51mmol/L): instead of LRS with 130
 Maintenance Na: 60/3 = 20 mmol/L because the patient only needs 97 mmol/L
o Divided by 3 bec it is given for the 1st 8 hours o 46 mmol/L Na: to compensate for the lack from D5
0.3NSS
 Deficit Na: (78 + 89) / 2 = 83.5 or 84
o 45mmol/L K: to compensate for the lack from D5
o 89 is from the computed excess Na deficit
0.3NSS (it is only composed of 4 mmol/LK).
 8-hr total Na: 20 + 84 = 104
 How many Na is given per liter?
Case 2
o Cross multiply:
Brandon, 45 y/o, married, was admitted to the hospital
→ 862_ = 104
five days earlier for an intracranial hemorrhage secondary to
1000ml X
vehicular accident that required emergency evacuation. His
→ 862 X = 104 (1000ml)
medical history includes poorly controlled hypertension and
862 862
diabetes type 2, controlled.
→ X = 120: For every 1000ml or 1L, the fluid
should contain 120 mEq of sodium.
On hospital day 5, he developed episodes of seizures. The
 Which among the IVF fluids contain approximately 120
patient appears euvolemic, with a blood pressure of 120/70
mEq of sodium? (see Table 2. Osmolarity and Electrolyte
mmHg and pulse rate of 85bpm. Urine output has been 2-3
Composition of Crystalloids and Colloids)
L/d despite a fluid restriction of <1.5 L/d. His sodium level has
o Plain LRS or D5 LR.
continued to decline after the fluid restriction.
o 45 mmol/L K: D5 LR only contains 4 mEq K and the
needed is 49, so 45 mmol/L K is added.
 What is the electrolyte disturbance is seen in this patient?
 How to compute for 108ml/hr?
o Hyponatremia
o 8-hr total fluid/ 8 hours
 What is the working diagnosis?
o 862ml/8hours = 108 ml/hr
o Hyponatremia secondary to SIADH
 What therapeutic measures are appropriate for this
patient?
o Water restriction

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HYPERNATREMIA (>150mEq)
Causes
 Pure Na excess (increased total body Na)
o Caused by disease, excess sweating, diarrhea
o Tx: PNSS until vital signs normalize followed by
hypotonic solution
 Water deficit (normal total body Na)
o Tx: D5 water
 Water deficit in excess of Na deficit (low total body Na)
o Tx: diuretic + D5 water, sometimes dialysis
Signs and Symptoms
 Most children with hypernatremia are dehydrated and
show the typical clinical signs and symptoms.
 Children with hypernatremic dehydration tend to have
better preservation of intravascular volume because of
the shift of water from the intracellular space to the
extracellular space.
 This shift maintains blood pressure and urine output and
allows hypernatremic infants to be less symptomatic
initially and potentially to become more dehydrated
before medical attention is sought.
CLINICAL PHARMACOLOGY – Fluids and Electrolytes
 Hypernatremia, even without dehydration, causes CNS
symptoms that tend to parallel the degree of sodium
elevation and the acuity of the increase.
 Patients are irritable, restless, weak, and lethargic. Some
infants have a high-pitched cry and hyperpnea.
 Alert patients are very thirsty, even though nausea may
be present.
 Brain hemorrhage is the most devastating consequence
of untreated hypernatremia.
 As the extracellular osmolality increases, water moves out
of brain cells, leading to a decrease in brain volume →
this decrease can result in tearing of intracerebral veins
and bridging blood vessels as the brain moves away from
the skull and meninges.
 Patients may have subarachnoid, subdural, and
parenchymal hemorrhages. Seizures and coma are
possible sequelae of the hemorrhage, although seizures
are more common during correction of hypernatremia.
Treatment
 The goal is to decrease the serum Na by < 12mEq/L every
24 hours, a rate of 0.5 mEq/L/hr.
 In the child with hypernatremic dehydration, as in any
child with dehydration, the first priority is restoration of
intravscular volume with isotonic fluid.
– –
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes

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