Fluid and Electrolyte Module: Parenteral Fluid Therapy 1.

Fluid and electrolyte requirements: - Maintenance requirements - Deficit replacement - Replacement of ongoing losses 2. Fluid Estimates in Children Caloric expense method Maintenance Holiday-Segar Method: -100 ml/kg: First 10 kg (4ml/kg/hour) -Add 50 ml/kg: 10-20kg (2 ml/kg/hour) -Add 20 ml/kg: >20kg (1 ml/kg/hour) 1.Insensible water loss (skin 40-45% of maintenance and lungs) 2.Sensible water loss 55-60% of maintenance (mainly urine output) Fever Increase fluid requirements by 12% per C above 37.8C Tachypnea Oliguria Increase fluid requirement 10-30% Fluid requirement: Insensible water loss + Measured urine output + Deficit Fluid requirement: Insensible water loss + Deficit Fluid requirement: Maintenance + Deficit + Ongoing losses Body surface area method 1500-1700 ml/m2/day

400-600 ml/m2/day 1000-1200 ml/m2/day

Anuria

Dehydration

3. Maintenance fluid calculation: 25 kg child - 100 ml/kg for first 10 kg: 100x10=1000 ml - 50 ml/kg for each kg between 10 and 20 kg: 50x10=500 ml - 20 ml/kg for each kg above 20 kg: 20x5=100 ml TOTAL: 1600 ml/day or 67 ml/hour

Normal electrolyte and fluid requirement for a 25 kg child Daily water and caloric requirements Sodium Potassium Chloride Dextrose As above calculation: Assume 100 ml/100Kcal 2-4 meq/100kcal 2-3 meq/100 kcal 5 meq/100 kcal 5 grams/100 kcal 1600 ml (1600 Kcal)

32-64 meq 32-48 meq 80 meq 80 grams

Composition of different parenteral fluids Liquid D5W D10W NS NS D5 1/4 NS 3% NaCl LR 8.4% Bicarb CHO (gms/100ml) 5 10 5 0-10 1000 Na (meq/L) 154 77 34 513 130 K (meq/L) 4 Cl (meq/L) 154 77 34 513 109 Bicarbonate (meq/L) mosmol/L 252 505 308 154 329 1027 273 2000

28 1000

4. Deficit replacement: Estimation of degree of dehydration Mild Weight loss: Infant Child Pulse/HR SBP Lips Anterior fontanel Eyes Skin turgor Skin Cap refill Urine output 5% (50ml/kg) 3% (30ml/kg) full, normal normal slightly dry normal normal normal normal normal normal Moderate 10% (100 ml/kg) 6% (100 ml/kg) rapid low to normal dry sunken sunken decreased cool 2 sec decreased Severe 15% (150 ml/kg) 9% (90ml/kg) rapid and weak shock parched very sunken very sunken very tented clammy, mottled > 3 sec anuric

Classification of dehydration based on the serum sodium Classification Sodium Incidence Etiology Rate of deficit (meq/L) replacement Isotonic 130-150 60% Vomiting, diarrhea Safe to replace over 24 hours Hypertonic >150 25% Vomiting, diarrhea, Free water deficit (FWD) excessive electrolyte intake, must be replaced over 48 diabetes insipidus, osmotic hours. Rate of decrease diuretics, insufficient of sodium is 12-15 lactation, sweating meq/24 hours. Complication of rapid replacement is cerebral edema. Hypotonic <130 15% Vomiting, diarrhea, Acute (24-48 hr electrolyte free fluid intake, duration): safe to replace CAH, burns, cystic fibrosis, deficit over 24 hours. diuretics, fluid sequestration Chronic or if duration (third spacing) unclear: Slow correction at a rate of 0.5 meq/l/hr. Fast correction leads to central pontine myelinosis. 5. Case 1: Isotonic dehydration 1 year old with vomiting and diarrhea - Illness weight: 9 kg - Pre-illness weight: 10 kg - sunken fontanels, sunken eyes, dry oral mucosa, tachycardic, 2 sec cap refill, weak-looking - Labs: Na 135, K 3.8, Cl 100, Bicarb 17, BUN 22, Crea 0.2 - Assessment: isotonic moderate dehydration Plan of Management: - Daily maintenance requirement (based on pre-illness weight): 1000 ml - Water deficit requirement (10% dehydration): 100x10kg= 1000 ml. Replace half over 8 hours and the other half over 16 hours. - Electrolyte deficit calculation: Isotonic sodium deficit: Fluid deficit (L)x 0.6x 145= 1 L x 0.6 x 145= 87 meq. Half to be replaced over 8 hours and the other half over 16 hours. Potassium deficit: Fluid deficit (L) x 0.4 x 150= 1 L x 0.4 x 150= 60 meq to be replaced over 24 hours.

First 8 hours: Water Na K Deficit 500 ml 44 meq 30 meq Maintenance 333 ml 10 meq 7 meq Total 833 ml 54 meq 37 meq Ideal fluid to use: D5 65 meq NaCl/L + 40 meq/L at 104 ml/hr over 8 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 NS + 40 meq KCl/L at 104 ml/hr over 8 hours. Subsequent 16 hours: Water Na K Deficit 500 ml 44 meq 30 meq Maintenance 667 ml 20 meq 14 meq Total 1167 ml 64 meq 44 meq Ideal fluid to use: D5 55 meq NaCl/L + 38 meq KCl/L at 73 ml/hr over 16 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 NS + 40 meq/L at 73 ml/hr over 16 hours. 6. Case 2: Hypotonic dehydration 1 year old boy with vomiting and diarrhea for 2 days Illness weight: 9 kg Pre-illness weight: 10 kg sunken fontanels, sunken eyes, dry oral mucosa, tachycardic, 2 sec cap refill, weak-looking - Labs: Na 115, K 3.8, Cl 94, Bicarb 19, BUN 22, Crea 0.2 - Assessment: hypotonic moderate dehydration Plan of Management: - Daily maintenance requirement (based on pre-illness weight): 1000 ml - Water deficit requirement (10% dehydration): 100x10kg= 1000 ml. Replace half of the 1000 ml over 8 hours and the other half over 16 hours. - Electrolyte deficit calculation: Total sodium deficit= Isotonic sodium deficit + hypotonic sodium deficit Isotonic sodium deficit: Fluid deficit (L)x 0.6x 145= 1 L x 0.6 x 145= 87 meq. Hypotonic sodium deficit: (130- Actual Na) x 0.6 x pre-illness weight= (130115) x 0.6 x 10 kg = 90 meq Total sodium deficit= Isotonic sodium deficit + hypotonic sodium deficit = 87 meq + 90 meq = 177 meq. Half of the 177 meq will be replaced over 8 hours and the other half over 16 hours. Potassium deficit: Fluid deficit (L) x 0.4 x 150= 1 L x 0.4 x 150= 60 meq to be replaced over 24 hours.

First 8 hours: Deficit Maintenance Total Water 500 ml 333 ml 833 ml Na 88.5 meq 10 meq 98.5 meq K 30 meq 7 meq 37 meq

Ideal fluid to use: D5 118 meq NaCl/L + 40 meq KCl/L at 92 ml/hr over 16 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 NS + 40 meq/L at 92 ml/hr over 8 hours. Subsequent 16 hours: Deficit Maintenance Total Water 500 ml 667 ml 1167 ml Na 88.5 meq 20 meq 108.5 meq K 30 meq 14 meq 44 meq

Ideal fluid to use: D5 93 meq NaCl/L + 38 meq KCl/L at 73 ml/hr over 16 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 NS + 40 meq/L at 73 ml/hr over 16 hours.

7. Case 3: Hypertonic dehydration 1 year old boy with vomiting and diarrhea for 2 days Illness weight: 9 kg Pre-illness weight: 10 kg sunken fontanels, sunken eyes, dry oral mucosa, tachycardic, 2 sec cap refill, weak-looking - Labs: Na 161, K 3.8, Cl 120, Bicarb 17, BUN 22, Crea 0.2 - Assessment: hypertonic moderate dehydration Plan of Management: - Daily maintenance requirement (based on pre-illness weight): 1000 ml - Water deficit requirement (10% dehydration): 100x10kg= 1000 ml. Water deficit is divided into free water deficit (FWD) and solute fluid deficit. 1. FWD (for initial Na levels < 170) = 4 x pre-illness weight x (Actual sodium - 145) FWD (for initial Na levels > 170) = 3 x pre-illness weight x (Actual sodium - 145) FWD should be replaced over 48 hours. For Na levels above 175, FWD should be replaced more than 48 hours, as rate of Na correction should not exceed 12-15 meq per 24 hours to avoid cerebral edema. 2. Solute fluid deficit = Total water deficit FWD. Solute fluid deficit can be Over 24 hours. For this patient, FWD= 4 x 10 x (162-145) = 640 ml which should be replaced over 48 hours or 320 ml per 24 hours. For this patient, the solute fluid deficit = 1000 ml 640 ml = 360 ml. This can be replaced over the first 24 hours.

- Electrolyte deficit calculation: Total sodium deficit= Isotonic sodium deficit + hypotonic sodium deficit Isotonic sodium deficit: solute fluid deficit (L)x 0.6x 145= 0.36 L x 0.6 x 145= 31 meq to be replaced over 24 hours. Potassium deficit: Solute fluid deficit (L) x 0.4 x 150= 0.36 L x 0.4 x 150= 21.6 meq to be replaced over 24 hours. First 24 hours: Solute fluid deficit of FWD Maintenance Total Water 360 ml 320 ml 1000 ml 1680 ml Na 31 meq 30 meq 61 meq K 21.6 meq 21 meq 42.6 meq

Ideal fluid to use: D5 36 meq NaCl/L + 25 meq KCl/L at 70 ml/hr over 24 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 1/4 NS + 20-30 meq/L at 70 ml/hr over 24 hours. Second 24hours: Solute deficit of FWD Maintenance Total Water 320 ml 1000 ml 1320 ml Na 30 meq 30 meq K 21 meq 21 meq

Ideal fluid to use: D5 23 meq NaCl/L + 16 meq KCl/L at 55 ml/hr over 24 hours. Convenient fluid to use (to avoid the pharmacy from concocting the above fluid): D5 NS + 20 meq/L at 55 ml/hr over 24 hours. 8. Replace ongoing losses - Gastric and upper GI: Replace with NS with KCl 20 meq/L - Biliary drainage, pancreatic, small intestine: Isotonic fluid or LR - Ileostomy: 1/2 NS or Isotonic fluid - Diarrheal: NS + 20-40 meq KCl/L - Burns: Isotonic plus serum protein 3-5 g % 9. Monitor adequacy of hydration: - Monitor weight daily - Monitor urinary output (1-2 ml/kg hour) - Monitor clinical condition

10. Oral rehydration (Finberg, 2002) Composition of common oral rehydration solutions CHO Na K Cl Base (g/dl) (meq/L) (meq/L) (meq/L) Pedialyte 2.5 45 20 35 30 Rehydralyte 2.5 75 20 65 30 WHO ORS 2 90 20 80 30 -

mosm/kg 250 310 310

Deficit phase: 50-100 ml/kg of initial solution of 75-90 meq/L Na over 4 hours slowly using a spoon or dropper Maintenance phase: Solution is changed to that with 40-50 meq/L Na or preferably diet is advanced Replace with 10 ml/kg ORS per stool Contraindications of ORS: Shock, intractable vomiting, coma, acute abdomen, gastric distension

11. Composition of common fluids CHO Na K (g/dl) (meq/L) (meq/L) Apple 11.9 0.4 26 juice Coke 10.9 4.3 0.1 Gatorade 5.9 21 2.5 Ginger 9 3.5 0.1 Ale Milk 4.9 22 36 Orange 10.4 0.2 49 juice

Cl (meq/L) 17 28 -

Base 13.4 30 3.6 30 50

Mosm/kg 700 656 377 565 260 654