Johns Hopkins: The Harriet Lane Handbook: A Manual for Pediatric House Officers, 17th ed.

, Copyright 2005 Mosby, An Imprint of Elsevier

283

Chapter 10 - Fluids and Electrolytes

Brian Stone MD

I - MAINTENANCE REQUIREMENTS
Maintenance requirements stem from basal metabolism. Metabolism creates two by-products, heat and solute, that need to be eliminated to maintain homeostasis. Heat dissipation through insensible losses and solute excretion in urine each can be considered as representing 50% of maintenance needs; that is, in the management of children who have anuric renal failure, maintenance fluid needs decrease by 50% because the only fluids that need to be replaced are insensible losses.[1]

A - CALORIC EXPENDITURE METHOD

The caloric expenditure method is based on the understanding that water and electrolyte requirements more accurately parallel caloric expenditure than body weight or body surface area (BSA). This method is effective for all ages, types of body habitus, and clinical states.
1. 2. 3.

Determine the childs standard basal calorie (SBC) expenditure as approximated by resting energy expenditure (REE) (see Table 201 in Chapter 20 ). Adjust caloric expenditure needs by various factors (e.g., fever, activity) as described in Chapter 20 . For each 100 calories metabolized in 24 hours, the average patient will need 100 to 120 mL H2 O, 2 to 4 mEq Na+ , and 2 to 3 mEq K+ , as seen in Table 101 .

B - HOLLIDAY-SEGAR METHOD ( Table 102 and Box 101 )

The Holliday-Segar method estimates caloric expenditure in fixed weight categories; it assumes that for each 100 calories metabolized, 100 mL of H2 O will be required. Specifically, for each 100 kcal expended, about 50 mL of fluid is required to provide for skin, respiratory tract, and basal stool losses, and 55 to 65 mL of fluid is required for the kidneys to excrete an ultrafiltrate of plasma at 300 mOsm/L without having to concentrate the urine. Note: The Holliday-Segar method is not suitable for neonates <14 days old; generally, it overestimates fluid needs in neonates compared with the caloric expenditure method.

C - BODY SURFACE AREA METHOD

The BSA method is based on the assumption that caloric expenditure is related to BSA ( Table 103 ). It should not be used for children <10 kg. See page 599 for BSA nomogram and conversion formula.
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TABLE 10-1 -- AVERAGE WATER AND ELECTROLYTE REQUIREMENTS PER 100 CALORIES PER 24 HOURS Clinical State Average patient receiving parenteral fluids * Anuria Acute CNS infections and inflammation Diabetes insipidus Hyperventilation Heat stress High-humidity environment CNS, central nervous system; Var, variable requirement.
* Adequate maintenance solution: dextrose 5% to 10% (as needed) in 0.2% NaCl + 20 mEq/L KCl or K acetate.

H2 O (mL) 100120 45 8090 Up to 400 120210 120240 80100

Na+ (mEq) 24 0 24 Var 24 Var 24

K+ (mEq) 23 0 23 Var 23 Var 23

TABLE 10-2 -- HOLLIDAY-SEGAR METHOD Water Body Weight First 10 kg Second 10 kg Each additional kg mL/kg/day 100 50 20 +24 hr/day +24 hr/day +24 hr/day mL/kg/hr 4 2 1 Electrolytes (mEq/100 mL H2 O) Na+ 3 Cl 2 K+ 2

TABLE 10-3 -- STANDARD VALUES FOR USE IN BODY SURFACE AREA METHOD H2 O Na+ K+ 1500 mL/m2 /24 hr 3050 mEq/m2 /24 hr 2040 mEq/m2 /24 hr

Data from Finberg L, Kravath RE, Fleishman AR: Water and Electrolytes in Pediatrics. Philadelphia, WB Saunders, 1982; and Hellerstein S: Pediatr Rev 1993;14(3):103115.

Box 10-1. HOLLIDAY-SEGAR METHOD Example: Based on the Holliday-Segar method, determine the correct fluid rate for an 8-year-old child weighing 25 kg:

II - DEFICIT THERAPY A - CALCULATED ASSESSMENT

The most precise method of assessing fluid deficit is based on preillness weight:

If this is not available, clinical observation may be used, as described subsequently.

B - CLINICAL ASSESSMENT ( Table 104 )

III - GUIDELINES FOR DEHYDRATION CALCULATION

The extracellular fluid space is about 20% of the bodys weight (40% in the newborn) and is divided 3:1 between interstitial (15% of body weight) and intravascular (5% of body weight) space.[2] TABLE 10-4 -- CLINICAL OBSERVATIONS IN DEHYDRATION * Older Child 3% (30 mL/kg) Examination Dehydration Skin turgor Skin (touch) Buccal mucosa/lips Eyes Tears Fontanelle CNS Pulse rate Pulse quality Capillary refill Urine output Infant 5% (50 mL/kg) Mild Normal Normal Moist Normal Present Flat Consolable Normal Normal Normal Normal 6% (60 mL/kg) 10% (100 mL/kg) Moderate Tenting Dry Dry Deep set Reduced Soft Irritable Slightly increased Weak 2 sec Decreased 9% (90 mL/kg) 15% (150 mL/kg) Severe None Clammy Parched/cracked Sunken None Sunken Lethargic/obtunded Increased Feeble/impalpable >3 sec Anuric

CNS, central nervous system. Data from Behrman RE, Kliegman RM, Arvin AM: Nelson Textbook of Pediatrics, 16th ed. Philadelphia, WB Saunders, 2000; and Oski FA: Principles and Practice of Pediatrics, 3rd ed. Philadelphia, JB Lippincott, 1999.

* For the same degree of dehydration, clinical symptoms are generally worse for hyponatremic dehydration than for hypernatremic dehydration.

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A - INTRACELLULAR FLUID (ICF) AND EXTRACELLULAR FLUID (ECF) COMPARTMENTS

1. 2.

Normal ICF and ECF composition ( Table 105 ). In dehydration, there are variable losses from the extracellular and intracellular compartments. The percentage deficit from these compartments is based on the total duration of illness ( Table 106 ). Electrolyte deficit (from ECF and ICF losses):
a.

3.

Na+ deficit is the amount of Na+ that was lost from the Na+ -containing ECF compartment during the dehydration period (see Table 105 ):

b.

K+ deficit is the amount of K+ that was lost from the K+ -containing ICF compartment during the dehydration period (see Table 105 ):

B - ELECTROLYTE DEFICITS (IN EXCESS OF ECF/ICF ELECTROLYTE LOSSES)

1. 2. 3.

HCO3 : 0.40.5. Cl : 0.20.3. Na+ : 0.60.7. Notewt = baseline weight before illness (kg).

TABLE 10-5 -- INTRACELLULAR AND EXTRACELLULAR FLUID COMPOSITION Intracellular (mEq/L) Na K

+ +

Extracellular (mEq/L) 133145 35 98110 2025 5 10

20 150 10 110115 75

ClHCO3 PO4
3-

Protein

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TABLE 10-6 -- PERCENTAGE OF DEFICIT FROM EXTRACELLULAR AND INTRACELLULAR COMPARTMENTS Duration of illness (%) <3 days 3 days Deficit from ECF (%) 80 60 Deficit from ICF 20 40

C - PROBABLE DEFICITS OF WATER AND ELECTROLYTES IN SEVERE DEHYDRATION ( Table 107 ) D - ONGOING LOSSES IN DEHYDRATION ( Tables 108 , 109 , and 1010 ) E - DEFICIT CALCULATIONS ( Fig. 101 )
1.

Sample calculations ( Tables 1011 , 1012 , and 1013 )

TABLE 10-7 -- DEFICITS OF WATER AND ELECTROLYTES IN SEVERE DEHYDRATION Condition Diarrheal dehydration Hyponatremic [Na+ ] * <130 mEq/L Isotonic [Na+ ] * = 130150 mEq/L Hypernatremic [Na+ ] * >150 mEq/L Pyloric stenosis Diabetic ketoacidosis
* [Na], serum or plasma sodium concentration.

H2 O (mL/kg) 100120 100120 100120 100120 100

Na+ (mEq/kg) 1015 810 24 810 8

K+ (mEq/kg) 815 810 06 1012 610

Cl- (mEq/kg) 1012 810 03 1012 6

Data from Hellerstein S: Pediatr Rev 1993;14(3):103115.

TABLE 10-8 -- ELECTROLYTE COMPOSITION OF VARIOUS BODY FLUIDS * Fluid Gastric Pancreatic Small bowel Bile Ileostomy Diarrhea Burns
*

Na+ (mEq/L) 2080 120140 100140 120140 45135 1090 140 1030 50130

K+ (mEq/L) 520 515 515 515 315 1080 5 310 525

Cl- (mEq/L) 100150 90120 90130 80120 20115 10110 110 1035 50110

Sweat Normal Cystic fibrosis

35 g/dL of protein may be lost in fluid from burn wounds. Data from Behrman RE, Kliegman RM, Arvin AM: Nelson Textbook of Pediatrics, 16th ed. Philadelphia, WB Saunders, 2000.
* This table is useful in determining ongoing electrolyte losses in dehydration.

TABLE 10-9 -- ORAL REHYDRATION SOLUTIONS CHO (g/dL) Ceralyte Infalyte Naturalyte Pedialyte Rehydralyte WHO/UNICEFORS * CHO, carbohydrate. Data from Snyder J: Semin Pediatr Infect Dis 1994;5:231.
* Available from Jianas Bros. Packaging Co., 2533 SW Boulevard, Kansas City, MO 64108.

Na+ (mEq/L) 70 50 45 45 75 90

K+ (mEq/L) Cl- (mEq/L) 20 25 20 20 20 20 60 45 35 35 65 80

Base (mEq/L) 30 30 48 30 30 30

mOsm/kg H2 O 220 200 265 250 310 310

4 3 2.5 2.5 2.5 2

TABLE 10-10 -- APPROXIMATE ELECTROLYTE COMPOSITION OF COMMONLY CONSUMED FLUIDS (NOT RECOMMENDED FOR ORAL REHYDRATION THERAPY) * CHO (g/dL) Na (mEq/L)
+

K (mEq/L)
+

Cl (mEq/L)
-

HCO3 (mEq/L) 13.4 3.6 30 50

mOsm/kgH2 O 700 656 377 565 260 654

Apple juice Coca-cola Gatorade Ginger ale Milk Orange juice

11.9 10.9 5.9 9 4.9 10.4

0.4 4.3 21 3.5 22 0.2

26 0.1 2.5 0.1 36 49

17 28

CHO, carbohydrate. Data from Behrman RE, Kliegman RM, Arvin AM: Nelson Textbook of Pediatrics, 16th ed. Philadelphia, WB Saunders, 2000.
* Values vary slightly depending on source.

TABLE 10-27 -- COMPOSITION OF FREQUENTLY USED PARENTERAL FLUIDS CHO Protein (g/100 * (g/100 Na+ K+ Cl HCO3 Ca2+ mL) mL) Cal/L (mEq/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L) mOsm/L 5 10 170 340 154 77 154 77 252 505 308 154

Liquid D5 W D10 W NS (0.9% NaCl) NS (0.45% NaCl) D5 NS (0.225% NaCl) 3% NaCl

170

34

34

329

513 1000

513

1000

1027 2000

8.4% sodium bicarbonate (1 mEq/mL) Ringer solution Lactated Ringer Amino acid 8.5% (Travasol) Albumin 25% (salt poor) Intralipid 010 010

8.5

0340 147 0340 130 340 3

4 4

155.5 109 34

28 52

4 3 273 880

Plasmanate

5 25

200 1000

110

50 <120

29

300

100160

2.25

1100

2.5

0.5

4.0

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CHO, carbohydrate; HCO3 - , bicarbonate; NS, normal saline.

* Protein or amino acid equivalent. Bicarbonate or equivalent (citrate, acetate, lactate). Values are approximate; may vary from lot to lot. Also contains <1.2% egg-phosphatides.

TABLE 10-11 -- EXAMPLE OF ISONATREMIC DEHYDRATION

Determine an adequate fluid schedule for a 7-kg (preillness weight) infant who has been ill for 3 days and clinically appears 10% dehydrated. Current weight is 6.3 kg. Serum Na+ = 137. An IV line has just been placed, and no IVF has been administered. Deficit Replacement Fluid deficit % Dehydration wt (kg) = 10% 7 kg (1000 mL/kg) Na+ deficit 0.7 0.6 145 = K+ deficit 0.7 0.4 150 = Maintenance H2 O 7 kg 100 mL/kg/day = Na+ 700 mL/day 3 mEq/100 mL = K+ 700 mL/day 2 mEq/100 mL = 24hour total Fluid Schedule First 8 hr First 8 hr total Next 16 hr Next 16hr total Answer Therefore, first 8 hr: Rate: 583 mL/8 hr = 73 mL/hr Na : 38 mEq/0.583 L = 65 mEq/L
+

H2 O (mL) 700

Na+ (mEq) 61

K+ (mEq)

42 700 21 14 1400 82 7 31 38 14 30 44 Next 16 hr: Rate: 817 mL/16 hr = 51 mL/hr Na+ : 44 mEq/0.817 L = 54 mEq/L K+ : 30 mEq/0.817 L = 37 mEq/L D5 NS + 40 mEq/L of KCl or K acetate @ 50 mL/hr 16 hr 56 5 21 26 9 21 30

Maintenance + Deficit Maintenance Deficit

233 350 583 467 350 817

K+ : 26 mEq/0.583 L = 45 mEq/L D5 NS + 40 mEq/L of KCl or K acetate @ 75 mL/hr 8 hr

In the absence of hypokalemia, 20 to 30 mEq/L of potassium is commonly used and is usually adequate; monitor carefully for hyperkalemia and adequate urine output if high concentrations of potassium are used. Potassium infusion rates should not exceed 1 mEq/kg/hr. If rate exceeds 0.5 mEq/kg/hr, the patient should be placed on a cardiorespiratory monitor. Note Remember to account for ongoing losses. They should be replaced concurrently (piggybacked) with a solution that matches the fluid being lost (see Table 108 ).

TABLE 10-12 -- EXAMPLE OF HYPONATREMIC DEHYDRATION Determine an adequate fluid schedule for a 7-kg (preillness weight) infant who has been ill for 3 days and clinically appears 10% dehydrated. Current weight is 6.3 kg. Serum Na+ = 115. An IV line has just been placed, and no IVF has been administered. Deficit Replacement Fluid deficit % Dehydration wt (kg) = 10% 7 kg (1000 mL/kg) Na+ deficit 0.7 0.6 145 = Excess Na+ deficit: (135115) 0.6 7 = K+ deficit 0.7 0.4 150 = Maintenance (see Table 1011 for exact calculations) 24hour total Fluid Schedule First 8 hr First 8hr total Next 16 hr Next 16hr total Answer Therefore, first 8 hr: Rate: 583 mL/8 hr = 73 mL/hr Na+ : 80 mEq/0.583 L = 137 mEq/L K+ : 26 mEq/0.583 L = 45 mEq/L D5 NS + 40 mEq/L of KCl or K acetate @ 75 mL/hr 8 hr Next 16 hr: Rate: 817 mL/16 hr = 51 mL/hr Na+ : 86 mEq/0.817 L = 105 mEq/L K+ : 30 mEq/0.817 L = 37 mEq/L D5 NS + 40 mEq/L of KCl or K acetate @ 50 mL/hr 16 hr maintenance deficit maintenance + deficit 233 350 583 467 350 817 7 73 80 14 72 86 5 21 26 9 21 30 700 1400 21 166 14 56 H2 O (mL) 700 61 84 42 Na+ (mEq) K+ (mEq)

In the absence of hypokalemia, 20 to 30 mEq/L of potassium is commonly used and is usually adequate; monitor carefully for hyperkalemia and adequate urine output if high concentrations of potassium are used. Potassium infusion rates should not exceed 1 mEq/kg/hr. If rate exceeds 0.5 mEq/kg/hr, the patient should be placed on a cardiorespiratory monitor. Note Remember to account for ongoing losses. They should be replaced concurrently (piggybacked) with a solution that matches the fluid being lost (see Table 108 ).

TABLE 10-13 -- EXAMPLE OF HYPERNATREMIC DEHYDRATION Determine an adequate fluid schedule for a 7-kg (preillness weight) infant who has been ill for 3 days and clinically appears between 10% and 15% dehydrated. Current weight is 6.1 kg. Serum Na+ = 160. Replacement Free-water deficit 4 mL/kg 7 kg [160145] Solute fluid deficit (SFD) Total fluid deficit (free water deficit) 900420 Solute Na+ deficit 0.48 0.6 145 Solute K+ deficit 0.48 0.4 150 Maintenance (see Table 1011 for exact calculations) Fluid Schedule First 24 hr 24hr maintenance + Free-water deficit Solute fluid and electrolyte deficit First 24hr total Second 24 hr 24hr Maintenance + Free-water deficit Second 24hr total Answer Therefore, first 24 hr: Rate: 1390 mL/24 hr = 58 mL/hr Na+ : 63 mEq/1.39 L = 45 mEq/L K+ : 43 mEq/1.39 L = 31 mEq/L D5 NS + 30 mEq/L KCl or K acetate @ 58 mL/hr 24 hr Second 24 hr: Rate: 910 mL/24 hr = 38 mL/hr Na+ : 21 mEq/0.91 L = 23 mEq/L K+ : 14 mEq/0.91 L = 15 mEq/L D5 NS + 10 mEq/L KCl or K acetate @ 38 mL/hr 24 hr 700 210 480 1390 700 210 910 21 14 42 63 21 29 43 14 21 14 700 21 14 H2 O (mL) 420 480 42 29 Na+ (mEq) K+ (mEq)

Follow serum Na+ and adjust fluid composition and rate based on clinical response. The second half of the free-water deficit may be replaced subsequently over the next 24 hr, or more rapidly depending on the rate of decline of serum Na+ (avoid decline of >15 mEq/L in 24 hr). Note In severe hypernatremic dehydration initial LR/NS resuscitation boluses should be accounted for in order to minimize dropping serum sodium >15 mEq/L per 24 hr to minimize risk of cerebral edema.

Figure 10-1 Algorithm for dehydration correction.

Figure 10-1 Algorithm for

dehydration correction.