Fluids & Electrolytes

Pediatric Emergency Medicine Boston Medical Center Boston University School of Medicine

Objectives
To discuss:
Maintenance

Fluids and Electrolyte Requirements

Types of Dehydration Management of Dehydration Electrolyte Abnormalities

Composition of Body Compartments

Total Body Water (TBW)= 50-75% of Total Body

Mass

TBW = Intracellular Fluid (ICF) + Extracellular Fluid (ECF)

ICF = 2/3 of TBW ECF = 1/3 of TBW -- 25% of body weight

ECF = Plasma (intravascular) + Interstitial fluid

Body Water Compartments Related to Age

80 70 60 50 40 30 20 10 0 0 years 1 year 10 years 20 years TBW ICF ECF

Regulation of Body Fluids and Electrolytes

Mechanism to Regulate ECF volume

Anti-Diuretic Hormone (ADH)

Kidney = Increase water reabsorption ADH secretion is regulated by tonicity of body fluids

Thirst

Not physiological stimulated until plasma osmolality is >290

Regulation of Body Fluids and Electrolytes

Aldosterone
Released from the adrenal cortex
Decrease circulating volume Stimulation by Renin-Angiotensin Aldosterone axis Increase plasma K

Enhanced renal reabsorption of Na in exchange for K (>Na = expansion of ECF)

Atrial Natriuretic Factor

Secreated by the cardiac atrium in response to atrial dilatation (regulates blood volume) Inhibits Renin secretion Increase GFR and Na excretion

Daily Maintenance Requirements

4cc, 2cc, 1cc rule

4 cc for the first 10 kg 2 cc for the next 10 kg 1 cc for each kg after

Example:

27 kg child

4 cc for the first 10 kg 2 cc for the next 10 kg 1 cc for each kg after

= 40cc = 20cc = 7 cc 67 cc/hr

Maintenance Requirements
Maintenance Fluids: weight dependent

& age dependent: (NS =0.9% Saline =154 meq Na/liter)

age

>2 -3 years: D5 0.5 NS + 20 meq KCl/liter Up to age 2-3 years: D5 0.2 NS + 20 meq KCl/liter
D5 = 50 gm/liter = 5 g/dl Newborns often require D10 = 100 gm/liter = 10 gm/dl

Dehydration
Epidemiology:

One of the most common medical problems In the U.S. - 10% of all pediatric admissions Worldwide, over 3 million children under 5

years die from dehydration

Estimation of Dehydration
Mild
Weight Loss Blood pressure Pulse Behavior Membranes Tears Cap. Refill Urine SG 3-5% Normal Normal Normal Moist Present 2 seconds >1.020

Moderate
6-9% Orthostatic Increase Irritable Dry Decrease 2-4 seconds >1.030

Severe
>10% Shock Tachycardic Lethargic Parched Absent >4 seconds Oliguria

Dehydration
Classification

Isotonic

Serum Sodium 130-150 mEq

Hypotonic

Serum Sodium < 130 mEq

Hypertonic

Serum Sodium >150 mEq

Management of Dehydration
General Principles:

Supply Maintenance Requirements

Correct volume and electrolyte deficit

Replace ongoing abnormal losses

Management of Dehydration
Oral Rehydration: Effective for mild and some moderate dehydrations Child may be able to tolerate PO intake Small aliquots as tolerated

Mild: 50 cc/kg over 4 hours Moderate: 100 cc/kg over 4 hours Maintenance Rehydration

2 types of oral solution

Commercial Oral Solutions

Na mEq/L K mEq/L Maintenance Reosol Ricelyte Pedialyte Rehydration
Rehydralyte

Cl mEq/L Base

CHO %

50 50 45

20 25 20

50 45 35

Citrate Citrate Citrate

Glucose 2 Rice syrup 3 Glucose 2.5

75 90

20 20

65 80

Citrate HCO3

Glucose 2.5 Glucose 2

W.H.O
For cholera use

Management of Dehydration: IV
Replacement of Fluid Deficit Based on %

Dehydration: Example: 5 kg child who is 6% dehydrated: 5 x 60cc/kg

fluid deficit (cc) = wt x % dehydration fluid deficit (cc) = wt in kg (1000cc/kg) x (1/100) estimate of dehydration fluid deficit (cc) = wt x 10 x estimate of dehydration fluid deficit (cc) = 5 x 10 x 6 fluid deficit (cc) = 300 cc

Management of Dehydration: IV
Initial:

NS or LR 20 cc/kg Bolus in first hour Then Remainder of Deficit

In previous example: total fluid deficit = 300cc for 5 kg child who is 6% dehydrated = 60cc/kg Replacement:
first hour: 20 cc/kg = 20 x 5 = 100 cc replace the rest: 40 cc/kg or 300 - 100 = 200 cc The type of fluid used and the rate of infusion depends on the age and Na status of the patient: for isonatremic dehydration: correct deficits of next 7 hours 200cc over 7 hours = 28 cc/hr

Hyponatremia
Predisposing Factors

Diabetes mellitus (hyperglycemia) Cystic fibrosis CNS disorders ( SIADH) Gastroenteritis Excessive water intake (formula dilution) Diuretics (thiazides and furosemide) Renal disease

Hyponatremia
Hyponatremic Dehydration

Hypovolemic Hyponatremic Dehydration

High urine output and Na excretion Increase in atrial natriuretic factor ADH mediated water retention Edematous disorder (nephrotic syndrome, CHF, cirrhosis) Water intoxication

Euvolemic Hyponatremic Dehydration

Hypervolemic Hyponatremic Dehydration

Hyponatremia
Acute Hyponatremia (<24 hours)

Early Onset (Serum Sodium <125 meq/L)

Nausea Vomiting Headache

Later or Severe (Serum Sodium <120 meq/L)

Seizure Coma Respiratory arrest

Hyponatremia

Chronic Hyponatremia (>48 hours)

Lethargy Confusion Muscle cramps Neurologic Impairment

Hyponatremia
Management

Na Deficit: Na Deficit = (Na Desired - Na observed) x 0.6 x body weight(kg) Replace half in first 8 hours and the rest in the following 16 hours Rise in serum Na should not exceed 2 mEq/L/h to prevent Central Pontine Myelinolysis (? Existence in children) In cases of severe hyponatremia (<120 mEq) with CNS symptoms: 3% NaCl 3-5 ml/kg IV push for hyponatremia induced seizures
6 ml/kg of NaCl will raise serum Na by 5 mEq/L

Hypernatremia

Hypernatremia leads to hypertonicity

Increase secretion of ADH Increase thirst

Patients at risk
Inability to secrete or respond to ADH No access to water

Hypernatremia

Etiology

Pure water depletion

Diabetes insipidus (Central or Nephrogenic) Salt poisoning (PO or IV)

Sodium excess

Water depletion exceeding Na depletion

Diarrhea, vomiting, decrease fluid intake

Lithium, Cyclophosphamide, Cisplatin

Pharmacologic agents

Hypernatremia
Signs and symptoms

Disturbances of consciousness

Lethargy or Confusion Muscle twitching, hyperreflexia

Neuromuscular Irritability

Convulsions Hyperthermia

Skin may feel thick or doughy

Hypernatremia

Management

Normal Saline or Ringer lactate to restore volume Hypotonic solution (D5 1/4 NS) to correct calculated deficit over 48 hours

Water Deficit

Normal body H20 - Current body H20 0.6 x body weight (kg) x Normal Na/Observed Na 0.6 x body weight (kg)

Current body water

Normal Body water

Decrease Na concentration at a rate of 0.5 mEq/hr or ~ 10 mEq/day: Faster correction can result in Cerebral Edema

Potassium
Most abundant intracellular cation
Normal serum values 3.5-5.5 mEq

Abnormalities of serum K are potentially life-

threatening due to effect in cardiac function

Hypokalemia

Diagnosis

Symptoms

Arrhythmias Neuromuscular excitability (hyporreflexia, paralysis) Gastrointestinal (decreased peristalsis or ileus)

Serum K < 3mEq/L ECG:

Flat T waves Short P-R interval and QRS U waves

Hypokalemia
Nutritional
Poor intake IVF low in K Anorexia

GI Loss
Diarrhea Vomiting Malabsorbtion Intestinal fistula Laxatives Enemas

Renal Loss
Renal tubular acidosis Chronic renal disease Fanconi's syndrome Gentamicin, Amphotericin Diuretics Bartter's syndrome

Endocrine
Insulin therapy Glucose therapy DKA Hyperaldosteronism Adrenal adenomas Mineralocorticoids

Bartters syndrome: Hypereninemia and hyperaldosteronism

Hypokalemia

Management:

Cardiac Arrhythmias or Muscle Weakness

KCl IV (cardiac monitor) Hypophoshatemia = KPO4 Metabolic acidosis = KCl Renal tubular acidosis = K citrate

PO K - Depend of etiology

Hyperkalemia
Differential Diagnosis

Pseudohyperkalemia - from blood hemolysis Metabolic Acidosis Chronic Renal Failure Congenital Adrenal Hyperplasia

Females = Usually Dx at birth - Ambiguous Genitalia Males = Dehydration, hyponatremia, hyperkalemia

Medications

ACE inhibitors and NSAIDs

Hyperkalemia

Diagnosis:

Symptoms

Cardiac Arrhythmias Paresthesias Muscle weakness or paralysis

ECG

Peaked T waves Short QT interval (K>6 mEq) Depressed ST segment Wide QRS (K>8 mEq)

Hyperkalemia

Management
Close cardiac monitoring Life -threatening hyperkalmia

Intravenous Calcium - rapid onset, duration< 30 min NaHCO3 or glucose and insulin Sodium polystyrene sulfonate (Kayexelate)

Ion exchange resins

PO or Enema

Hemodyalisis