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
Electrolyte

of Dehydration

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

TBW
ICF
ECF

40
30
20
10
0
0 years

1 year

10 years 20 years

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
Body Weight

0-10 kg

10-20 kg

>20 kg

Total Water
Volume

100 ml/kg

Sodium

3 meq/kg

1000 ml + 50
ml/kg for each
kg>10 kg
3 meq/kg

1500 ml + 20
ml/kg for each
Kg > 20kg
3 meq/kg

Potassium

2 meq/kg

2 meq/kg

2 meq/kg

Chloride

5 meq/kg

5 meq/kg

5 meq/kg

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
In

of the most common medical problems

the U.S. - 10% of all pediatric admissions

Worldwide,

over 3 million children under 5

years die from dehydration

Estimation of Dehydration
Mild

Moderate

Severe

Weight Loss

3-5%

6-9%

>10%

Blood pressure

Normal

Orthostatic

Shock

Pulse

Normal

Increase

Tachycardic

Behavior

Normal

Irritable

Lethargic

Membranes

Moist

Dry

Parched

Tears

Present

Decrease

Absent

Cap. Refill

2 seconds

2-4 seconds

>4 seconds

Urine SG

>1.020

>1.030

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

types of oral solution

Maintenance
Rehydration

Commercial Oral Solutions

Na mEq/L K mEq/L

Cl mEq/L Base

CHO %

Maintenance
Reosol

50

20

50

Citrate

Glucose 2

Ricelyte

50

25

45

Citrate

Rice syrup 3

Pedialyte

45

20

35

Citrate

Glucose 2.5

Rehydration
Rehydralyte

75

20

65

Citrate

Glucose 2.5

W.H.O

90

20

80

HCO3

Glucose 2

For cholera use

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

x 60cc/kg

5 kg child who is 6% dehydrated: 5

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

High urine output and Na excretion

Increase in atrial natriuretic factor

Euvolemic

Hyponatremic Dehydration

Hyponatremic Dehydration

ADH mediated water retention

Hypervolemic

Hyponatremic Dehydration

Edematous disorder (nephrotic syndrome, CHF,

cirrhosis)
Water intoxication

Hyponatremia
Acute Hyponatremia (<24 hours)
Early

Nausea
Vomiting
Headache

Later

Onset (Serum Sodium <125 meq/L)

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)

Sodium

Salt poisoning (PO or IV)

Water

excess

depletion exceeding Na depletion

Diarrhea, vomiting, decrease fluid intake

Pharmacologic

agents

Lithium, Cyclophosphamide, Cisplatin

Hypernatremia
Signs and symptoms
Disturbances

of consciousness

Lethargy or Confusion

Neuromuscular

Irritability

Muscle twitching, hyperreflexia

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

Current body water

0.6 x body weight (kg) x Normal Na/Observed Na

Normal Body water

Normal body H20 - Current body H20

0.6 x body weight (kg)

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

Renal Loss

Endocrine

Diarrhea
Renal tubular acidosis
Insulin therapy
Vomiting
Chronic renal disease
Glucose therapy
Malabsorbtion
Fanconi's syndrome
DKA
Intestinal fistula
Gentamicin,
Hyperaldosteronism
Laxatives
Amphotericin
Adrenal adenomas
Enemas
Diuretics
Mineralocorticoids
Bartter's syndrome

Bartters syndrome: Hypereninemia and hyperaldosteronism

Hypokalemia
Management:
Cardiac

Arrhythmias or Muscle
Weakness

KCl IV (cardiac monitor)

PO

K - Depend of etiology

Hypophoshatemia = KPO4
Metabolic acidosis = KCl
Renal tubular acidosis = K citrate

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

Ion

exchange resins

Sodium polystyrene sulfonate (Kayexelate)

PO or Enema

Hemodyalisis