IV FLUIDS

Basic
Principles
 BASIC PRINCIPLES

1. Osmolality/Osmolarity

2. Tonicity

3. Sodium & Water balance

 What is
Osmolality
?
 OSMOLALITY

Measurement of concentration of
particles in a solution
(Total concentration of penetrating & nonpenetrating
solutes)
i.e. Concentration of
electrolytes, drugs, glucose in a
solution such as serum or urine
 OSMOLALITY

Normal = 285-295 mOsm/kg

The ICF and ECF are in osmotic

equilibrium
 OSMOLALITY

OSMOLALITY = mOsm/kg of solvent

OSMOLARITY = mOsm/liter of a
solution
 What is
Tonicity?
 TONICITY

measure of the ability of a

solution to cause a change in
the volume or tone of a cell by
promoting osmotic flow of water
(Total concentration of
penetrating solutes only)
TONICITY
Who
regulates
osmolality?
Water
 WATER BALANCE

Important in the regulation

of osmolality

Modification of water intake

and exretion
 60%

ICF
TOTAL
BODY Interstitial Fluid
EC
WATER
F Plasma
 FORCES THAT MOVE WATER

Osmolality

Tonicity

Na/K ATPase pump

Hydrostatic pressure

Oncotic pressure
 SODIUM BALANCE

The main regulator of

intravascular volume
status
Electrolyte composition
EXTRACELLULAR FLUID INTRACELLULAR
FLUID
WHAT IS THE BODYS GOAL?

PHYSIOLOGIC HOMEOSTASIS

EUVOLEMIA

ISOTONIC ENVIRONMENT
What mechanisms in the body
makes sure that the balance of
sodium and water is normal?

What hormones play a big role in

the maintenance of physiologic
homeostasis?
There are upper & lower
limits to the amount
needed to achieve ideal
physiologic homeostasis
WATER REPLACEMENT

1.5 to 2 liters / day

 SODIUM REQUIREMENT

DIET: RDA = < 2400mg/day (1 teaspoon/day)

or < 104 meq/day

PLASMA : Normal levels = 135-145meq/L

FOR Na CORRECTION:
Maintenance of 2-4 meq/kg/day
Intravenou
s Fluids
 INTRAVENOUS FLUIDS

chemically prepared solutions

Achieve and maintain a euvolemic and isotonic

environment within the body

They are tailored to the bodys needs and used

to replace lost fluid and/or aid in the delivery
of IV medications
 ISOTONIC IV FLUIDS

created to distribute evenly between the

intravascular, interstitial, and cellular spaces.
 HYPOTONIC IV FLUIDS

What IV fluids are specifically designed so the

fluid leaves the intravascular space and
enters the interstitial and intracellular
spaces?
 HYPERTONIC IV FLUIDS

What IV fluids are designed to stay in the

intravascular space (intra, within; vascular,
blood vessels) to increase the intravascular
volume, or volume of circulating blood?
 ISOTONIC SOLUTIONS = 285-295 mOsm/L

Na = 135-145meq/L

HYPERTONIC SOLUTIONS = > 300 mOsm/L

Na = > 150meq/L

HYPOTONIC SOLUTIONS = < 260 mOsm/L

Na < 130meq/L
 CRYSTALLOIDS

contain electrolytes (e.g., sodium, potassium,

calcium, chloride) but lack the large proteins and
molecules found in colloids.

classified according to their tonicity.

describes the concentration of electrolytes (solutes)

dissolved in the water, as compared with that of
body plasma (fluid surrounding the cells).
 COMPOSITION OF IV FLUIDS

IV FLUID OSMOLAR Na+ K+ Cl- Base

ITY (mmol/L)
(mosm/L)
PNSS 308 154 0 0 ?
PLR 273 130 ? ? ?
D5LR 525 130 4 109 28
D5NR 552 140 ? 98 50
D50.3NaCl 355 51 0 51 0
D5IMB 350 25 20 22 23
D5NM 368 40 3 40 16
D5W 255 0 0 0 0
 COLLOIDS

contain solutes in the form of large proteins

or other similarly sized molecules.

Remain in the blood vessels for long periods of

time and can significantly increase the
intravascular volume (volume of blood).
 COLLOIDS/PLASMA
EXPANDERS
Albumin = 1-2 kg/dose infused in 2 hours

Haes-teryl = 20-40ml/kg

Voluven = 20-40ml/kg

Gelofuschin = 20-40ml/kg

Fresh frozen plasma = 10-15ml/kg x 4 hours

Dextran 40 or 60
BLOOD AND BLOOD PRODUCTS

are the most desirable fluids for replacement

but are not the first choice for immediate
volume expansion in children with shock

Not only is the intravascular volume increased,

but the fluid administered can also transport
oxygen to the cells.
 BLOOD AND BLOOD
PRODUCTS
BLOOD PRODUCT COMPUTATION

pRBC 10 ml/kg to run for

4 hours
Fresh whole blood 10-20 ml/kg in 4-6
hours
Platelet 15-20 ml/kg as
Concentrate fast drip
Cryoprecipitate 1 unit/6kg/dose
Computatio
n
OVERALL GOALS
 STEP ONE: Estimate Losses
SEVERITY INFANT ADOLESCE CLINICAL SIGNS
OF (ml/kg) NT (ml/kg)
DEHYDRATI
ON
MILD 5% (50) 3% (30) Dry mucous membranes
Oliguria
MODERATE 10% (100) 6% (60) Poor skin turgor
Sunken fontanel
Marked oliguria
Tachycardia
Quiet tachypnea
SEVERE 15% (150) 9% (90) Marked tachycardia
Weak to absent distal pulses
Narrow pulse pressure
Quiet tachypnea
Hypotension and altered
mental status
STEP TWO: In shock?
1. MACRODRIP SETS = 10 15 drops (gtts)/ml

2. MICRODRIP SETS= 60 microdrops (ugtts)/ml)

(Volume in mL) x (drip set) gtts

------------------------------------ = ------

(Time in minutes) min

 CONVERSION FACTORS

1 ml = 15 drops (gtts) = 60 microdrops

(ugtts)
1 drop (gtt) = 4 microdrops (ugtts)

1 microdrop (ugtts)/min = 1 ml/hour

 FLUID DEFICITS
Ludans Method
WEIGHT MILD MODERATE SEVERE
DEHYDRATI DEHYDRATI DEHYDRATI
ON ON ON
ml/kg/8
hours
<15 kg 50 100 150
>15 kg 30 60 90
Give in 1 Give 1/3 in 1
hr hr
Give in 7 Give 2/3 in
hr 7hr
PLAIN PLAIN LR/
LR/PLAIN NSS PLAIN NSS
D5LR D5LR
 FLUID DEFICITS WHO
*Use Ringers Lactate
SOME DEHYDRATION
75ml/kg in 4 hours

SEVERE
DEHYDRATION
AGE FIRST GIVE THEN GIVE
30ml/kg in: 70ml/kg in:
Infants under 1 hour 5 hours
12 months
Older 30 minutes 2 hours
 SODIUM CORRECTION

1. DEFICIT CORRECTION: desired-actual x weight x 0.6

* Desired Na+ is 135-145 meq

2. MAINTENANCE COMPUTATION: maintenance x weight

*Maintenance is 2-4meq/kg

3. COMPUTE FOR ACTUAL Na+ Needed to be incorporated

in your IV FLUID = Maintence + Deficit

*Give the First in 8 hours then in each succeeding 8 hour

shifts to complete your 24 hour correction
 POTASSIUM CORRECTION

1. COMPUTE FOR THE K+ REQUIREMENT = 2-4meq/kg/day

2. DETERMINE how much KCL you will be incorporating in

your IV fluid to complete a 24 hour correction
a) Check IV fluid rate
b) *Maximum 40meq/Liter of KCL incorporation in IV Fluid

3. CHECK POTASSIUM INFUSION RATE (KIR) =

meq of KCL x IV rate (ml/hour) x weight
(maximum of 0.2meq/kg/hour)
 MAINTENANCE REQUIREMENTS
Holliday-Segar Method
BODY WEIGHT WATER (ml/kg/day)

First 10 kg 100 ml/kg

Second 10 kg (<20kg) 50ml/kg for each kg > 10kg

+ 1000ml

Each additional kg 20ml/kg for each kg > 20kg

(>20kg) + 1500ml
MAINTENANCE REQUIREMENTS
Ludan Method
BODY WEIGHT (kg) TOTAL FLUID
REQUIREMENT (TFR)
at ml/kg/day

> 3-10 kg 100ml/kg/day

> 10-20 kg 75ml/kg/day
> 20-30 kg 50-60ml/kg/day
>30-60 kg 40-50ml/kg/day
 IV FLUID SELECTION

INITIAL REPLACEMENT (GOAL: Restore

Intravascular volume & Tissue Perfusion) always
with an ISOTONIC SOLUTION
PNSS , PLR, PNR

FOLLOW UP HYDRATION (For Ongoing Losses)

Isotonic/Hypertonic, can be Glucose containing
D5LR, D5NR

MAINTENANCE Usually Hypotonic

D5IMB , D5NM
 FLUIDS NOT WORKING?

Review medications:
Dopamine
Dobutamine
Norepinephrine
Epinephrine
Milrinone
Vasopressin
Nitroprusside
 STEP THREE: Frequent
Reassessment
Pulse quality Oxygen saturation

Heart Rate Breath sounds and

respiratory rate
Capillary Refill Time

Urine Output

Temperature

Blood Pressure

Neurologic Function
 STEP FOUR: Ancillary studies &
Pharmacologic interventions
ANCILLARY STUDIES TREATMENT
Shock etiology & severity Medications

Organ dysfunction Correct metabolic

derangements
Metabolic derangements
Manage pain and anxiety
Response to therapeutic
interventions

Subspecialty consult
 ADDITIONAL READING
CASES
HYPOVOLEMI DISTRIBUTIV OBSTRUCTIV CARDIOGENI NEUROGENIC OTHERS
C SHOCK E SHOCK E SHOCK C SHOCK SHOCK

Diarrhea Sepsis Pericardial Brain tumor Poisonings

tamponade
DKA Tension Brain trauma Nephrotic/Nep
pneumothorax hritic
syndrome

Burns Ductal Fluids for

dependent newborns
heart lesions

Dengue Massive Anaphylactic

pulmonary shock
embolism
Trauma Surgical cases
 BURNS
Parkland Formula
Crystalloid at 4ml/kg x % BSA burned
+ Maintenance requirement
Give over the first 8 hours

Then over the next 16 hours

*See Burn Assesment Chart for %BSA burned

 DENGUE
PPS 2010 Recommendations
NOT in Shock With MILD Dehydration

D5LR/ D5NSS/ D50.9NaCl D5LR/ D5NSS/ D50.9NaCl

Maintenance rate using Maintenance rate (Ludan) +

Holliday Segar/Ludan Mild Dehydration (Ludan)

Correct in 24 hours Give in the first 8 hours

Give the rest in the

remaining 16 hours
END
NELSONS TEXTBOOK OF PEDIATRICS
HARRIET LANE
PPS DENGUE 2010 GUIDELINES
 CASE

1 year old MALE was brought to the ER by his

hysterical mother due to sudden generalized
tonic clonic convulsions and upward rolling of
the eyeballs which occurred five minutes prior
to consult. This is reported to be his first
attack.

On further investigation, you noted a 3 day

history of vomiting followed by diarrhea.
The vomiting occurs 2x/day, postprandial,
amounting to cup per episode.
The frequency of the diarrhea was 6-8 stools/day
amounting to 1 cup/episode, watery, blood
streaked;

This was accompanied by fever (tmax 39) and

intermittent episodes of abdominal pain;

No known unusual food intake but the child plays

with the neighborhood kids a lot and comes
home very dirty.

(+) decrease in appetite; Noted progressive

decrease in activity
Last urine output noted 9 hours prior to
consult;

(+) Family history of BFC paternal relatives

The rest of the history was unremarkable

 PHYSICAL EXAMINATION

Temperature 39; Heart rate 140/ minute;

Respiratory rate 42/min; Blood pressure 90/60

Asleep, arousable; Not in respiratory distress;

Good skin turgor;

Pink, dry lips, no tpc, dry oral mucosa, sunken

eyeballs, no clad;

Equal chest expansion, clear breath sounds, no

retractions;
Heart with regular rhythm, no murmurs;

Abdomen tympanitic, soft, hyperactive bowel

sounds

Full and equal pulses