Fluid Therapy in

Various Conditions

Iyan Darmawan
 FLUID THERAPY

RESUSCITATION CORRECTION MAINTENANCE

• Is aimed to maintain
• Is aimed to replace e.g: Serum K+ <2.5
balance of body fluid &
acute body fluid loss. Na+ < 115
nutrition status.
• Can use crystalloid Acid-Base disorders
• Classified into electrolyte
• and/or colloid.
and nutrition maintenance
ASERING 3% NaCl
RL/NS 7.46% KCL added to KAEN KAEN 3B
Hypertonic Saline/Lactate 8.4% Meylon KAEN MG3
 • Survey: > 20% of hospitalized patients hypok+ (< 3.5 mmol/L 1).
(Normal 3.5 to 5.0 mmol/L).

• A reduction in K intake to < 10 mEq/day ------------------>

cumulative deficit in the range of 250 to 300 mEq in 7 to 10 days 2.

• Most of the hospitalized patients was infused by RL, NS or D5

for their maintenance infusion solution. RL and NS have low
potassium content ( < 10 mEq/L) and D5 have no potassium
content.

• Daily potassium and sodium requirement for children and adult :

Potassium Sodium
Children 2.5 mEq/kgBW 3 mEq/kgBW
Adult  1 mEq/kgBW 2 mEq/kgBW
(homeostasis requirement in adult) 20 – 30 mEq/day

1. Cohn, J.N. et al. New Guideline for potassium replacement in clinical practice. Arch. In Int. Med. Vol.160 No.16 September 11, 2000.
2. Tannen R.L: Potassium Disorders. In Kokko & Tannen. Fluid and Electrolytes. WB Saunders Company 3 rd ed, pp 123
3. Pharmacia. Paediatric Parenteral Nutrition. Pharmacia page.11
4. Page C.P., Thomas C.H. and George M. Nutritional Assessment and Support. A primer 2 nd Ed. P : 26. 1994.
MEDICAL CONCEPT

• PEDIATRICIAN

• Fluid and electrolyte Imbalance can be caused by various diseases.

Most of them occur in the G.I. Tract. Conditions that commonly
occur in G.I. Tract are vomiting and diarrhea.

Diarrhea >>> Ringer’s acetate

Vomiting >>> : Normal saline

• Baby and children often suffer from with vomiting and diarrhea. Baby
and Children having secretory diarrhea may lose excessive sodium
and potassium. On the other hand, diarrhea caused by rotavirus can
cause loss of potassium and bicarbonate. This can lead patients to
metabolic acidosis and potassium suppression 1.

Ref. : M. Juffrie. Gangguan Keseimbangan Cairan dan Elektrolit pada Penyakit Saluran Cerna. SARI PEDIATRI. Vol. 6 No.1, Juni
2004. Jakarta.
MEDICAL CONCEPT

• Some of iv solution that are popular in clinicians currently are below

(compared to daily requirement of K and Na) :

No. PRODUCT NAME Water Kandungan Elektrolit (mEq) & Calorie (Kcal)
(mL/kgBW/day) Na K Calorie

Patient's Body Weight = 2.7 kgs.

Body's requirement
1 270 mL 8.1 mEq 5.4 mEq 270 kcal
(adult)
2 KA-EN 4A 270 mL 8.1 mEq - 43 kcal
3 KA-EN 4B 270 mL 8.1 mEq 2 mEq 41 kcal
4 1/2 NS - D5 group 270 mL 21 mEq - 54 kcal
5 1/4 NS - D5 group 270 mL 10.4 mEq - 54 kcal
 Hypernatremia in Children

68 patients (average age 3.9 yr) with Na+ >150 (151-184 mEq/L)

Hypernatremia is hospital acquired in in 60%

76% caused by inadequate fluid intake

20% gastreonteritis (14/68)

60/68 : neurologic impairment,critical illness, chronic disease or prematurity

Michael L. Moritz* and J. Carlos Ayus The Changing Pattern of Hypernatremia in Hospitalized Children.
PEDIATRICS Vol. 104 No. 3 September 1999, pp. 435-439
MEDICAL CONCEPT - Spec : PEDIATRICIAN -

• Causes of hypokalemia:

• Prolonged diuretic use

• Inadequate potassium intake
• Laxative use
• Diarrhea
• Hyperhydrosis
• Hypomagnesemia

Acute causes :
• Diabetic ketoacidosis
• Severe GI losses from vomiting and diarrhea
• Dialysis and diuretic therapy

Ref. : Malone DR, Mc Namara RM, Malone RS, Fleisher GS, Spivey WH. Hypokalemia complicating
emergency fluid resuscitation in children. Pediatr Emerg Care. 1990 Mar:6(1) : 13 - 6
MEDICAL CONCEPT - Spec : PEDIATRICIAN -

Drugs that may cause potassium depletion are :

• Theophylline
• Verapamil (with overdose)
• High dose of penicilline
• Ampicilline
• Carbenicilline
• Drug associated with Mg depletion, such as
aminoglycoside, amphotericin B and cisplatin

Therefore, patients taking the above drugs should

also receive potassium supply to avoid potassium depletion

Ref. : Malone DR, Mc Namara RM, Malone RS, Fleisher GS, Spivey WH. Hypokalemia complicating
emergency fluid resuscitation in children. Pediatr Emerg Care. 1990 Mar:6(1) : 13 - 6
MEDICAL CONCEPT

• Specialist : SURGEON / ANESTHESIOLOGIST

• Digestive surgery has a close relationship with a risk of

electrolyte imbalance, for example : jejunostomy.
• Complication seen with jejunostomy can be mechanical,
infectious, gastrointestinal, and metabolic.
And those can lead to hypokalemia 1.

• A study of protein sparing effect in post-op patients showed that

Effect of added hypocaloric glucose or lipid result in lesser
negative nitrogen balance in patients receiving protein plus
150 gram of glucose than patients receiving protein alone 2.

Ref. :
1. Tapia J., Murguia R., Garcia G., de los Morentos PE., and Onate E. Jejunostomy : techniques, indications, And complications.
World J Surg. 1999 Jun; 23(6) : 596 – 602.
2. Greenberg G.R. Et al. Protein sparing therapy in postoperative patients. Effect of added hypocaloric glucose or lipid.
New England Journal of Medicine Vol. 294:1411 – 1416. 1976.
 • A study of protein sparing effect in post-op patients showed that
effect of added hypocaloric glucose or lipid result in lesser
negative nitrogen balance in patients receiving protein plus
150 gram of glucose than patients receiving protein alone 1.

• KA-EN MG3 has 400 kcal/L of NPC, therefore amino acids should
be administered with KA-EN MG3 concomitantly to prevent protein
loss.

1. Greenberg G.R. Et al. Protein sparing therapy in postoperative patients. Effect of added hypocaloric glucose or lipid.
New England Journal of Medicine Vol. 294:1411 – 1416. 1976.
MEDICAL CONCEPT

• Fluid management is important for surgical patients.

Mismanagement in fluid therapy can lead patients into fatal result 1,2

• Allan I. Arieff reported that pulmonary edema can occur within the
initial 36 postoperative hours when net fluid retention exceeds 67
mL/kg/d 2.

• Holte, K. et al., then stated that infusion of 40 mL/kg of lactated

Ringer’s solution in volunteers led to a significant decrease in
pulmonary function and a significant weight gain for 24 h but without
effects on exercise capacity 1.

Ref. :
1. Allen I. Arieff, MD. Fatal Postoperative Pulmonary Edema* : Pathogenesis and Literature Review. Chest. 1999;115:1371-1377. 1999. USA.
2. Holte, K., Peter J., Hendrik K. . Physiologic effects of IV fluid administration in healthy volunteers. Anesth Analg 2003; 96:1504 – 1509. Denmark.
MEDICAL CONCEPT

• The stress of operation stimulates the release of aldosterone and

vasopressin with the accompanying retention of sodium and water.
Therefore, these may be harmful to the patients with compromised
renal or cardiac reserve, if restriction of fluid administration is not
made. 1

• Then, Robert et al (1985) in Hill (1992) suggested that adequate

intraoperative maintenance of extracellular fluid volume will
overcome this operative need for fluid restriction, but nevertheless
the doctors should be ready to restrict i.v. fluid for the first 24 hour or
so. This is especially important in patients who are nutritionally
depleted.

Ref. :
1. Hill G.L. Disorder of Nutrition and Metabolism in Clinical Surgery : Understanding and Management. Churchill Livingstone. 1992.
MEDICAL CONCEPT

Sodium requirement for surgical patients postoperatively is not as

high as for resuscitation therapy.
Hill, G.L. provide 2 regimens for sodium supply as follows :

• 500 mL of 0.9% NS + 2 L of 5% Dextrose or

• 2500 mL of fifth NS (0.18% NS + 4.2% Dextrose)

Ref. :
1. Hill G.L. Disorder of Nutrition and Metabolism in Clinical Surgery : Understanding and Management. Churchill Livingstone. 1992.
MEDICAL CONCEPT

• Specialist : INTERNIST

• Potassium depletion can be caused from : gastrointestinal disease

such as vomiting, diarrhea, nasogastric suction, villous adenoma, fistula1.

• List of the approximate elect. composition of GI losses :2

No Fluid Electrolyte (mEq/L)
Na+ K+ Cl- Protein (g/dl)
1 Gastric 20 - 80 5 - 20 100 - 150 -
2 Pancreatic 120 - 140 5 - 15 40 - 80 -
3 Small Bowel 100 - 140 5 - 15 90 - 130 -
4 Bile 120 - 140 5 - 15 80 - 120 -
5 Ileostomy 45 - 135 3 - 15 20 - 115 -
6 Diarrhea 10 - 90 10 - 80 10 - 110 -
7 Burns 140 5 110 3-5

Ref. :
1. Eddy Suwandoyo. Masalah Hipokalemia dan Penatalaksanaannya. Unpublished. 2002.
2. Viviana Martinez-Bianchi, M.R. Peterson, and M.A. Graber. Pediatrics : Vomiting, Diarrhea and Dehydration.
Univ. of Iowa Family Practice Handbook 3rd Ed. Chapter 10.
MEDICAL CONCEPT - Spec : INTERNIST -

THERAPY FOR POTASSIUM DEPLETION

• Preventing cardiac complications (fatal case).

• Conserving total body potassium content.
• Maximal rate of i.v replacement is 20 mEq/hour.
• Serum potassium values can be monitored until normokalemia is
achieved.
• Generally i.v. replacement is 50 mEq/day.
• 1-4 mEq/kg/day for baby or children.
• 2 liters of KA-EN 3B or KA-ENMG-3 (each containing 40 mEq
potasium) for adult.

Ref. :
1. Eddy Suwandoyo. Masalah Hipokalemia dan Penatalaksanaannya. Unpublished. 2002.
MEDICAL CONCEPT

• Diabetic ketoacidosis (DKA) is an emergency condition that can be life-

threatening if not treated properly. DKA occurs most often in patients
with type 1 DM.
• The management of patients with DKA is initial rehydration (using
isotonic saline) with subsequent potassium replacement and low dose
insulin therapy.
• Although the typical potassium deficit in DKA patients is 500 – 700
mEq, most patients are hyperkalemic at the time of diagnosis because
of the effect of insulinopenia, hyperosmolality and acidemia. During
rehydration and insulin therapy, the serum potassium concentration
decline rapidly as potassium re-enters the intracellular compartment 1.
• Protocol for potassium addition for DKA patients :
• K serum less than 5.5 mEq/L --> add 20-30 mEq/L potassium.
Ref. : Diabetes Care 25:S100-S108, 2002
© 2002 by the American Diabetes Association, Inc.
MEDICAL CONCEPT

• HYPERNATREMIA is a common in he elderly patients, particularly

among those who are hospitalized in long-care facilities.
Hypernatremia is a defect in water intake and usually implies an
impairment in the thirst mechanism or a lack access to adequate fluid
intake.
• Hypernatremia in the elderly is common due to the combination of
inadequate fluid intake and increased fluid loss. Age-related
impairment in the thirst mechanism and urine loss are often
contributing to this condition.
• Treatment of hypernatremia has to consider body weight, input-
output of body fluid and how to maintain it in a balance volume 1.

Ref. :
1. www.emedicine.com.
MEDICAL CONCEPT

• Specialist : NEUROLOGIST

• Beneficial effect of potassium are :

• Lower blood pressure in both hypertension and normotensive people.
• Reduce the risk of stroke and prevent renal vascular, glomerular
and tubular damage.
• Reduces the risk of ventricular arrhythmias in patients with ischaemic
heart disease, heart failure and left ventricular hypertrophy.

• There are many research stated that serum potassium level has
a correlation with the risk of stroke.
• Using the normal range (3.5 – 5.0 mEq/L), hypokalemia was associated
with an elevated risk of ischaemic and hemorrhagic stroke.

Ref. :
1. Smith N.L. et al. Serum Potassium and Stroke Risk among Treated Hypertensive Adult. Am J Hypertens.
2003 Oct; 16(10)806 – 13.
MEDICAL CONCEPT

• Specialist : NEUROLOGIST

Hypokalemia occurred more frequently in stroke

patients than in patients with myocardial infarction

Gariballa SE, Robinson TG, Fotherby MD. Hypokalemia and potassium excretion in stroke patients.
J Am Geriatr Soc. 1997 Dec;45(12):1454-58.
 Hypokalemia (K+ serum < 3.4 mEq/L)

• Observational study in 421 stroke patients

• More often in stroke than MI (84 (20%) vs 15(10%) or
hypertension(84 (20%) vs 13(10%), even when patients
taking diuretics were excluded.
• Increased chance of death
• Hypokalemia post streoke is common and may be
associated with poor outcome

Garibella SE, Robinson TG, Fotherby MD. Hypokalemia and potasssium excretion in
stroke patients.J Am Geriatr Soc 1997 Dec;45(12):1454-58
MEDICAL CONCEPT

• Specialist : OBSTETRIC & GYNAECOLOGIST

• Following the previous data table of approximately electrolyte composition

loss from GI tract, pregnant women with H.E.G. will have much
electrolyte loss.

• H.E.G. may result in weight loss, nutritional deficiencies, abnormalities

in fluid and electrolyte (usually hypokalemia), and acid-base imbalance.

• Treatment consist of mainly supportive care, IV fluid upto 5 to 6 liters

per day using appropriate amount of sodium, potassium, chloride, lactate
or bicarbonate, glucose and water.

• KA-EN MG3 can supply electrolyte and dextrose.

Ref. :
1. Chudacoff, R., MD. Hyperemesis Gravidarum. www.surrogacy.com/medres/article/hyperem.htm
2. Mother & Child Glossary. Hyperemesis Gravidarum. www.hon.ch/dossier/motherchild/preexisting_conditions.htm
MEDICAL CONCEPT

• Electrolyte maintenance therapy, particularly sodium and potassium,

should be supported by an iv solution that has already contain
potassium and sodium in a proper amount that can meet to the body’s
daily requirement. Minimally for body’s daily minimum requirement.
• Too many iv solutions in the market currently. Some of them that are
popular in clinicians are below (compared to daily requirement of K and
Na) :
No. PRODUCT NAME Water Kandungan Elektrolit (mEq) & Calorie (Kcal)
(mL/kgBW/day) Na K Calorie

Patient's Body Weight = 50 kgs.

Body's requirement
1 1250 - 2000 mL 50 - 100 50 1500 - 2000
(adult)
2 KA-EN 3A 2000 mL 120 20 216
3 KA-EN 3B 2000 mL 100 40 216
4 RL group 2000 mL 260 8 -
5 D5 group 2000 mL - - 400
6 NS dorup 2000 mL 308 - -
7 1/2 NS - D5 group 2000 mL 154 - 400
8 Euroion in D5 2000 mL 50 40 400
9 Eurosol M 2000 mL 80 26 400
 Conclusion

• Fluid Therapy should be tailored to individual need, based on the electrolyte

and dehydration status
• RL , D5W and N/2-D5 are not suitable for maintenance because they do not
address the daily potassium and sodium requirement
• As maintenance infusion solutions, KA-EN logically can be administered to
all hospitalized patients that have no contra-indications to the potassium or
sodium or lactate.
• It can be said that KA-EN group are the first choice infusion solutions for
electrolyte maintenance therapy, compared to RL, D5, NS or the
combination of NS – D5.
Thank you
Apakah bisa diresusitasi dg KAEN3B?

KAEN3B : 50 mEq Na, 50 mEq CL; 20 mEq K, laktat 20 mEq, glu 27 g

Kasus: Anak usia 8 bulan dg diare, terlalu lemah untuk respon thd
rangsang nyeri; upaya pernapasan menurun, asidosis metabolik,
intermittent sinaatrial block, dan nadi 72 beat/menit (tidak sinkron
jika dipandang dari derajat dehidrasinya). BB 8 kg.

Kalau dari referensi yang ada selama ini: kec infus K maksimum
0,3-0,5 mmol/kg/jam. Namun pada pasien ini risiko terapi yang tidak
adekuat jauh lebih besar daripada risiko pemberian cairan dan kalium
yang agresif. Oleh karena itu, pasien ini mendapat K dengan kecepatan
maksimum 3-4 kali dari anjuran -- dan anak selamat.
Usia 8 bl; Kadar K 0,7; pH 7,09; BE –24,5 BB~ 8 kg

Diberikan Total cairan dalam 24 jam 220 ml/kg ~ 1760 ml

Kec maks K+ 2 mmol/kg/jam ~ 16 mmol/jam
Total K dalam 24 jam 14,5 mmol/kg ~ 116 mmol

Perubahan K serum : early 1,1 mmol/L; late 2,7 mmol/L

BE pada ~ 24 jam –19,2

Pasien selamat
KAEN 3B mengandung 20 mEq K /L

Pada resusitasi 30 ml/kg/jam anak 8 Kg = 240 ml/jam

Jika yang digunakan KAEN3B berarti K+ ~ 5 mEq/jam

= ~ 0,6 mEq/kg/jam

Dari aspek kecepatan pemberian K bisa diberikan

Potentially life threatening profound hypokalaemia with
metabolic acidosis may not be adequately dealt with by
current treatment recommendations
Abnormalities of serum potassium are associated with well
described clinical features: lassitude when potassium <3.5
mmol/l, possible muscle necrosis at < 2.5 mmol/l, and a flaccid
paralysis with respiratory compromise at <2 mmol/l.1 World
wide, hypokalaemia is most often caused by diarrhoea, although
specific treatment of hypokalaemia is not mentioned in
international guidelines for managing gastroenteritis.2
Furthermore, a recent case made us concerned that the
potassium replacement recommended in medical texts (a
maximum rate of infusion of 0.3-0.5 mmol/kg/hour and a
maximum daily replacement of 3-5 mmol/kg) may be
inadequate for profound hypokalaemia ( 1.5 mmol/l).
Terapi Cairan Rumatan
pada Anak
 FLUID THERAPY

RESUSCITATION MAINTENANCE

Crystalloid Colloid ELECTROLYTES NUTRITION

REPAIR

1. Replace acute loss 1. Replace normal loss

(hemorrhage, GI loss, (IWL + urine+ faecal)
3rd space etc) 2. Nutrition support
 PEMAKAIAN INFUS DI UGD
SYOK HIPOVOLEMIK

Ya

ASERING
20-30 ml/kg/jam
Observasi/
monitor

nadi teraba
akral hangat
urine output +

kecepatan bisa
diturunkan 10 73 ml/kg/jam
 PEMAKAIAN INFUS DI UGD
SYOK HIPOVOLEMIK

TIDAK

< 3 tahun > 3 tahun

Bgmn Jika KAEN 4A KAEN 1B

Hipoglisemik?

Normo/hipoK Normo/
hipoK

Otsu-N/5-D10
KAEN 4B KAEN 3B/MG3
MAINTENANCE FLUID
. THERAPY

• Supplies daily requirement of water,

electrolyte (Na+, K+), glucose
• Replaces IWL + urine + faecal loss
• Does not correct deficit or abnormal losses,
e.g due to diarrhea, vomiting or intestinal
drainage
Rasionale of maintenance
. solutions

• Fluid redistribution
• Basal requirement of potassium &
sodium
• electrolyte concentration in infusion
solutions
• ‘Ready for use’ solutions minimises risk
of contamination
 KAEN SOLUTIONS

Na+ K+ Mg++ Cl- P Lactate Glucose pH mOsm/L

(mEq/L) (mEq/L) (mEq/L) (mEq/L) (mmol/L) (mmol/L) (gr/L)

KAEN 1B 38,5 - - 38,5 - - 37,5 4,8 285

KAEN 3A 60 10 - 50 - 20 27 5,4 290
KAEN 3B 50 20 - 50 - 20 27 5,4 290
KAEN 4A 30 - - 20 - 10 40 5,5 282
KAEN 4B 30 8 - 28 - 10 37,5 5,5 284
 COMMON ILLNESSES
• Ileus : RL/RA to replace 3rd space loss,
followed by KAEN
• Pneumonia/bronchopneumonia: KAEN
3A/3B (watch for SIADH--- NS)
• Meningitis/encephalitis : KAEN 4A/4B if
hypertonic dehydration
• Postoperative : Asering followed by KAEN
3A (watch for hyponatremia)
KA-EN 4A® Maintenance Infusion Solutions
KA-EN 4B® for Pediatric Patients

KA-EN 4A®
KA-EN 4A®  without kalium
Initial maintenance solution for infant & children.

Can be given to patient with unknown potassium

concentration
Na requirement (3 mEq/kg/hari)*

Age < 1 month

3,5 kg : Na 10,5 mEq KAEN4A 30 mEq/L
Water 350 ml 10,5 mEq
3 months
5- 5,6 kg: Na 15- 16,8 mEq KAEN4A 30 mE/L
Water 500-600 ml 15-18 mEq
2 years
11 kg; 33 mEq KAEN4A 30 mEq/L
Water 1050 ml 31,50 mEq

Ref. Birmingham Children Hospital

KA-EN 4A® Maintenance Infusion Solutions
KA-EN 4B® for Pediatric Patients

KA-EN 4B®

KA-EN 4B®  8 mEq/L potassium

Potassium supplement minimizes risk of
hypokalemia
K requirement (2 mEq/kg/day)*

< 1 month
3,5 kg : K 7 mEq KAEN4B 8 mEq/L
Water 350 ml 2,8 mEq
3 months
5 kg: K 10 mEq KAEN4B 8 mE/L
as supplement
Water 500 ml 4 mEq
2 years
11 kg; K 22 mEq KAEN4B 8 mEq/L
Air: 1050 ml 8,4 mEq

Ref. Birmingham Children Hospital

 RL atau Ringer Solution bukan untuk Maintenance

Kebutuhan
anak *
RL D5 KAEN 3B KAEN 3A

Na+ 130 - 50 60 3 meq/kg

K+ 4 - 20 10 2,5 meq/kg

Glukosa - 50 27 27
 Kasus Maintenance Anak

Dewasa BB 25 kg :

Kebutuhan air 1,5 L RL 1,5 L KAEN3A 1,5L KAEN 3B 1,5L

Na+ 75 mEq 195 mEq 80 mEq 75 mEq

K+ 50 mEq 6 15 30
 Kasus Maintenance Anak

Dewasa BB 25 kg :

Kebutuhan air 1,5 L RL 1,5 L KAEN3A 1,5L KAEN 3B 1,5L

Na+ 75 mEq 195 mEq 80 mEq 75 mEq

K+ 50 mEq 6 15 30
 INDICATIONS
• KAEN 1B • Initiating > 3yr
(Na 38.5,Cl 38.5,Glu 37.5)
• KAEN 3B • Maintenance >3 yr
(Na 50 K 20, Glu 27)
• KAEN 3A • Maintenance > 3 yr
(Na 60 K 10, Glu 27)
• KAEN 4A
(Na 30)
• Initiating < 3 yr
• KAEN 4B
(Na 30,K 8) • Maintenance < 3 yr
 Conclusion
• Maintenance fluid therapy : normal loss
• (IWL + Urine)
• Different types of dehydration
• ‘Ready for use” product associated with less risk of
contamination
• Suitable in hypertonic dehydration
• KAEN 4B, 3B & 3A minimize risk of potassium
depletion
• Beware of iatrogenic imbalances;
monitoring
The correct, and simpler, method to correct hyponatraemia
with 3% saline is as follows:
1. 3% saline (513 mmol/l) contains approximately 1 mmol
sodium in 2 ml.
2. Total body water is 60% of body weight.
3. Therefore the volume (in ml) of 3% saline which will raise
the serum sodium by 1 mmol/l is twice total body water
(in litres).
4. This volume can then be infused at whatever rate is
chosen to correct the serum sodium.

For example, a child of 10 kg has a total body water of 6

litres. Therefore 12 ml 3% saline will raise the serum
sodium by 1 mmol/l. Hence an infusion of 24 ml/hour
will raise the serum sodium by 2 mmol/l per hour.
 Use of Bicarbonate
1. If metabolic acidosis persists, it generally means that the fluid resuscitation
has been inadequate and more volume is needed, not bicarbonate. The routine
use of sodium bicarbonate is not recommended under these conditions.

In the severely dehydrated patient with a pH <7.1 and calculated bicarbonate

<12 judicious use of bicarbonate can be considered using the following
guidelines:

mmols NaHCO3 = 0.6 x body weight (kg) x base deficit (mmol/L)

2 Either use this formula or give a trial dose of 1-2 mmols of bicarbonate/kg
of body weight.

Give over 15 to 30 minutes.

 Correction of Hypokalemia

Usual dose for potassium replacement: 0.5-1 mEq/kg IV;

not to exceed 30-40 mEq/dose
not to exceed 0.3-0.5 mEq/kg/h for noncritical
hypokalemia; however, this rate may be inadequate in life-threatening
hypokalemia

Infusion rates: 0.5 mEq/kg/h or more can be delivered but

require ECG monitoring to detect potentially fatal
arrhythmia, especially ventricular dysrhythmia, because it can
lead rapidly to cardiac arrest
Thank you
Kalkulasi Kebutuhan Elektrolit berdasarkan usia dan BB (KMS)
No Usia Berat Badan (kg) Kebutuhan Harian (mEq/hari) Kebutuhan Air Kebutuhan Keb. Karbohidrat
(bulan) Batas Bawah Batas Atas Natrium Kalium Chlor ( mL/hari ) Protein (Glukosa)
Ref : 1 Ref : 1 Ref : 1 Ref; 2 Ref: 2 Ref: 4 Ref; 3 (gr/hari) (gr/hari)
Ref: 2 Ref:2

1 1 3.5 4.1 10.5 - 12.3 8.8 - 10.3 10.5 - 12.3 350 - 410 8.75 - 10.25 49.00 57.40
2 2 4.2 4.9 12.6 - 14.7 10.5 - 12.3 12.6 - 14.7 420 - 490 10.50 - 12.25 58.80 68.60
3 3 5 5.6 15.0 - 16.8 12.5 - 14.0 15.0 - 16.8 500 - 560 12.50 - 14.00 70.00 78.40
4 4 5.7 6.1 17.1 - 18.3 14.3 - 15.3 17.1 - 18.3 570 - 610 14.25 - 14.00 79.80 85.40
5 5 6.2 6.9 18.6 - 20.7 15.5 - 17.3 18.6 - 20.7 620 - 690 15.50 -17.25 86.80 96.60
6 6 6.6 7.5 19.8 - 22.5 16.5 - 18.8 19.8 - 22.5 660 - 750 16.50 -18.75 92.40 105.00
7 7 7.0 7.9 21.0 - 23.7 17.5 - 19.8 21.0 - 23.7 700 - 790 17.50 -19.75 98.00 110.60
8 8 7.4 8.4 22.2 - 25.2 18.5 - 21.0 22.2 - 25.2 740 - 840 18.50 - 21.00 103.60 117.60
9 9 7.7 8.8 23.1 - 26.4 19.3 - 22.0 23.1 - 26.4 770 - 880 19.25 - 22.00 107.80 123.20
10 10 8.1 9.1 24.3 - 27.3 20.3 - 22.8 24.3 - 27.3 810 - 910 20.25 - 22.75 113.40 127.40
11 11 8.5 9.4 26.0 - 28.2 21.3 - 23.5 26.0 - 28.2 850 - 940 21.25 - 23.50 119.00 131.60
12 12 8.8 9.8 26.4 - 29.4 22.0 - 24.5 26.4 - 29.4 880 - 980 22.00 - 24.50 123.20 137.20

13 13 8.8 10 26.4 - 30.0 22.0 - 25.0 26.4 - 30.0 880 - 1000 22.00 - 25.00 123.20 75.00
14 14 9.2 10.2 27.6 - 30.6 23.0 - 25.5 27.6 - 30.6 920 - 1010 23.00 - 20.40 128.80 76.50
15 15 9.4 10.4 28.2 - 31.2 23.5 - 26.0 28.2 - 31.2 940 - 1020 23.00 - 20.80 131.60 78.00
16 16 9.8 10.6 29.4 - 31.8 24.5 - 26.5 29.4 - 31.8 980 - 1030 24.50 - 21.20 137.20 79.50
17 17 9.9 10.8 29.7 - 32.4 24.8 - 27.0 29.7 - 32.4 990 - 1040 19.80 - 21.60 138.60 81.00
18 18 10.3 11.1 30.9 - 33.3 25.8 - 27.8 30.9 - 33.3 1015 - 1055 20.60 - 22.20 77.25 83.25
19 19 10.5 11.3 31.5 - 33.9 26.3 - 28.3 31.5 - 33.9 1025 - 1065 21.00 - 22.60 78.75 84.75
20 20 10.5 11.5 31.5 - 34.5 26.3 - 28.7 31.5 - 34.5 1025 - 1075 21.00 - 23.00 78.75 86.25
21 21 10.7 11.7 32.1 - 35.1 26.8 - 29.3 32.1 - 35.1 1035 - 1085 21.40 - 23.40 80.25 87.75
22 22 10.9 11.9 32.7 - 35.7 27.3 - 29.8 32.7 - 35.7 1045 - 1095 21.80 - 23.80 81.75 89.25
23 23 11.1 12.1 33.3 - 36.3 27.8 - 30.3 33.3 - 36.3 1015 - 1105 22.20 - 24.20 83.25 90.75
24 24 11.3 12.3 33.9 - 36.9 28.3 - 30.8 33.9 - 36.9 1065 - 1115 22.60 - 24.60 84.75 92.25

No Usia Berat Badan (kg) Kebutuhan Harian (mEq/hari) Kebutuhan Air Kebutuhan Keb. Karbohidrat
(bulan) Batas Bawah Batas Atas Natrium Kalium Chlor ( mL/hari ) Protein (Glukosa)
Ref : 1 Ref : 1 Ref : 1 Ref; 2 Ref: 2 Ref: 4 Ref; 3 (gr/hari) (gr/hari)
Ref: 2 Ref:2

25 25 11.4 12.4 34.2 - 37.2 28.5 - 31.0 34.2 - 37.2 1070 - 1120 22.80 - 24.80 85.50 93.00
26 26 11.6 12.6 34.8 - 37.8 29.0 - 31.5 34.8 - 37.8 1080 - 1130 23.20 - 25.20 87.00 94.50
27 27 11.7 12.8 35.1 - 38.4 29.3 - 32.0 35.1 - 38.4 1085 - 1140 23.40 - 25.60 87.75 96.00
28 28 11.9 12.9 35.7 - 38.7 29.8 - 32.3 35.7 - 38.7 1095 - 1145 23.80 - 25.60 89.25 96.75
29 29 12.1 13.1 36.3 - 39.3 30.3 - 32.8 36.3 - 39.3 1105 - 1155 24.20 - 26.20 90.75 98.25
30 30 12.3 13.3 36.9 - 39.9 30.8 - 33.3 36.9 - 39.9 1115 - 1165 24.60 - 26.60 92.25 99.75
31 31 12.4 13.5 37.2 - 40.5 31.0 - 33.8 37.2 - 40.5 1120 - 1175 24.80 - 27.00 93.00 101.25
32 32 12.6 13.7 38.4 - 41.1 31.5 - 34.3 38.4 - 41.1 1130 - 1185 25.20 - 27.40 94.50 102.75
33 33 12.7 13.8 38.1 - 41.4 31.8 - 34.6 38.1 - 41.4 1135 - 1190 25.40 - 27.60 95.25 103.50
34 34 12.7 14.0 38.1 - 42.0 31.8 - 35.0 38.1 - 42.0 1135 - 1120 25.40 - 28.00 95.25 105.00
35 35 13.0 14.2 39.0 - 42.6 32.5 - 35.5 39.0 - 42.6 1150 - 1210 26.00 - 28.40 97.50 106.50
36 36 13.2 14.3 39.6 - 42.9 33.0 - 35.75 39.6 - 42.9 1160 - 1215 26.4 - 28.6 99.00 107.25

KaEn 4B 30 8 28 37.5
N5D4 50 - 50 40
No Usia Berat Badan (kg) Kebutuhan Harian (mEq/hari) Kebutuhan Air
(bulan) Batas Bawah Batas Atas Natrium Kalium Chlor ( mL/hari )
Ref : 1 Ref : 1 Ref : 1 Ref; 2 Ref: 2 Ref: 4 Ref; 3

1 1 3.5 4.1 10.5 - 12.3 8.8 - 10.3 10.5 - 12.3 350 - 410
2 2 4.2 4.9 12.6 - 14.7 10.5 - 12.3 12.6 - 14.7 420 - 490
3 3 5 5.6 15.0 - 16.8 12.5 - 14.0 15.0 - 16.8 500 - 560
4 4 5.7 6.1 17.1 - 18.3 14.3 - 15.3 17.1 - 18.3 570 - 610
5 5 6.2 6.9 18.6 - 20.7 15.5 - 17.3 18.6 - 20.7 620 - 690
6 6 6.6 7.5 19.8 - 22.5 16.5 - 18.8 19.8 - 22.5 660 - 750
7 7 7.0 7.9 21.0 - 23.7 17.5 - 19.8 21.0 - 23.7 700 - 790
8 8 7.4 8.4 22.2 - 25.2 18.5 - 21.0 22.2 - 25.2 740 - 840
9 9 7.7 8.8 23.1 - 26.4 19.3 - 22.0 23.1 - 26.4 770 - 880
10 10 8.1 9.1 24.3 - 27.3 20.3 - 22.8 24.3 - 27.3 810 - 910
11 11 8.5 9.4 26.0 - 28.2 21.3 - 23.5 26.0 - 28.2 850 - 940
12 12 8.8 9.8 26.4 - 29.4 22.0 - 24.5 26.4 - 29.4 880 - 980

13 13 8.8 10 26.4 - 30.0 22.0 - 25.0 26.4 - 30.0 880 - 1000

14 14 9.2 10.2 27.6 - 30.6 23.0 - 25.5 27.6 - 30.6 920 - 1010
15 15 9.4 10.4 28.2 - 31.2 23.5 - 26.0 28.2 - 31.2 940 - 1020
16 16 9.8 10.6 29.4 - 31.8 24.5 - 26.5 29.4 - 31.8 980 - 1030
17 17 9.9 10.8 29.7 - 32.4 24.8 - 27.0 29.7 - 32.4 990 - 1040
18 18 10.3 11.1 30.9 - 33.3 25.8 - 27.8 30.9 - 33.3 1015 - 1055
19 19 10.5 11.3 31.5 - 33.9 26.3 - 28.3 31.5 - 33.9 1025 - 1065
20 20 10.5 11.5 31.5 - 34.5 26.3 - 28.7 31.5 - 34.5 1025 - 1075
21 21 10.7 11.7 32.1 - 35.1 26.8 - 29.3 32.1 - 35.1 1035 - 1085
22 22 10.9 11.9 32.7 - 35.7 27.3 - 29.8 32.7 - 35.7 1045 - 1095
23 23 11.1 12.1 33.3 - 36.3 27.8 - 30.3 33.3 - 36.3 1015 - 1105
24 24 11.3 12.3 33.9 - 36.9 28.3 - 30.8 33.9 - 36.9 1065 - 1115

No Usia Berat Badan (kg) Kebutuhan Harian (mEq/hari) Kebutuhan Air

(bulan) Batas Bawah Batas Atas Natrium Kalium Chlor ( mL/hari )
Ref : 1 Ref : 1 Ref : 1 Ref; 2 Ref: 2 Ref: 4 Ref; 3

25 25 11.4 12.4 34.2 - 37.2 28.5 - 31.0 34.2 - 37.2 1070 - 1120
26 26 11.6 12.6 34.8 - 37.8 29.0 - 31.5 34.8 - 37.8 1080 - 1130
27 27 11.7 12.8 35.1 - 38.4 29.3 - 32.0 35.1 - 38.4 1085 - 1140
28 28 11.9 12.9 35.7 - 38.7 29.8 - 32.3 35.7 - 38.7 1095 - 1145
29 29 12.1 13.1 36.3 - 39.3 30.3 - 32.8 36.3 - 39.3 1105 - 1155
30 30 12.3 13.3 36.9 - 39.9 30.8 - 33.3 36.9 - 39.9 1115 - 1165
31 31 12.4 13.5 37.2 - 40.5 31.0 - 33.8 37.2 - 40.5 1120 - 1175
32 32 12.6 13.7 38.4 - 41.1 31.5 - 34.3 38.4 - 41.1 1130 - 1185
33 33 12.7 13.8 38.1 - 41.4 31.8 - 34.6 38.1 - 41.4 1135 - 1190
34 34 12.7 14.0 38.1 - 42.0 31.8 - 35.0 38.1 - 42.0 1135 - 1120
35 35 13.0 14.2 39.0 - 42.6 32.5 - 35.5 39.0 - 42.6 1150 - 1210
36 36 13.2 14.3 39.6 - 42.9 33.0 - 35.75 39.6 - 42.9 1160 - 1215