Fluid TherapyFluid Therapy

24 April, 2009

review

Ⅰ Ⅰ fluid balance in child

1. 1. The total amount of body fluids in childrenThe total amount of body fluids in children ：：

　　　　 The younger, The younger,

the greater the proportion of waterthe greater the proportion of water Neonate 80%80% 11month 75%75% Infant 70%70% Child 65% 65% Adult 60%60% ．．

2. The distribution of body fluids2. The distribution of body fluids ：：

The younger,The younger,

the volume of extracellular fluid more relativelythe volume of extracellular fluid more relatively

body fluids ：： Intracellular Fluid Extracellular Fluid ： Interstitial fluid, plasma, lymph fluid, cell secretion

血浆

间质液

细胞内液

The distribution of Body fluids in all ages The distribution of Body fluids in all ages

（ （ accounted foraccounted for WeightWeight %% ））

血5%

间质40%

细胞内35%

间质20%

间质10~15%

间质25%

细胞内40%

血5%

血5%

血5%

细胞内40%

细胞内40~45%

新生儿 80% ~1 岁 70%

2~14 岁 65% 成人 55~60%

3. Water demand volume3. Water demand volume

Children need a large number of water, poor of Children need a large number of water, poor of

Regulatory function, Prone to disorders of water Regulatory function, Prone to disorders of water metabolismmetabolism• In a period of rapid growth and development, Daily intake of In a period of rapid growth and development, Daily intake of

water to retain the 0.5%water to retain the 0.5%~3%~3% for the physical growthfor the physical growth

• Relatively more water loss is not dominant: Relatively more water loss is not dominant: about 2 times of about 2 times of adultsadults

• Fluid exchange of the digestive tract Fluid exchange of the digestive tract fasterfaster

• Water metabolism is highWater metabolism is high ：：– infant: Accounted for half of the total liquid volumeinfant: Accounted for half of the total liquid volume ；；– AdultAdult: : compared with 1 / 7compared with 1 / 7

• Water metabolism regulatory function of poor: kidney, lungWater metabolism regulatory function of poor: kidney, lung 。。

ⅡⅡEElectrolyte Component◆Pediatric electrolyte Component of body fluids similar to adults.

Extracellular Fluid

Na+ 、 Cl- 、 Hco3-

Intracellular Fluid

K+ 、 Mg 、 Hpo4=

protein

◆Neonatus characteristic ：◆A few days after birth, serum potassium, chlorine, phosphorus an

d lactate Higher, Sodium, calcium, bicarbonate lower

◆A few days after birth, discharge hydrogen poor, prone to acidosi

s

ⅢⅢ balance and adjustment

• Humoral regulation of acid-base balanceHumoral regulation of acid-base balance BuBuffer systemffer system

•NaHCONaHCO33/H/H22COCO33=20:1=20:1• NaNa22HPOHPO44/NaH/NaH22POPO44

•plasma proteins buffer systemLungLung ：： Discharge or accumulate Discharge or accumulate COCO22 （（ RespiratoryRespiratory ））Kidney Kidney ：： Discharge hydrogen accumulate SodiumDischarge hydrogen accumulate Sodium

（（ MetabolismMetabolism ）） regulated HCOHCO33

-- NaHCO NaHCO33/H/H22COCO33=20:1=20:1

There is a limit compensatory adjustmentThere is a limit compensatory adjustment

ⅣⅣacid-base balance marker•blood gas analysis ：： ((normal value))

PHPH ：： 7.4(7.357.4(7.35~7.45)~7.45) PaCOPaCO22 ：： 40(3440(34~45)mmHg ~45)mmHg (respiratory)(respiratory)

HCOHCO33- - ：： 24(2224(22~27)mmol/L (SB) ~27)mmol/L (SB) ((Metabolism)Metabolism)

BEBE ：： -3-3~+3mmol/L ~+3mmol/L ((Metabolism)Metabolism)

COCO22CPCP ：： 22(1822(18~27)mmol/L~27)mmol/L

Disturbance of acid-base balance

• respiratory acidosis

• respiratory alkalosis

•metabolic acidosis

•metabolic alkalosis

（（ Compensatory, DecompensatoryCompensatory, Decompensatory ））

Fluid TherapyFluid TherapyTreatment

Ⅰ Ⅰ Purpose Purpose of Fluid TherapyFluid Therapy

Restore and maintain blood volume, osmolality, pH and electrolyte composition

To restore normal physiological function

Correct to the body of water,

electrolyte disturbance (Already exists)

Ⅱ The way of Fluid Therapy

OralInjection

of vein

Ⅲ Ⅲ Fluid therapyFluid therapy

11 ）） accumulated loss volumeaccumulated loss volume 22 ）） Continued loss volumeContinued loss volume 33 ）） Physiological needsPhysiological needs

The amount of liquid, the composition The amount of liquid, the composition and completion timeand completion time 　　

Cumulative Cumulative loss loss

supplementsupplement To determine

the volume

mild ： 50ml/kg

moderate ： 50~100ml/kg

severe ： 100~120ml/kg

According to the degree of dehydration,

decision rehydration volume, composition,

speed

((ⅠⅠ) ) Cumulative loss supplementCumulative loss supplement

To determine the component

Isotonic dehydration ： 2/3~1/2 张Hypotonic dehydration ：等张 ~2/3 张Hypertonic dehydration ： 1/3~1/8 张

To determine the speed

Principle ： first quickly, then slow

Severe ： fluid expansion ： 20ml/kg within30’~1h

the rest ： completed in 8~12h

Cumulative Cumulative loss loss

supplementsupplement

Common:1/2~1/3 张

10~40ml/kg.d

(Ⅱ)(Ⅱ) Continued loss supplementContinued loss supplement

To determine

the volume

To determine the component

To determine the speed

ContinuedContinued loss loss

supplementsupplement Should be instillation evenly within 24 hoursShould be instillation after end up a cumulative loss within 14 ~ 16h

Common: 1/5 张

60~80ml/kg.d（ Including oral ）

( )Ⅲ( )Ⅲ PPhysiological needshysiological needs supplement supplement

To determine

the volume

To determine the component

To determine the speed

PPhysiological hysiological

needsneeds supplementsupplement

Should be instillation evenly within 24 hoursShould be instillation plus continued loss within 14 ~ 16h

(Ⅲ) (Ⅲ) To correct acidosisTo correct acidosis

• mild ： ： deal withdeal with toto causecause• Moderate, severe ：：

(40 - (40 - 所测所测 COCO22CP Vol%)CP Vol%)　　　 　　　 2.22.2 =(22 - =(22 - 所测所测 COCO22CP mmol/L) CP mmol/L) 0.6 0.6 kg kg

= BE = BE 0.30.3 kgkg

= 0.6 kg

Usually use half the amount

需碱性液需碱性液 mmol mmol

ⅣⅣ Principles of TherapyPrinciples of Therapy

11 、先快后慢、先快后慢

22 、先浓后淡、先浓后淡

33 、见尿补钾、见尿补钾

44 、随时调整、随时调整

Supplement Potassium Supplement Potassium NotesNotes

• Give potassium after get urine• Concentration of Supplement Potassium in Supplement Potassium in ve

ins<0.3%• Supplement Potassium speed: Supplement Potassium speed: >4~6 hours• Severity hypokalaemia ： Potassium supplemPotassium supplem

ent should be continued 4 to 6 daysent should be continued 4 to 6 days

Conversion the solution usedConversion the solution used

•10%NaCl10%NaCl ： ： 1ml=1.7mmol1ml=1.7mmol

•5%NaHCO35%NaHCO3 ：： 1ml=0.6mmol1ml=0.6mmol

•11.2%NaL11.2%NaL ： ： 1ml=1mmol1ml=1mmol

•10%KCl10%KCl ： ： 1ml=1.34mmol1ml=1.34mmol

OOral ral RRehydration ehydration SSaltsalts ((ORS ORS ))

• sodium chloridesodium chloride ：： 3.5g3.5g• sodium bicarbonatesodium bicarbonate((sodium citrate)) ：： 2.5g(2.92.5g(2.9

g)g)• potassium chloridepotassium chloride ：： 1.5g 1.5g • glucoseglucose ：： 20g20gAdd water to 1000mlAdd water to 1000ml ，， to become2/32/3 张．张．（（ NaNa++ 90mmol/L 90mmol/L ， ， KK+ + 20mmol/L20mmol/L ））

child Should be dilutedchild Should be diluted

ORSORS 机制机制• NaNa + + - glucose coupling, - glucose coupling,

transfer of small intestinetransfer of small intestine

Na+– 葡萄糖载 体

小肠上皮细胞刷状缘

Na+

葡萄糖

Na+

葡萄糖转运

细胞内 细胞间隙 血液促进

Na+ 、水吸收

Na+( 钠泵 ) 细胞间隙 (Cl- ) 渗透压 水分进入血液

Characteristics of ORSORS•Advantage ：：

– Close to plasma osmolalityClose to plasma osmolality– Content of the concentration of NaContent of the concentration of Na+ + 、、 KK+ + 、、 CC

ll- - can correct the amount of losscan correct the amount of loss – Children easily accept the tasteChildren easily accept the taste– Sodium citrate to correct metabolic acidosisSodium citrate to correct metabolic acidosis– 2% glucose to promote sodium and water abs2% glucose to promote sodium and water abs

orption maximumorption maximum

Characteristics of ORSORS

•Disadvantage ：：– Liquid Tension higherLiquid Tension higher （（ 2/32/3 张）张）– Can not be used as supplementary to maiCan not be used as supplementary to mai

ntain the liquidntain the liquid– For newborns and infants, concentration For newborns and infants, concentration

of sodium is higher of sodium is higher (Should be an appropriate dilution)(Should be an appropriate dilution)