fluids and electrolytes in pediatrics final

7/24/2019 Fluids and Electrolytes in Pediatrics Final

http://slidepdf.com/reader/full/fluids-and-electrolytes-in-pediatrics-final 1/41

Kathleen Asas, MD.MPH

Inpatient Pediatrics

Jan 2011



Objectives T revie! basics " #aintenance $%id and

electrl&te re'%ire#ents

T (ain c#"rt in classi)catin "deh&dratin and ptins "r $%id s%pprt

T per"r# case*based practice+



Back to Basics….Fluid compartments Ttal bd&

!ater I- /-

Ttal bd& !ater

0*3 4 " 5d&!ei(ht



I#prtant -nceptsPlas#a Os#lalit& -ncentratin " sl%tes in

bld

Plas#a Os#lalit& 2 6 plas#a 78a9

Change in plasma osmolality --> change in ECFosmolality with water movement across cell

membranes

Remember: The body has an immediate need torestore intravascular volume over osmolality.



Ttal 5d& :ater

-#psitin b& A(e



-nceptsMaintenance; 8r#al n(in( lsses " $%ids

and electrl&tes

De)cit; <sses " $%ids and electrl&tesres%ltin( "r# an illness

On*(in( <sses; =e'%ire#ent " $%ids andelectrl&tes t replace n(in( lsses



Factors IncreasingMaintenance FluidRequirements

Factors DecreasingMaintenance FluidRequirements

ever*each 1 de(ree-elci%s ver >? de(reesincreases #aintenance

$%id re'%ire#ents b&124

H&perventilatin

Increased te#perat%re "the envirn#ent

5%rnsOn(in( lsses*diarrhea,

v#itin(, 8@ t%be %tp%t

Bin; Mist tent, inc%batr7pre#at%re in"ants9

<%n(s; H%#idi)edventilatr

Mist tent

=enal; Oli(%ria, an%ria

Misc; H&pth&ridis#



@al " l%id Therap& T prevent deh&dratin

T prevent electrl&te abnr#alities

T prevent prtein de(radatin T prevent acidsis and circ%latr& cllapse



Calculation of MaintenanceFluid Requirements…the

Holliday!egar Method

Example:

A 30-kg child would require (100 × 10) + (50 × 10) + (20 × 10) 1!"00 cc#da$

or (% × 10) + (2 × 10) + (1 × 10) "0 cc#h&



Maintenance "lectrolyteRequirements

8a and K are the pri#ar& electrl&tes that (vern -and I- s#lalit&.

#$a% in "CF & '()'*) m"q+,- negligile in ICF#/% in ICF & ')0 m"q+,- negligile in "CF

Maintenance "lectrolyte Requirements18a; 2( #'C100#l !ater Cda&

O= 2*> #'CB(Cda&K; '2 #'C100#l " !aterCda&

O= 1*2#'CB(Cda&-hlride; 2 #'C100#l " !ater Cda&



1. ?B( in"ant; ?B( 6 #lCB(Chr >2#lChr

8a; 13*>0#'C< K; ?*13#'C<

D3 E 8 / 10#e' K-lC< F >2#lChr

2. :t*33 B(; =ate G3#lChr

8a; 3*? #'C< K; 22*3 #'C<

I; D3 8 / 20 #' K-lC< FG3#lChr

>. :t*?0B(; =ate 120#lChr

8a; 3.*?3 #'C< K; 2?.?*3?#'C<

I; D3 8 / 20#' K-lC< F120#lChr

tandard 8a cntent in I; 8 70.G4 8a-l9 13 #'Cl 8a

8 70.34 8a-l9 #'Cl8a

1C> 8 70.>>4 8a-l9 31

#'Cl 8aE 8 70.234 8a-l9 >G #'Cl

8a

1C3 8 70.24 8a-l9 >1 #'Cl8a

tandard K cntent in I;

10#' K-lC<

20 #' K-lC<

0 #' K-lC<

-hsin( MI..these are best

esti#ates



Concepts in Dehydration

Initial lss " $%id "r# the bd& depletes thee6tracell%lar $%id 7-9.

@rad%all&, !ater shi"ts "r# the intracell%lar

space t #aintain the -, and this $%id islst i" deh&dratin persists.

3cute Illness 45( days 61 708 of the 9uidloss is from the "CF and 208 is from the

intracellular 9uid 4ICF6.:rolonged Illness 4; ( days61 <08 9uid

loss from "CF and *08 loss from ICF.



Pre*Illness :ei(ht sti#ate "Deh&dratin

cenari 1 7i" pre*illness !tBn!n9

8eed t acc%ratel& #nitrpatient !ei(hts "re'%entl&

l%id de)cit 7<9 PI: 7B(9

I: 7B(9

7@enerall& 100ccCB(9

PI: Pre*illness !ei(ht

I: Illness !ei(ht

4 Deh&dratin PI: 7B(9 I: 7B(9 61004

PI: 7B(9

cenari 2; 7In =9 8eed illness !t

4 DH8 based n e6a#

tep 1;

-alc%late pre*illness !t 7PI:9;

-%rrent !t PI: !t71*4 DH89

tep 2; -alc%late !t lss andrespective de)cit $%idvl%#e

PI:*I: !t lss

8te;

1B( L 1000#l $%id de)citDe)cit l%id vl%#e 100ccCB( !t lss



Maintenance lectrl&tes



Oral =eh&dratin vs Ithe

5i( Debate



=ral Rehydration1 /ey

ConceptsMild t #derate deh&dratin #a& be#ana(ed s%ccess"%ll& !ith ral reh&dratin inthe #ajrit& " cases.

Oral reh&dratin sl%tins sh%ld cntainglucose and sodium in a ratio not toe>ceed 21'

A#%nt " reh&dratin sl%tin t be (iven is

based n the esti#ated percenta(e "deh&dratin b& !ei(ht.



Oral =eh&dratinPatient v#itin(

3*10#< 3*10 #in%tes and increase as

tleratedMild Deh&dratin

De)cit replace#ent; 30 #<CB( ver h%rs

Mderate Deh&dratin

De)cit replace#ent; 100 #<CB( ver h%rs



Develpin( a Plan "ActinDeter#ine de(ree " deh&dratin

stablish phases 7ttal " > phases*

=es%scitatin, =eplace#ent, and tabiliNatin9



Phase I; =es%scitatin %sin(Istnic l%ids 78C<=9 at

20#lCB(.=e*eval%atin %ntil %rine

%tp%t and deh&dratin si(ns

i#prved

Phase II; -alc%late#aintenance de)cit $%id

Deter#ine i" Istnic,H&ptnic r H&pertnic

Deh&dratin

H&ptnic8a 1>0

Istnic1>0 8a

130

H&pertnic8a Q130=eplace

$%ids ver?hrsRR



:hase I ? Resuscitationphase@al; =estre circ%latin, re*per"%se brain,

Bidne&s

Mild*Mderate

20 #<CB( bl%s (iven ver >0 0 #in%tes

evere

Ma& repeat bl%s as needed 7ideall& %p t0#lCB(9

l%ids s#ethin( istnic s%ch as 8 rlactated rin(ers 7<=9

ase ; ep ace#ent ase



ase ; ep ace#ent asePhase III; tabiliNatin Phase

7r IstnicCH&ptnicDeh&dratin9

@al; =eplace de)cit " $%ids and electrl&tes

Replacement:hase'st 7 hrs

!taili@ation:hase$e>t '< hrs

MI andMaint 8a 1C> 2C>

De)cit l%id De)cit 8a

1C2 1C2



H&pertnic Deh&dratin

Phase 2; =eplace#ent Phase@al; =eplace de)cit " $%ids and electrl&tes

and dail& #aintenance

A#%nt; De)cits / dail& #aintenance l%id;

@ive ver 2*? h%rs

IMPO=TA8T; <!er ser%# 8a b& n #re than

10*12 #'C< per da& r 0.3#'C<Chr



H&pertnic Deh&dratin

Phase >; tabiliNatin Phase

@al; =eplace n(in( lsses and transitin

t!ards #aintenance therap&A#%nt; =eplace#ent / dail& #aintenance



• er%# 8a 120, -8 s&#pt#sA#%nt " >S 8a-l; 7Desired 8a*bserved 8a9 6 !t 6 0.<CB(

0.3#'C<

=e#e#ber >4 8a-l 70.3#' 8aC#l9

The in"%sin sh%ld be (iven at a rate t increase the ser%#

sdi%# b& n #re than 3 #'C<Ch and is "ten (iven #resl!l& ver the c%rse " > h

• Do not replace $a faster than '0'2 meq+, per 2*hrs.Ahy

Central pontine myelinosis: rapid brain cell shrinkage withrapid increase in ECF a



!teps in Fluid Replacement3. :hase I1 Rapid :hase

Restore intraascular olume

a6 se Istnic l%id 78C<=9b9 =eplace ther c#pnents 7-aC(l%cse9 separatel& based n dc%#entedde)cit

c9 l%#e; 10*20ccCB(U repeat %p t 0ccCB( then re*eval%ate

B. :hase 21 Replacement :hase

Determine type of dehydration ased on $aleel 4Isotonic-Hypotonic- or Hypertonic6

a6 Calculate 2*hr ater needs -alc%late #aintenance !ater

-alc%late de)cit !ater

6 Calculate 2*hr electrolyte needs

-alc%late #aintenance sdi%# and ptassi%#

-alc%late de)cit sdi%# and ptassi%#

c6 !elect an appropriate 9uid 4ased on total ater and electrolyteneeds6

!ypotonic and "sotonic #ehydration: $dminister % calculated &uid during the'st ( hrs. $dminister remainder over the ne)t '* hrs.

C. :hase (1 !taili@ation Replace ongoing losses as they occur 7e6;diarrhea9

a9 Meas%re ever& * hrs and replace !ith apprpriate $%ids



">ceptions1 Ereatment ofHypernatremic Dehydration

=estre intravasc%lar vl%#e. Deter#ine ti#e "r crrectin based n initial V8aW;

V8aW 13*13 #'C< ; 2 hr

V8aW 13?*10 #'C<; ? hr

V8aW 11*1?> #'C<; 2 hr

V8aW 1?*1G #'C<; ? hr

Ad#inister $%id at a cnstant rate ver the ti#e "r crrectin

T&pical $%ids; D3E 8 r D3 8 7!ith 20#'C< K-l %nlesscntraindicated9

ll! ser%# 8a

di%# decreases t rapidl&* Increase V8aW " I r decrease rate" I

di%# decreased t sl!l&*Decrease V8aW " I r increase rate" I

RRR<!er ser%# 8a b& n #re than 10*12 #'C< per da&



TaBe H#e Messa(e

Oral reh&dratin is a sa"e and eXectiveinterventin in patients !ith #ild*t*#deratedeh&dratin !h are able t tlerate ral re(i#en.

l%id calc%latins are Ybest esti#ates.Z Al!a&s#nitr the eXects " &%r interventins.

De)cit $%id re'%ire#ents are based nclassi)catin " deh&dratin.

H&ptnic and istnic deh&dratin are crrectedin ?*hr and 1*hr blcBs.

H&pertnic deh&dratin is crrected based n 8alevel 7%s%all& ver ?hrs9.

l! crrectin " bth h&pnatre#ia andh&pernatre#ia.



-ase;A 12 #nth ld #ale is #ade 8PO "r s%r(er&,

!t*10 B(.

:hat !%ld be his #aintenance $%id andelectrl&te re'%ire#ent[



-ase 1;

:t; 10B(Phase 1 7res%scitatin9; 8 res%scitatin phase

re'%ired

Phase 2 7replace#ent9; Maintenance l%id; 10 6ccChr 0#lChr 7r 1000#lCda&9

Maintenance 8a;

2*> #'C100cc $%id >0 #' 8aC<D3 E 8

Maintenance K; 1*2 #'C100 cc $%id 10 #'C< K-l

Maintenance $%id chice;D3 E 8 / 10#' K-lC< at 0#lChr



-ase 2A &ear ld #ale presents !ith a histr& " v#itin( and

diarrhea. He has had 10 episdes " v#itin( 7clear then&ell! tin(ed9 and ? episdes " diarrhea. The diarrhea isn! !ater& and the last "e! episdes have been red inclr. The diarrhea dr is ver& "%l. He "eels !eaB.

6a#; T >?.2 de(rees 7ral9, P 110, =3, 5P G0C3,6&(en sat%ratin 1004 in r# air. :t* 1? B(.

He is alert and cperative, b%t nt ver& active. He is ntt6ic r irritable. His e&es are nt s%nBen. TMs are nr#al.His ral #%csa is #ist b%t he j%st v#ited. His necB iss%pple. Tach&cardic, 5!el s%nds are nr#active.

His verall clr is sli(htl& pale, his capillar& re)ll ti#e is 2secnds ver his chest, and his sBin t%r(r "eels s#e!hatdi#inished.



%estins 5ased n clinical criteria, !hat is his 4 deh&dratin[

Optin 1 7-alc%late PI:9 1?B(C71*0.039 1?.G 7PI:9

1?.GB( 1?B( 0.G 7100#l 6 0.G9

:hat #ethd " $%id ad#inistratin !%ld &% chse[

The parents are insistent n I $%ids. :hat !%ld be &%r steps in $%idad#inistratin[

*5l%s " 20#lCB(

*=e*assess#ent

* I vs ral reh&dratin



Oral vers%s I reh&dratin isdisc%ssed !ith his parents

!h indicate that the& havetried ral h&dratin and arent happ& !ith the res%lts sthe& !%ld liBethe I "r hi#.

An I is started and ache#istr& panel is dra!n.

8a 1>3, K>., -l GG, bicarb13.

:t*1?B(.

Phase I; res%scitatin c#pleted !C8 bl%s

Phase II; Deter#ined Istnic Deh&dratin

Maint $%id; 100#l

Maint 8a; > #'C100#l 2 #' 8aC100#l (0m"q+, $a

Maint K; 2 #'C100#l 2?#' KC100#l*Q 20m"q+, /

De)cit $%id in 34 DH8; 1? 6 0.03 6 1000*Q G00#l *>0#l 30#l

5 ( days illness 0.7 4G00ml6 20ml 4loss from "CF6

0.2 4G00lm6 '70ml 4loss from ICF6

Decit $a1 #$a% in "CF J ol decit #"CFK

'() > 0.20, G m"q $a ? ))m"q $a 4receied6 *2 m"q$a

Decit /1 #/% in ICF > proportion of 9uid loss from ICF >decit

')0 > 0.'70 , 2 m"q /

'st :hase1 $! olus 4(<0ml- ))m"q $a receied6

2nd phase1

'st 7 hr1 Replace '+( of maintenance $a L H20 L decit$a and H201

$a1 '0 m"q L 2' m"q; ('m"q+()ml ; *2 m"q $a+,

*<)ml 20ml

/1 m"q L '*m"q 2'm"q+() 27m"q+, /

'st 7hrs1 () ml of D) '+( $! L 2)m"q /Cl+, N G2ml+hr

$e>t '<hrs1 Replace 2+( maint $a L H20 3$D decit $a LH201

$a; 20m"qL 2'm"q; *'m"q $a+'20) ml (*m"q+,$a

D) '+* $!

/1 2<m"q+'20)ml 2'm"q+, /

$e>t '<hrs1 '20) ml of D) '+* $! L 20m"q /+, at )ml+hr



%estin 3;D= is a &ear ld (irl 71B(9 !h presents t

the e#er(enc& r# !ith "ati(%e,headache,(eneraliNed #alaise, and severe

(astrintestinal distress. The = tea# (ets ache#* and discvers her sdi%# t be 11?.

The& !%ld liBe t (ive >4 8a-l and asB &%"r a rec##endatin n h! #%ch t (ive,

and at !hat rate.



Ans!erA#%nt " >S 8a-l; 7Desired 8a*bserved 8a9 6 !t 60.<CB(

0.3#'C<

=e#e#ber >4 8a-l 70.3#' 8aC#l9@al t increase 8a b& n #re than 3#'C<

-alc%latin; 7123*11?9 6 1 6 0.<CB( 1>#l " >4 8a-lver >* hrs

0.3 #'C<



) kg child ith *day h+o omiting+diarrhea- '08dehydration- #$a% of '27 m"q+,Fluid

olume$a / 4replacement oer

2 days6

Maintenance

3 6 100 300#l >#'C100#l $%id 13 #' 2#'C100#l

10 #' K

De)cit 3 6 0.1 300#l

V-W lss

0.7300#l9 >00#l

V I-W lss 0.

7300#l9 200#l

V$a% in "CF > propor. ,oss > 9uiddecit L

#os $adesired $a > t > prop $aloss%1

1>3 6 0.>< / V1>3*12?6 3 6 0.W0#' / 21 #' 1 #'

#/% in ICF > prop loss> 9uid decit1

130 6 0.2<

>0 #' K

=ngoing,osses

=eplace cc; cc 3dd $a in proportion to e>pectedconcentration in lost 9uid 4e.g.- stool-gastric contents6

3dd / in proportion toe>pected concentrationin lost 9uid 4e.g.- stool-gastric contents

Ttal

1st ?hrs;

8e6t 1hrs;

1000#l

13#l / 230#l;L 00#l00#l

1 / 13 #' 8a

3#' / >0#' >3#' 8aC00#l;

'<) ml 2)0ml 7 m"q$a+,

10#' 8a / >0 #' 8a 0 #'

8aC00#l

<<m"q $a+,

0 #' K

1? #' K-lC<

2> #' K-lC<

1st ?hrs; D3 8 / 20 #' KC< F 30#lChr



Deter#ine ade'%ate $%ids "r *B( child !ith 134,8a10

Fluid olume $a / 4replacement oer2 days6

Maintenance

00#lCda& >#'C100#l $%id 21#' 8a 2#'C100#l 1#' K

De)cit 6 0.13 1030#lD >0#l:D*20 #l

ree H20 de)cit; B( 6 #lCB( 6 Ver%#8a*desired 8aW 20#l

8a; V8a in -W 6 prp 8a lss 6 Vl%te

de)citWV1>3 6 0.W 6 V1030*20W31 #' 8a

#/% in ICF > prop loss> 9uid decit

(7m"q

=ngoing,osses

=eplace cc; cc 3dd $a in proportion to e>pectedconcentration in lost 9uid 4e.g.- stool-gastric contents6

3dd / in proportion toe>pected concentrationin lost 9uid 4e.g.- stool-gastric contents

1st 2hr 2*hr #aint / ree H20 de)cit /D; 00 / 210/ >0

130#l

l%te l%id /lect De)cits

Ttall%id Order;

Maint $a L Def $a2'm"q L )' m"q 2 m"q

2m"q+'.)*, * m"q $a+,

D) '+( $! L (0m"q /Cl+, N <*ml+hr

1#'

>?#'

32#'C1.3<>#'

KC<

8e6t 2hrs 2*hr #aint / 21#' 8aC0.G1< 2>#' 8aC< 1#'C0.G1#l 13#'



=e"erencesleisher, @. et al. 720039. =enal and lectrl&te #er(encies.

In -rnan, K. Kst 7ds9, Te)tbook o+ ,ediatric Emergencyedicine.

Klei(#an, =. et al. 8elsn ssentials " Pediatrics. -hapter>2; l%ids and lectrl&tes. 3th editin. pp.13*1>.

=bertsn, J. hil"sBi, 8. 720039. l%ids and lectrl&tes.The !arriet ane !andbook. 7pp. 2?*>009.

&Bes, =. 72009. ,ediatric Fluids and Electrolytes.VP!erPint slidesW.

fluids and electrolytes in pediatrics final

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