Fluid & Electrolyte Replacement

Calculating Full Maintenance = 100ml x 1st 10kgs + 50ml x 2nd 10kgs + 20ml x >20kgs
Full Maintenance = Sensible (⅔)+ Insensible losses (30ml/kg/24hr or ⅓ maintenance)
 When patients should receive more than full maintenance:
 Febrile child on maintenance requires an additional 10% of total maintenance for every 1° > 38°C.
 When patients should receive less than full maintenance:
 Anuric patient should only have insensible losses replaced (i.e. third maintenance, 30ml/kg/24hr).
 CHF and SIADH (as can occur in post-meningitis increased ICP); patient should receive two-
thirds maintenance.
Example I: 10 kg boy with renal failure, calculate his maintenance fluid dose.
 Anuric patient should be put on a third maintenance: 30ml x 10kg = 300ml / 24hr = 12.5 ml/hr
Example II: 27 kg boy, calculate maintenance dose of fluid.
 100ml x 1st 10kg + 50ml x 2nd 10kg + 20ml x 7kg = 1640ml / 24hr = 68.5ml/hr
Calculating Electrolyte Replacement:
Na Cl K
3 mEq/kg/day 5 mEq/kg/day 2 mEq/kg/day
 Potassium is not given unless kidney function is known (i.e. patient passes urine ruling out
kidney impairment/failure).
Replacement Therapy:
 When using weight comparison, measurements before disease should < 2 months past.
Calculation of Deficit (for isotonic dehydration): 1 kg wt = 1 000 ml fluid
e.g. 10% dehydration (calculated by wt/CS)  means for every 1 kg, we lose 10% water, i.e. we lost
10% of 1 000 ml = 100 ml loss
e.g. 15% dehydration = 1 000 ml x 0.15 = 150 ml loss
Example III: 10 kg girl has 10% dehydration, isotonic, calculate rehydration fluid.
 Maintenance = 100 ml x 10 kg = 1 000 ml
 Deficit = 10 kg x 1 000 ml (volume of body water) x 0.1 ( ° of dehydration) = 1 000 ml
 Moderate to severe dehydration, we give a “challenge test” which is a bolus of 20ml/kg/1hr
(Nelson’s 20 min) for rapid replacement and to see if patient passes urine (subtracted from the
deficit total).
 Bolus = 20 ml x 10 kg = 200 ml/hr (subtracted from deficit, see next)
 Total = Deficit + Maintenance  Deficit = 1 000 ml – 200 ml = 800 ml  Total = 1 800 ml
 For rapid perfusion, we give half total over 8 hr and the rest over the remaining 16 hr.
 1 800/2 = 900 ml/8hr = 112 ml/hr for 8 hr, and 900ml/16hr = 56.25 ml/hr for next 16 hr.
Hypernatremic Dehydration: same as above, but after bolus, we give half total over the first 24 hr (i.e.
900ml/24hr = 37.5 ml/hr) and give the second half over the second 24 hr (avoiding brain herniation).
 Medscape: Dehydration Treatment
Severe dehydration
 Laboratory evaluation and intravenous rehydration are required. The underlying cause of the
dehydration must be determined and appropriately treated.
 Phase 1 focuses on emergency management. Severe dehydration is characterized by a state of
hypovolemic shock requiring rapid treatment. Initial management includes placement of an intravenous
or intraosseous line and rapid administration of 20 mL/kg of an isotonic crystalloid (eg, lactated Ringer
solution, 0.9% sodium chloride). Additional fluid boluses may be required depending on the severity of
the dehydration. The child should be frequently reassessed to determine the response to treatment. As
intravascular volume is replenished, tachycardia, capillary refill, urine output, and mental status all
should improve. If improvement is not observed after 60 mL/kg of fluid administration, other etiologies
of shock (eg, cardiac, anaphylactic, septic) should be considered. Hemodynamic monitoring and
inotropic support may be indicated.
 Phase 2 focuses on deficit replacement, provision of maintenance fluids, and replacement of ongoing
losses. Maintenance fluid requirements are equal to measured fluid losses (urine, stool) plus insensible
fluid losses. Normal insensible fluid loss is approximately 400-500 mL/m2 body surface area and may be
increased by factors such as fever and tachypnea. Alternatively, daily fluid requirements may be roughly
estimated as follows:
o Less than 10 kg = 100 mL/kg
o 10-20 kg = 1000 + 50 mL/kg for each kg over 10 kg
o Greater than 20 kg = 1500 + 20 mL/kg for each kg over 20 kg
 Severe dehydration by clinical examination suggests a fluid deficit of 10-15% of body weight in infants
and 6-9% of body weight in older children. The daily maintenance fluid is added to the fluid deficit. In
general, the recommended administration is one half of this volume administered over 8 hours and
administration of the remainder over the following 16 hours. Continued losses (eg, emesis, diarrhea)
must be promptly replaced.
 If the child is isonatremic (130-150 mEq/L), the sodium deficit incurred can generally be corrected by
administering the fluid deficit plus maintenance as 5% dextrose in 0.45-0.9% sodium chloride.
Potassium (20 mEq/L potassium chloride) may be added to maintenance fluid once urine output is
established and serum potassium levels are within a safe range.
 An alternative approach to the deficit therapy approach is rapid replacement therapy. With this
approach, a child with severe isonatremic dehydration is administered 20-40 mL/kg of isotonic sodium
chloride solution or lactated Ringer solution over 15-60 minutes. As perfusion is restored, the child
improves and is able to tolerate an oral rehydration solution for the remainder of his rehydration. This
approach is not appropriate for hypernatremic or hyponatremic dehydration.
Hyponatremic dehydration

 Phase 1 management of hyponatremic dehydration is identical to that of isonatremic dehydration. Rapid

volume expansion with 20 mL/kg of isotonic (0.9%) sodium chloride solution or lactated Ringer
solution should be administered and repeated until perfusion is restored.
 Severe hyponatremia (<130 mEq/L) indicates additional sodium loss. In phase 2 management,
rehydration is calculated as for isonatremic dehydration. The additional sodium deficit must be
calculated and added to the rehydration fluids. The deficit may be calculated to restore the sodium to
130 mEq/L and administered over 24 hours.
o Sodium deficit = (sodium desired - sodium actual) X volume of distribution X weight (kg)
 o Example: Sodium = 123, weight = 10 kg, assumed volume of distribution of 0.6; Sodium deficit
= (130-123) X 0.6 X 10 kg = 42 mEq sodium
 A simplified approach is to use 5% dextrose in 0.9% sodium chloride as the replacement fluid. The
sodium is closely monitored, and the amount of sodium in the fluid is adjusted to maintain a slow
correction (<0.5 mEq/L/h).
 Frequently reassessing the serum sodium level during correction is imperative. Rapid correction of
chronic hyponatremia (>2 mEq/L/h) has been associated with central pontine myelinolysis. Rapid partial
correction of symptomatic hyponatremia has not been associated with adverse effects. Therefore, if the
child is symptomatic (seizures), a more rapid partial correction is indicated. Hypertonic (3%) sodium
chloride solution (0.5 mEq/mL) may be used for rapid partial correction of symptomatic hyponatremia.
A bolus dose of 4 mL/kg raises the serum sodium by 3-4 mEq/L.
Hypernatremic dehydration
 Phase 1 management of hypernatremic dehydration is identical to that of isonatremic dehydration. Rapid
volume expansion with 20 mL/kg of isotonic sodium chloride solution or lactated Ringer solution should
be administered and repeated until perfusion is restored.
 Varied regimens may be successfully followed to achieve correction of severe hypernatremia (>150
mEq/L). In phase 2 management, the most important goal is to reestablish intravascular volume and
return serum sodium levels toward the reference range by not more than 10 mEq/L/24h. Rapid
correction of hypernatremic dehydration can have disastrous neurologic consequences, including
cerebral edema and death.
 The most cautious approach is to plan a slow correction of the fluid deficit over 48 hours. Following
adequate intravascular volume expansion, rehydration fluids should be initiated with 5% dextrose in
0.9% sodium chloride. Serum sodium levels should be assessed every 4 hours. If the sodium has
decreased by less than 0.5 mEq/L/h, then the sodium content of the rehydration fluid is decreased. This
allows for a slow controlled correction of the hypernatremic state.
 Hyperglycemia and hypocalcemia are sometimes associated with hypernatremic dehydration. Serum
glucose and calcium levels should be closely monitored.
Pharmacologic management
 Antidiarrheal agents are not recommended because of a high incidence of side effects including
lethargy, respiratory depression, and coma.
 Routine empiric antibiotics should be avoided and may worsen some specific diarrheal disease states
(eg, hemolytic-uremic syndrome, Clostridium difficile).
 Over-the-counter antiemetics are not recommended due to side effects including drowsiness and
impaired oral rehydration.
 In an emergency department study, ondansetron has been shown to decrease likelihood of vomiting,
increase oral intake, and decrease emergency department length of stay but has not shown significant
effects on hospitalization rates or long-term outcomes.8
 Dimenhydrinate, although used in Europe and Canada, has not been found to improve oral rehydration.9