Fluid and Electrolytes:

TUSM III Pediatric Clerkship

Lecture Series
Paul D. Carlan, MD
Baystate Medical Center
Departments of Pediatrics and Medicine
April 16, 2004
 Parenteral Fluid Therapy
 IVF is a basic component of the care of
hospitalized infants and children
 Fluid and electrolyte problems can be
challenging, but can be “tamed” by an
organized approach
 Useful to consider separately the following
questions:
 “How much?” or volume and rate
 “What kind?” or electrolyte constitution
 Parenteral Fluid Therapy
 IVF therapy is tailored
to address differing
clinical needs
 Maintenance
 Deficit
 Ongoing losses
 Maintenance: Fluid
 Metabolism creates two by-products which must be actively
eliminated to maintain homeostasis
 Heat: dissipated by insensible losses from skin and lung
 Solute: waste products of metabolism excreted into the urine
 Maintenance: Fluid
 Basal Metabolic Rate
does not directly relate
to body weight
 BMR is much higher in
the neonate than the
adult and the transition is
not linear
 As a result, adults need
less fluid and electrolytes
than children per kg of
bodyweight
Methods of Estimating Maintenance
Fluids
 Methods of estimating basal or maintenance fluid
requirements
 Basal Surface Area
 Need to know height and weight, requires table, does not allow for
deviations from normal activity
 Basal or Calorie Expenditure Method
 Requires a table, involves calculations, permits correction for
changes in activity or injury, “drier”
 Holliday-Segar System
 Easy to remember, does not require table or difficult calculations,
does not allow for deviations from normal activity
 Holliday-Segar Formula
 How does it work?
 Estimates that 1 kcal of energy requires 1 cc of
fluid to maintain homeostasis
 Derives from fact that for each 100 kcal of energy
expended, 50 cc of fluid are lost through the skin and
airways, and 55 to 65 cc of fluid are required to
generate an isosmotic urine (300 mOsm/L)
 Heat dissipation and solute excretion each represent
roughly 50% of maintenance needs
 Anuric patients have one-half maintenance needs
 Maintenance: Electrolytes
 No electrolytes are lost in sweat or exhaled
water vapor; all electrolyte losses are urinary
 Thus, anuric patients have no maintenance sodium
or potassium needs
 Since sodium and fluid requirements are based
on BMR, the ratio of electrolyte to water is
fixed and maintenance fluid requirements are
the same for all patients (regardless of age)
 D5 0.2 NS + 20 mEq/L of K+.
 Deficit: Fluid
 Definition: Amount of fluid lost before treatment is
begun
 One-time estimate; additional losses after therapy is
begun are considered “on-going losses”
 Methods:
 Preillness and current weight change
 Fluid deficit (L) = Preillness weight (kg) – current weight (kg)
 % Dehydration = (Fluid deficit (L)/Preillness weight (kg))x100
 Clinical estimates of weight loss
 Deficit: Electrolytes
 Sodium: usually in pediatrics, losses are
gastrointestinal or due to a relatively short period of
decreased oral intake
 approximated by 0.45 NS
 Potassium: deficit replacement is based on rate of
safe replacement and not amount since danger of
hyperkalemia is greater than hypokalemia
 Add 20 mEq potassium/L after UOP is established
 Potassium infusion rate should not exceed 1 mEq/kg/hour
unless in monitored setting
 Ongoing losses: Fluid and
Electrolytes
 Fluid: abnormal losses that occur after the one-
time determination of a deficit
 Diarrhea, vomiting, NG aspirates, polyuria
 Measured and replaced cc for cc

 Electrolytes:
 Consult tables for electrolyte composition of on-
going losses
 GI losses = 0.45 NS
 Transudates = 0.9 NS
 Radiant losses = sodium free
Overview of Parenteral Rehydration
Strategy
 Phase I (emergency): If the patient is hemodynamically
unstable or in shock, “one or more” boluses of 20 cc/kg
isotonic fluid should be given in the first 30 minutes
 Phase II (deficit, maintenance, ongoing fluid replacement):
1. Calculate fluid deficit
2. Calculate maintenance fluid
3. Give ½ of deficit therapy + maintenance over first 8 hours
and remainder of deficit + maintenance over next 16 hours
4. Adjust above based on consideration of ongoing losses
likely to be encountered
 Case 1
 A 5 month male old infant is brought to your ER with
4 day history of vomiting, diarrhea, and reduced oral
intake. UOP is markedly reduced. On exam, the
infant is fussy but consolable. He pushes you away
when you try to examine him. Weight is 6.3 kg (5-
25th %ile), BP is 90/55 (50th %ile), HR is 190 (>95th
%ile). The fontanelle is slightly sunken and his skin
turgor is diminished. The cardiopulmonary,
abdominal, and neurologic exams are normal. He has
stopped vomiting but refuses to drink.
 Case 1: Solution A
Combined Deficit/Maintenance
 Bolus: 140 cc (20 cc/kg) of NS given for
hemodynamic instability
 Deficit Fluid:
 No preillness weight, so must estimate
 Oliguria, tachycardia, no shock  10% dehydrated
 Deficit = 10% or 100 cc/kg x 7kg*= 700 cc
 Maintenance Fluid:
 Holliday-Segar: 4 cc/kg for first 10 kg = 7 kg x 4 cc/kg =
28 cc/hr

*Note: Should use preillness weight to calculate deficit = (6.3 kg x 100)/(100-

10%) = 7 kg
 Case 1: Solution A
Combined Deficit/Maintenance
 First 8 hours:
 Maintenance:
 28 cc/hr x 8 hours = 224 cc of D5 0.2 NS + 20 mEq
KCl/L
 Half Deficit = 700/2 = 350 cc of 0.45 NS
 Total Fluid = 574 cc/ 8 hour = 71.8 cc/hr

 IVF: 75 cc/hr of D5 0.3 NS + 20 mEq KCl/L

 Case 1: Solution A
Combined Deficit/Maintenance
 Next 16 hours:
 Maintenance:
 28 cc/hr x 16 hours = 448 cc of D5 0.2 NS + 20 mEq
KCl/L
 Half Deficit = 700/2 = 350 cc of 0.45 NS
 Total Fluid = 798 cc/ 16 hour = 49.9 cc/hr

 IVF: 50 cc/hr of D5 0.2 NS + 20 mEq KCl/L

 Case 1: Solution B
Sequential Deficit/Maintenance
 Bolus: 140 cc (20 cc/kg) of 0.9 NS
 First 8 hours:
 Remainder of Deficit: 20 cc/kg bolus represents
2% of body weight. Since infant was 10%
dehydrated, the remainder of deficit after the bolus
is 8% (or 80 cc/kg). This can be replaced over next
8 hours at 1%/hr.
 1%/hr = 10 cc/kg/hr = 70 cc/hr

 IVF (Deficit): D5 0.45 NS + 20 mEq/L KCl

 Case 1: Solution B
Sequential Deficit/Maintenance
 Next 16 hours
 Day’s worth of maintenance fluid is then provided
in next 16 hours
 4 cc/kg/hr x 7 kg x 24 hours = 672 cc Fluid

 672 cc/16 hours = 42 cc/hr

 IVF (Maintenance): D5 0.2 NS + 20 mEq/L KCl

Monitoring Effectiveness of
Parenteral Therapy
 Oral Rehydration Therapy
 Indications: mild to moderate dehydration
 Contraindications: shock, severe dehydration,
intractable vomiting, coma, gastric distension
 Method: give 5-10 cc or ORT q 5-10 minutes
 Fluids: Cerealyte, Pedialyte, Naturalyte, Rehydralyte,
WHO/UNICEF ORS
 Avoid soda, juice, gatorade, jello
 Lack sufficient sodium and potassium, are often
hyperosmolar, can perpetuate diarrhea
 Disorders of Sodium
 Serum Sodium = Osmolality = Water
 Regulated by thirst , ADH, & renal water handling
 A disruption in water balance is manifested as an
abnormality in serum sodium
 Sodium is a functionally impermeable solute, so it
contributes to tonicity and induces water movement
across membranes
 Hypernatremia = hyperosmolar (hypertonic) dehydration
 Hyponatremia = hyposmolar (hypotonic) dehydration
 Hypernatremia = Serum
Sodium > 145 mmol/L
 Hypernatremia
represents a deficit of
water in relation to the
body’s sodium stores
 Net water loss
 Common
 Hypertonic sodium gain
 Uncommon
 Usually iatrogenic
 Hypernatremia: Clinical
Manifestations
 Related to CNS dysfunction; sequelae are
prominent when the increase in serum sodium
is rapid or large
 Affects the very young or very old
 Infants: hyperpnea, muscle weakness,
restlessness, high-pitched cry, insomnia,
lethargy, or coma. Seizures are uncommon.
 Elderly: often asymptomatic until Na > 160
 Hypernatremia: Management
 Approach
 Identify Cause
 Correct Hypertonicity

 Rapid Correction
 Improves prognosis in patients in whom
hypernatremia developed acutely (sodium loading)
 Correct serum sodium by up to 1 mmol/L/hr
 Hypernatremia: Management
 Slow Correction
 Prudent in patients with hypernatremia of longer or unknown
duration
 Correct sodium by 0.5 mmol/L/hr or 10 mmol/d with goal of 145
mmol/L
 Others suggest adding the calculated fluid deficit to maintenance
fluid requirements and giving over 48 hours
 IVF
 Only hypotonic fluids are appropriate unless frank circulatory
collapse exists
 The more hypotonic the infusate, the lower the required volume
to correct the hypertonicity, and the lower the risk of cerebral
edema
 Hypernatremia: Management
 Rate of infusion is
calculated using the Madias
Formula which estimates
the change in serum sodium
caused by 1 liter of any
infusate. The required
volume, and thus rate, is
determined by dividing the
change in serum sodium
desired for a given period of
time by the value obtained
from Madias formula.
 Case 2
 A 1 week old female neonate is admitted to the
PICU after increasing lethargy and difficulty
with breastfeeding. Her birthweight was 3.8 kg.
Her admission weight is 3.3 kg. On exam, the
infant is difficult to arouse. BP is 72/62 (75th
%ile), HR is 120 (50th %ile), RR is increased at
60. The PE is unrevealing except for hypotonia
and decreased level of consciousness. The nurse
informs you the sodium is 165 mmol/liter.
 Case 2: Solution A
 Bolus?: no
 Deficit Fluid:
 Deficit = 3.8 kg – 3.3 kg = 0.5 kg or 500 cc
 Maintenance Fluid:
 Holliday-Segar: 4 cc/kg for first 10 kg: 3.8 kg x 4 cc/kg = 15.2
cc/hr
 48 hours needs:
 Deficit = 500 cc of 0.45 NS
 Maintenance = 15 cc/hr x 48 hr = 720 cc of D5 0.2 NS + 20 mEq KCl/L
 Total Fluid = 500 cc + 720 CC = 1200 cc/ 48 hour = 25 cc/h
 IVF: 25 cc/hr of D5 0.3 NS + 20 mEq KCl/L
 Case 2: Solution B
 Deficit (Madias Formula)
 TBW: (0.8 x 3.8kg) = 3 L
 Retention of 1 L of 0.2 NS will reduce the serum sodium by 40 ([34-
195]/[3+1])
 The goal of therapy is to reduce the serum sodium by 20 mmol/L in 48
hours. Therefore, 20/40 is 0.5 L or 500 cc of fluid is required.
 48 hour needs:
 Deficit = 500 cc of D5 0.2 NS
 Maintenance = 3.8 kg x 4 cc/kg = 15.2 cc/hr x 48 hr = 720 cc of D5 0.2
NS + 20 mEq KCl/L
 Total Fluid = 500 cc + 720 CC = 1200 cc/ 48 hour = 25 cc/h
 IVF: 25 cc/hr of D5 0.2 NS + 20 mEq KCl/L
 Hyponatremia
 Serum Sodium < 136 mmol/L
 Hypotonic hyponatremia results from an
excess of water in relation to existing sodium
stores, which can be decreased, normal, or
increased.
 Impaired renal water excretion
 common
 Excess water intake
 uncommon
 Adults: thiazide
diuretics, SIADH,
polydipsia, and TURP

 Children: GI fluid loss,

ingestion of dilute
formula, accidental
ingestion of water, and
multiple tap water
enemas.
 Hyponatremia: Clinical
Manifestations
 Related to CNS dysfunction; sequelae are
prominent when the decrease in serum sodium
is rapid or large
 Symptoms: Headache, nausea, vomiting,
muscle cramps, lethargy, restlessness,
disorientation, and depressed reflexes
 If Na < 125 mmol/L: seizure, coma, brain
damage, herniation, and death
 Hyponatremia: Management
 Symptomatic: Hypertonic saline therapy (can
be combined with furosemide to limit
expansion of ECF)
 Correct 1-2 mmol/L/hour x several hours if severly
symptomatic
 Target for increase in serum sodium of no more
than 8 mmol/d to prevent osmotic demyelination
 Asymptomatic: Fluid therapy is guided by
Madias Formula
 Hyponatremia: Management
 Rate of infusion is
calculated using the Madias
Formula which estimates
the change in serum sodium
caused by 1 liter of any
infusate. The required
volume, and thus rate, is
determined by dividing the
change in serum sodium
desired for a given period of
time by the value obtained
from Madias formula.
 Case 3
 A 12 year old male is found unresponsive at the
bottom of a swimming pool. He is resuscitated in the
field and on arrival to the ER is intubated and
ventilated but has a spontaneous pulse. In the trauma
room, he develops generalized tonic-clonic seizures.
He is loaded with phenytoin. His stat sodium then
returns at 110 mmol/L. His weight is 45 kg, BP is
100/70 (normal), HR is 100 (normal). On exam, he is
unresponsive and his right pupil is sluggish.
 Case 1: Solution
 Initial management is to prevent cerebral edema and
herniation; TBW: 0.6 x 45 kg = 27 L
 Madias Formula: Retention of 1 L of 3% NS will
increase the serum sodium by 14.4 mmol ([513-110])/
([27+1])
 The goal of therapy is to increase the serum sodium
by 5 mmol/L in 3 hours. Therefore, 5/14 = 350 cc of
fluid is required.
 IVF: 350 cc/3 hr = 120 cc/hr of 3% NS x 3 hours.
 References
Adrogue, HJ and NE Madias. Hypernatremia. New England Journal of
Medicine. 2000; 342(20): 1493-1499.

Adrogue, HJ and NE Madias. Hyponatremia. New England Journal of

Medicine. 2000; 342(21): 1581-1589.

Choukair, MK. Fluids and Electrolytes. In: Siberry GK and R. Iannone, ed.
The Harriet Lane Handbook. 15th ed. St. Louis, MO: Mosby; 2000: 229-
240.

Roberts, KB. Fluid and Electrolytes: Parenteral Fluid Therapy. Pediatrics in

Review. 2001; 22(11): 380-387.