INTRODUCTION DEFINITION NORMAL BODY FLUID AND ELECTROLYTE FLUID AND ELECTROLYTE PROBLEMS FLUID AND ELECTROLYTE THERAPY

RAPY IN INFANTS AND CHILDREN CONCLUSION

Body fluid, bodily fluids, or biofluids are liquids originating from inside the BODIES of living people. They include fluids that are excreted or secreted from the body as well as body water that normally is not.

The dominating content of body fluids is body water. Approximately 60-65% of body water is contained within the cells (in intra cellular fluid) with the other 35-40% of body water contained outside the cells (in extracellular fluid). This fluid component outside of the cells include the fluid between the cells (interstitial fluid) lymph, and blood

Fluid and electrolytes therapy points at replacing fluid secondary to pathologic loss majorly and also in patients who cannot take in fluids orally either because of disease or a surgical condition. Replacement could also be required secondary to malnutrition but along with other macronutrient.

Body fluids include: Amniotic fluid Aqueous humour and vitreous humour Bile Blood serum Breast milk Cerebrospinal fluid Mucus Saliva sweat

Fluid and electrolyte therapy is a type of treatment directed towards restoring the body fluids and electrolytes concentration to their normal level following certain derangements either by replacement or maintenance.

The total body water (T.B.W) of the adult male is about 60%(42L) of body weight and of the female about 50 %(35L) . In general,total body water. depends on age, sex and degree of obesity, being lower in the obese and the aged.

The body water is distributed in 2 compartments: 1. Intracellular - 40% of body weight.(28L) 2. Extracellular - 20% of body weight.(14L) (I) Intravascular (plasma) - 4%. (ii) Extravascular (a) Transcellular - l % (b) Interstitial- 15 %.

The TotalBodyWater and ExtraCellularFluid in the full-term neonate are 75 % and 35% of body weight respectively. By 2 years, the total body water is 65% and extracellular fluid is 20 % . The intracellular fluid changes very little.

Intracellular ions: Potassium is the most important cation in the cells, about 140 mmol/L. Magnesium 15mmol/L Sodium 8 mmol/L Phosphates, 26 mmol/L and Proteins, 9 mmol/L are the most important anions.

Extracellular ions: Sodium is the most important cation 135-145mmol/L. Other cations are; Potassium 3.6-5.2mmol/L Calcium 2.1-2.6mmol/L Magnesium 0.7 - 0.9. mmol/L

The main anions are; Chloride 95-105 mmol/L Bicarbonate 24-29 mmol/L.

ION
SODIUM
POTASSIUM MAGNESIUM

INTRAVASCULAR FLUID(mmol/L)

INTERSTIAL FLUID(mmol/L)

INTRACELLULAR FLUID(mmol/L)

140
4 1.25

143
4 0.625 0.75 115 30 1.6

8
140 1 15 8 14 25.8

CALCIUM(IONIZE 0.7-0.9 D) CHLORIDE BICARBONATE PHOSPHATE 95-105 24-27 0.8-1.4

ION
PROTEIN SULPHATE

INTRAVASCULAR FLUID(mmol/L)
2 1

INTERSTITIAL FLUID(mmol/L)
0 1 3

INTRAVASCULAR FLUID(mmol/L)
9 20 _

ORGANIC ACIDS 3

WATER: The body loses water through expired air, skin, urine and faeces And gains it from food,fruits, liquids and endogenous metabolism of carbohydrate, protein and fat. Sodium and potassium are lost in sweat, urine and faeces and are replaced from food.

WATER
LOSSES;
PULMONARY & CUTANEOUS URINE FEACES TOTAL

TROPICS

TEMPERATE

1700 1500 200 3400

1000 1500 200 2700

WATER
GAIN
METABOLISM OF FAT NET WATER REQUIREMENT

TROPICS

TEMPERATE

200 3200

200 2500

After dehydration. Shock Electrolytes imbalances. Post operatively.

DEHYDRATION Water loss is accompanied by loss of electrolytes (especially sodium) The loss is of extracellular fluid (E.C.F), but there may be loss of intracellular fluid (I.C.F) as well.

Dehydration may be rapid as in acute intestinal obstruction, or in diarrhoea, when the loss is essentially of E.C .F. (acute dehydration). It may, on the other hand be slow over a period of many days or weeks as in gastric outlet obstruction, when both E. C.F. and I.C.F. with large amounts of potassium are lost (chronic dehydration).

The causes of dehydration are: 1. Vomiting. 2. Diarrhoea 3. Excessive sweating. 4. Polyuria.

The main clinical features are: 1. Dry, inelastic skin with loss of turgor. 2. Dry mouth. 3. Sunken eyes in severe cases. 4. Collapsed veins. 5. Tachycardia. 6. Scanty highly concentrated urine.

Crystalloids are started as soon as blood is taken for blood chemistry A litre of Ringer's lactate (Na 130, K4, Ca 4, Cl 111, HCO 27 mmol/L), normal saline (Na 154, Cl- 154 mmol/L) or dextrose saline is infused in 30-45 minutes. Ringer's lactate is the most suitable as its electrolyte concentration is about the same as that of E.C.F., the fluid lost.

But it should not be used in gastric outlet obstruction because of a tendency to alkalosis in that condition. This is continued until the urine output is 30-50 ml/hr, the subcutaneous veins are filled and the skin and tongue are moist

3g of KCl is then added to the infusion. The rate of infusion is reduced to a litre in 8h and the appropriate maintenance solution (either 3L, Badoe's solution or 2L, 5% dextrose, 1L Ringer's, 3g KCI) given to provide the daily requirements of water, sodium and potassium

During rehydration, the following parameters are observed: 1. Hourly urine output.(normal for adults 0.51ml/kg/hr, while in children it is 1-2ml/kg/hr) 30-50ml/hr is aimed at. In very ill patients, a urethral catheter should be inserted under aseptic conditions for the accurate measurement of the hourly urine. 2. Skin turgor, moistness of tongue, filling of subcutaneous veins

This develops more quickly and has more serious effects. May be mild, moderate or severe. FEATURES; 1. Mild dehydration (2.54% weight loss). The child is irritable and fretful. The tongue is dry but the skin turgor is not altered

2. Moderate dehydration (5-10% weight loss). The tongue is dry, the skin inelastic and the eyes and fontanelle sunken. The temperature may be elevated and the cry high pitched. The urine is scanty.

3. Severe dehydration : -In addition to the signs of moderate dehydration, there is hypotonia and the child is unable to raise his head. the feet and hands may be cold. The urine is highly concentrated and the output very low

The fluids commonly used are 4.3% /dextrose in 1/5 normal saline or 2.5 % dextrose in 1/2 normal saline. Potassium chloride is added as required. Normal saline, Ringer's lactate, 5% dextrose may also be used.

In shock, more fluids are needed - about 3.5L on the average. If hypotension is severe, a litre of a plasma expander e.g. gelofusine, hetastarch or gelatin 7% may first be given to raise the blood pressure before crystalloids are administered.

If in spite of intensive treatment the blood pressure remains low, complicating septic shock should be suspected and hydrocortisone (2-6g) and a broad-spectrum antibiotic started

A litre of diarrhoeal stools contains approximately, 120mmol of sodium, 25 of potassium, 90 of chloride and 45 of bicarbonate In cholera, the electrolyte concentrations of the "rice water" stools are sodium 130, potassium 12, chloride 100, and bicarbonate 45 mmol/L. The stools are very profuse and the metabolic effects correspondingly profound

It is the same as for dehydration with rapid infusion of crystalloids. In cholera, fluid 5 :4: 1 (5g Na Cl, 4g Na HCO, and lg KCl) containing Na+ 130, K+ 14, C1-99 and HCO-, 48 mol/L is preferred if available. Otherwise, Ringer's lactate, dextrose/saline or normal saline is administered and KCl added later.

Hypokalaemia, i.e. a serum potassium of less than 3.5mmol/L can therefore occur rapidly Potassium in diarrhoea stool is 20-40 mmol/L, and in gastric juice 9mmol/L

The usual features are muscle weakness, ,slurred speech, paralytic ileus, cardiac arrhythmia and hyporeflexia. Hypotension may occur especially in the postoperative period and precipitate cardiac arrest.

After ensuring satisfactory urinary output with dextrose saline or normal saline, 90150 mmol of potassium in 5 % dextrose is given at a rate not exceeding 20 mmol/h in order to prevent cardiac arrest This is repeated daily until the serum potassium rises to normal

Citrus fruits, tomato juice, coconut milk, milk, tea and meat soups contain adequate amounts of potassium and so may be given to patients who can take oral fluids. Potassium chloride mixture or tablets may also be given.

In hyperkalaemia, the serum potassium is over 6mmol/L. It usually occurs in renal failure, shock, severe metabolic acidosis (due to exchange of intracellular potassium for hydrogen ions), destruction of a large number of cells -massive injury or burns - or massive transfusion of old stored blood.

The underlying cause should be treated, 1. Sodium bicarbonate 80-100 mm01 is given to combat associated acidosis. 2. Glucose under the influence of insulin uses potassium to form glycogen. Ten units of soluble insulin in one litre of 5% dextrose is given intravenously

There is 1000mmol in a 70kg man. Sixty percent of it is in bone, most of the remainder is intracellular (35 % of the total magnesium is in muscle) and only l % is in the extracellular compartment

Magnesium is essential for the elaboration and activation of certain enzymes. It activates alkaline phosphatase, pyrophosphatases, some peptidases, and some enzymes which transfer phosphates from ATP or to ADP. Of the daily requirement of 12.5 mmol, 2/3 is lost in faeces and one-third in urine.

Hypomagnesaemia (Serum magnesium less than 0.5 mmol/L) It should always be considered in any patient who has been on a drip for more than 7 days and shows behavioural disturbances, depression or confusion Myocardial Ischaemia which may deplete high-energy stores may also cause hypomagnesaemia. It is therefore advisable to supplement such fluids with magnesium

Patients with acute pancreatitis, because magnesium may combine with fatty acids from saponification of fat by lipase, with cirrhosis, chronic alcoholism, or malabsorption syndrome, because of inadequate reserves, are liable to magnesium deficiency. Also, patient on antibiotics and chemotherapeutic agents

Hypomagnesaemia, like hypocalcaemia, causes neuromuscular hyperactivity coarse, irregular tremors, muscular twitches, abdominal cramps, hyper-reflexia, convulsions, ventricular arrhythmias and paralytic ileus. Behavioural disturbances, irritability, disorientation, depression, confusion may be predominant. Trousseau's and Chvostek's signs may be positive

Magnesium sulphate in 25 % or 50% solution is used. 1ml of 50% solution contains 2mmol of magnesium and 0.25mmol/kg is given daily until the serum concentration becomes normal In a severe case, l mmol/kg is administered in 0.5L of 5 % dextrose infusion in 4-8hrs.

FLUID

Na

Ca

Cl

HCO

Glucos e g/L

Osmol ality mOsm/ L 278 276

5%Gluc ose Ringer 130 s lactate 4 4 111 27

50

5% glucos e in normal saline

4.3% glucos e in1/5 NS

154

154

50

586

30.8

30.8

43

300

Darrow 124 s solution

36

104

56

320

FLUID

Na

Ca

Cl

HCO

Glucos eg/L

Osmol ality mOsm/ L 334

Sodium 167 lactate 1/6M GI 100 replac ement solution Badoe 43.6 s mainte nance solution ORS 90 solution 12 (NH4) 10 122

167

50

522

16

1.3

51.7

Sorbitol

20

80

30

20

Solutio Na n
Hartman ns 130

K
4

Ca
2.7

Cl
109 154

Lactat e
28

Colloid

Normal 154 saline(0.9 % NaCl) Dextrose saline(4% in 0.18% saline) 30

30

Gelofusin 150 e

<1

150

Gelatin 4%

Haemac el
Hetastar ch

145

5.1

6.26

145

Polygelin 75g/l
Hydroxye thyl starch 6%

As the respiratory rate is higher and the surface area relative to the body weight greater than in adults, infants and children have a relatively greater insensible water loss than adults.

The kidneys of infants cannot concentrate urine as effectively as those of older children or adults, and with a greater solute load (15-20mOsm/kg/24h) because of a higher metabolic rate must excrete relatively more urine (60-85ml/kg/24h) than adults. Water loss is therefore relatively greater than in aduIts and constitutes 50% of the E.C.F. in a 7kg infant compared with 15-20% in a 70kg adult

Water (ml)
premature 1st 4 days of life Up to 10kg 10kg to 20kg Over 20kg 50 80 120 80 80

Na(mmol)
3-4 2 2 2 2-3

K(mmol)
1-2 1-2 1-2 1-2 1-2

WEIGHT

WATER(ml/kg)

Na(mmol/kg)

K(mmol/kg)

5%(mild)

50

10%(moderate)

100

15%(severe)

150

12

To maintain normal funtional volume of body fluids,normal concentration of electrolytes,normal pH,and correct fluids and electrolytes deficits, an understanding of the daily exchange of water and electrolytes is essential.