Inpatient Pediatrics

2016
Objectives
To review basics of maintenance fluid and electrolyte
requirements
To gain comfort in classification of dehydration and
options for fluid support
To perform case-based practice!
Back to Basics….Fluid compartments
 Total body water=
ICF + ECF
 Total body water =
60-75 % of Body
weight
 Important Concepts
Plasma Osmolality= Concentration of solutes in blood
Plasma Osmolality= 2 x plasma (Na)

Change in plasma osmolality --> change in ECF

osmolality with water movement across cell membranes

Remember: The body has an immediate need to restore

intravascular volume over osmolality.
Total Body Water Composition
by Age
Concepts
Maintenance: Normal ongoing losses of fluids and
electrolytes

Deficit: Losses of fluids and electrolytes resulting

from an illness

On-going Losses: Requirement of fluids and

electrolytes to replace ongoing losses
 Factors Increasing Factors Decreasing
Maintenance Fluid Maintenance Fluid
Requirements Requirements
Fever-each 1 degree Celcius
Skin: Mist tent, incubator
over 38 degrees increases
maintenance fluid (premature infants)
requirements by 12% Lungs: Humidified ventilator
Hyperventilation Mist tent
Increased temperature of the Renal: Oliguria, anuria
environment
Misc: Hypothyroidism
Burns
Ongoing losses-diarrhea,
vomiting, NG tube output
Goal of Fluid Therapy
To prevent dehydration
To prevent electrolyte abnormalities
To prevent protein degradation
To prevent acidosis and circulatory collapse
 Calculation of Maintenance Fluid
Requirements…the Holliday-Segar Method

Example:
A 30-kg child would require (100 × 10) + (50 × 10) + (20 × 10) = 1,700 cc/day
or (4 × 10) + (2 × 10) + (1 × 10) = 70 cc/h.
 Maintenance Electrolyte
Requirements
Na and K are the primary electrolytes that govern ECF and ICF
osmolality.
[Na] in ECF = 135-145 mEq/L, negligible in ICF
[K] in ICF = 150 mEq/L, negligible in ECF

Maintenance Electrolyte Requirements:

Na: 2-3 mEq/100ml water /day
OR 2-3 mEq/kg/day
K: 1-2 mEq/100ml of water/day
OR 1-2mEq/kg/day
Chloride: 2 mEq/100ml of water /day
 Choosing MIVF..these are best estimates…
1. 8kg infant: 8kg x 4ml/kg/hr 32 ml/hr Standard Na content in IVF:
Na: 15-30mEq/L K: 8-15 mEq/L  NS (0.9% NaCl) = 154 mEq/l Na
D5 ¼ NS + 10meq KCl/L @ 32 ml/hr  ½ NS (0.45% NaCl) = 77 mEq/l Na
 1/3 NS (0.33% NaCl) = 51 mEq/l Na
2. Wt-55 kg: Rate 95ml/hr
 ¼ NS (0.25% NaCl) = 39 mEq/l Na
Na: 45-68 mEq/L K: 22-45 mEq/L
 1/5 NS (0.2% NaCl) = 31 mEq/l Na
IVF: D5 ½ NS + 20 mEq KCl/L @
95ml/hr

3. Wt-80kg: Rate 120ml/hr Standard K content in IVF:

Na: 57.6-85 mEq/L K: 28.8-58 mEq/L 10mEq KCl/L
IVF: D5 ½ NS + 20mEq KCl/L @ 20 mEq KCl/L
120ml/hr 40 mEq KCl/L
Concepts in Dehydration
Initial loss of fluid from the body depletes the
extracellular fluid (ECF).
Gradually, water shifts from the intracellular space to
maintain the ECF, and this fluid is lost if dehydration
persists.
Acute Illness (<3 days ): 80% of the fluid loss is
from the ECF and 20% is from the intracellular
fluid (ICF).
Prolonged Illness (> 3 days): 60% fluid loss from
ECF and 40% loss from ICF.
 Pre-Illness Weight Estimate of Dehydration
Scenario 1 (if pre-illness wt known) Scenario 2: (In ER)
 Need illness wt
 Need to accurately monitor
 % DHN based on exam
patient weights frequently
 Fluid deficit (L) = PIW (kg) – IW Step 1:
Calculate pre-illness wt (PIW):
(kg)
Current wt = PIW wt
(Generally 100cc/kg)
(1-% DHN)
 PIW = Pre-illness weight
 IW = Illness weight
Step 2: Calculate wt loss and
respective deficit fluid volume
% Dehydration = PIW (kg) – IW (kg) x 100% PIW-IW = wt loss
PIW (kg)
Note:
1kg ~ 1000ml fluid deficit
Deficit Fluid volume= 100cc/kg wt loss
Maintenance Electrolytes
Oral Rehydration vs IVF…the Big Debate
Oral Rehydration: Key Concepts
Mild to moderate dehydration may be managed
successfully with oral rehydration in the majority of
cases.
Oral rehydration solutions should contain glucose
and sodium in a ratio not to exceed 2:1
Amount of rehydration solution to be given is based
on the estimated percentage of dehydration by
weight.
Oral Rehydration
Patient vomiting
– 5-10mL Q 5-10 minutes and increase as tolerated
Mild Dehydration
– Deficit replacement: 50 mL/kg over 4 hours
Moderate Dehydration
– Deficit replacement: 100 mL/kg over 4 hours
Developing a Plan of Action
Determine degree of dehydration
Establish phases (total of 3 phases- Resuscitation,
Replacement, and Stabilization)
 Phase I: Resuscitation using
Isotonic Fluids (NS/LR) at
20ml/kg.
Re-evaluation until urine output
and dehydration signs improved

Phase II: Calculate maintenance &

deficit fluid

Hypotonic Determine if Isotonic, Hypotonic Hypertonic

Na <130 or Hypertonic Dehydration Na >150
Replace fluids
over 48hrs**

Isotonic
130< Na <150
Phase I – Resuscitation phase
Goal: Restore circulation, re-perfuse brain, kidneys
Mild-Moderate
 20 mL/kg bolus given over 30 – 60 minutes
Severe
May repeat bolus as needed (ideally up to 60ml/kg)
Fluids – something isotonic such as NS or lactated
ringers (LR)
 Phase II: Replacement Phase
Phase III: Stabilization Phase
(For Isotonic/Hypotonic Dehydration)

Goal: Replace deficit of fluids and electrolytes

Replacement Phase Stabilization Phase

1st 8 hrs Next 16 hrs
MIVF and 1/3 2/3
Maint Na
Deficit Fluid 1/2 1/2
& Deficit Na
Hypertonic Dehydration
Phase 2: Replacement Phase
Goal: Replace deficit of fluids and electrolytes
and daily maintenance
Amount: Deficits + daily maintenance Fluid:
Give over 24-48 hours
IMPORTANT: Lower serum Na by no more than
10-12 mEq/L per day or <0.5mEq/L/hr
Hypertonic Dehydration
Phase 3: Stabilization Phase
Goal: Replace ongoing losses and transition towards
maintenance therapy
Amount: Replacement + daily maintenance
• Serum Na < 120, CNS symptoms
 Amount of 3# NaCl: (Desired Na-observed Na) x wt x 0.6L/kg
0.5mEq/L
 Remember 3% NaCl (0.5mEq Na/ml)
 The infusion should be given at a rate to increase the serum sodium
by no more than 5 mEq/L/h and is often given more slowly over the
course of 3–4 h

• Do not replace Na faster than 10-12 meq/L per 24hrs. Why?

Central pontine myelinosis: rapid brain cell shrinkage with rapid
increase in ECF Na
Steps in Fluid Replacement
A. Phase I: Rapid Phase Restore intravascular volume
a) Use Isotonic Fluid (NS/LR)
b) Replace other components (Ca/glucose) separately based on documented deficit
c) Volume: 10-20cc/kg; repeat up to 60cc/kg then re-evaluate
B. Phase 2: Replacement Phase
Determine type of dehydration based on Na-level (Isotonic, Hypotonic, or
Hypertonic)
a) Calculate 24-hr water needs
Calculate maintenance water
Calculate deficit water
b) Calculate 24-hr electrolyte needs
Calculate maintenance sodium and potassium
Calculate deficit sodium and potassium
c) Select an appropriate fluid (based on total water and electrolyte needs)
Hypotonic and Isotonic Dehydration: Administer ½ calculated fluid during the 1st 8
hrs. Administer remainder over the next 16 hrs.
C. Phase 3: Stabilization Replace ongoing losses as they occur (ex: diarrhea)
a) Measure every 4-6 hrs and replace with appropriate fluids
 Exceptions: Treatment of Hypernatremic
Dehydration
 Restore intravascular volume.
 Determine time for correction based on initial [Na]:
[Na] 145-157 mEq/L : 24 hr
[Na] 158-170 mEq/L: 48 hr
[Na] 171-183 mEq/L: 72 hr
[Na] 184-196 mEq/L: 84 hr
 Administer fluid at a constant rate over the time for correction
Typical fluids: D5¼ NS or D5 ½ NS (with 20mEq/L KCl unless
contraindicated)
 Follow serum Na
 Sodium decreases too rapidly- Increase [Na] of IVF or decrease rate of IVF
 Sodium decreased too slowly-Decrease [Na] of IVF or increase rate of IVF
***Lower serum Na by no more than 10-12 mEq/L per day
 Take Home Message
Oral rehydration is a safe and effective intervention in
patients with mild-to-moderate dehydration who are able
to tolerate oral regimen.
Fluid calculations are “best estimates.” Always monitor the
effects of your interventions.
Deficit fluid requirements are based on classification of
dehydration.
Hypotonic and isotonic dehydration are corrected in 8-hr
and 16-hr blocks.
Hypertonic dehydration is corrected based on Na level
(usually over 48hrs).
Slow correction of both hyponatremia and hypernatremia.
Case:
A 12 month old male is made NPO for surgery,
wt-10 kg.
What would be his maintenance fluid and electrolyte
requirement?
Case 1:
Wt: 10kg
Phase 1 (resuscitation): No resuscitation phase required
Phase 2 (replacement): Maintenance Fluid: 10 x 4cc/hr
40ml/hr (or 1000ml/day)
Maintenance Na:
2-3 mEq/100cc fluid 30 mEq Na/LD5 ¼ NS
Maintenance K: 1-2 mEq/100 cc fluid 10 mEq/L KCl
Maintenance fluid choice:
D5 ¼ NS + 10mEq KCl/L at 40ml/hr
Case 2
 A 4 year old male presents with a history of vomiting and diarrhea. He
has had 10 episodes of vomiting (clear then yellow tinged) and 8
episodes of diarrhea. The diarrhea is now watery and the last few
episodes have been red in color. The diarrhea odor is very foul. He
feels weak.
 Exam: VS T 38.2 degrees (oral), P 110, R45, BP 90/65, oxygen saturation
100% in room air. Wt- 18 kg.
 He is alert and cooperative, but not very active. He is not toxic or
irritable. His eyes are not sunken. TMs are normal. His oral mucosa is
moist but he just vomited. His neck is supple. Tachycardic, Bowel
sounds are normoactive.
 His overall color is slightly pale, his capillary refill time is 2 seconds
over his chest, and his skin turgor feels somewhat diminished.
 Questions
 Based on clinical criteria, what is his % dehydration?
Option 1 (Calculate PIW) 18kg/(1-0.05)= 18.9 (PIW)
18.9kg – 18kg= 0.9 (100ml x 0.9)

 What method of fluid administration would you choose?

 The parents are insistent on IV fluids. What would be your steps in fluid administration?
-Bolus of 20ml/kg
-Re-assessment
- IVF vs oral rehydration
  Phase I: resuscitation completed w/NS bolus
 Phase II: Determined Isotonic Dehydration
Maint fluid: 1400ml
Maint Na: 3 mEq/100ml 42 mEq Na/1400ml 30mEq/L Na
 Oral versus IV rehydration is
Maint K: 2 mEq/100ml 28mEq K/1400ml-> 20mEq/L K
discussed with his parents who Deficit fluid in 5% DHN: 18 x 0.05 x 1000-> 900ml -360ml  540ml
indicate that they have tried oral < 3 days illness; 0.8 (900ml) 720ml (loss from ECF)
hydration and are not happy with 0.2 (900lm) 180ml (loss from ICF)
the results so they would like
the IV for him. Deficit Na: [Na] in ECF × vol deficit [ECF}
 An IV is started and a chemistry 135 x 0.720L  97 mEq Na – 55mEq Na (received) 42 mEq Na
panel is drawn.
 Na 135, K3.4, Cl 99, bicarb 15. Deficit K: [K] in ICF x proportion of fluid loss from ICF x deficit
150 x 0.180 L  27 mEq K
 Wt-18kg.
1st Phase: NS bolus (360ml, 55mEq Na received)
2nd phase:
1st 8 hr: Replace 1/3 of maintenance Na + H20 + ½ deficit Na
and H20:
Na: 10 mEq + 21 mEq-> 31mEq/735ml -> 42 mEq Na/L
465ml 270ml
K: 7mEq + 14mEq 21mEq/735 28mEq/L K
1st 8hrs: 735 ml of D5 1/3 NS + 25mEq KCl/L @ 92ml/hr
Next 16hrs: Replace 2/3 maint Na + H20 AND ½ deficit Na + H20:
Na-> 20mEq+ 21mEq-> 41mEq Na/1205 ml 34mEq/L Na
D5 1/4 NS
K: 26mEq/1205ml 21mEq/L K
Next 16hrs: 1205 ml of D5 1/4 NS + 20mEq K/L at 75ml/hr
Question 5:
DR is a 4 year old girl (16kg) who presents to the
emergency room with fatigue,headache, generalized
malaise, and severe gastrointestinal distress. The ER
team gets a chem-7 and discovers her sodium to be
118. They would like to give 3% NaCl and ask you for a
recommendation on how much to give, and at what
rate.
Answer
 Amount of 3# NaCl: (Desired Na-observed Na) x wt x 0.6L/kg
0.5mEq/L
 Remember 3% NaCl (0.5mEq Na/ml)
 Goal to increase Na by no more than 5mEq/L

 Calculation: (125-118) x 16 x 0.6L/kg 134ml of 3% NaCl over 3-4 hrs

0.5 mEq/L
5 kg child with 4-day h/o vomiting/diarrhea, 10% dehydration, [Na] of 128
mEq/L
Fluid volume Na K (replacement over 2
days)
Maintenance 5 x 100= 500ml 3mEq/100ml fluid 15 mEq 2mEq/100ml
10 mEq K

Deficit 5 x 0.1 500ml [Na] in ECF x propor. Loss x fluid deficit + [K] in ICF x prop loss x
[obs Na-desired Na x wt x prop Na loss]: fluid deficit:
[ECF] loss 0.6 150 x 0.2L  30 mEq K
(500ml) 300ml 135 x 0.3L + [135-128x 5 x 0.6]
[ ICF] loss  0.4 40mEq + 21 mEq 61 mEq
(500ml) 200ml
Ongoing Replace cc: cc Add Na in proportion to expected concentration Add K in proportion to
Losses in lost fluid (e.g., stool, gastric contents) expected concentration in
lost fluid (e.g., stool, gastric
contents

Total 1000ml 61 + 15 = 76 mEq Na 40 mEq K

1st 8hrs: 165ml + 250ml: 5mEq + 30mEq  35mEq Na/400ml: 18 mEq KCl/L
~ 400ml 165 ml 250ml 87 mEq Na/L
Next 16 hrs: 600ml 23 mEq KCl/L
10mEq Na + 30 mEq Na 40 mEq Na/600ml
66mEq Na/L
1st 8hrs: D5 ½ NS + 20 mEq K/L @ 50ml/hr

Next 16hrs D5 ½ NS + 20mEq/L KCl @ 35-40ml/hr

Determine adequate fluids for 7-kg child with 15%, Na=160
Fluid volume Na K (replacement over 2
days)
Maintenance 700ml/day 3mEq/100ml fluid 21mEq Na 2mEq/100ml 14mEq K

Deficit 7 x 0.15= 1050ml Free H20 deficit: 7kg x 4ml/kg x [Serum Na- [K] in ICF x prop loss x
SFD= 630ml desired Na] 420ml fluid deficit 38mEq
FWD-420 ml Na: [Na in ECF] x prop Na loss x [Solute deficit]
[135 x 0.6] x [1050-420]=51 mEq Na

Ongoing Replace cc: cc Add Na in proportion to expected concentration Add K in proportion to

Losses in lost fluid (e.g., stool, gastric contents) expected concentration in
lost fluid (e.g., stool, gastric
contents

1st 24hr 24-hr maint + ½ Free Maint Na + Def Na 14mEq

H20 deficit + SFD: 21mEq + 51 mEq 72 mEq
700 + 210+ 630
1540ml

Solute Fluid + Elect 38mEq

Deficits
Total 72mEq/1.54L 47 mEq Na/L 52mEq/1.54L34mEq K/L
Fluid Order: D5 1/3 NS + 30mEq KCl/L @ 64ml/hr
Next 24hrs 24-hr maint + ½ FWD 21mEq Na/0.91L 23mEq Na/L 14mEq/0.91ml 15mEq K/L
700ml + 210ml->
910ml D5 ¼ NS + 15mEq KCL/L @ 38ml/hr
References
 Fleisher, G. et al. (2005). Renal and Electrolyte Emergencies. In
Cronan, K. & Kost (Eds), Textbook of Pediatric Emergency Medicine.
 Kleigman, R. et al. Nelson Essentials of Pediatrics. Chapter 32: Fluids
and Electrolytes. 5th edition. pp.157-163.
 Robertson, J. & Shilfoski, N. (2005). Fluids and Electrolytes. The
Harriet Lane Handbook. (pp. 287-300).
 Sykes, R. (2007). Pediatric Fluids and Electrolytes. [PowerPoint slides].