FLUIDS AND ELECTROLYTES

Prepared by Shelley D. Pantinople

Sources: Nelson textbook of Pediatrics, 20th ed

Consensus statements on Parenteral fluid therapy in infants, children, and adolescents, 2017
TOTAL BODY WATER
• Term infant - 75%
• 1year old to puberty - 60%
• End of puberty
Males - 60% (due to muscle mass)
Females - 50% (due to fat content)

• Decrease total body water:

Obese
Dehydrated
FLUID COMPARTMENTS
• Intracellular Fluid (ICF) - 30-
40% of body weight

• Extracellular Fluid (ECF) - 20-

25% of body weight

• Males - higher ICF due to

muscle mass
FLUID COMPARTMENTS

• Extracellular Fluid (ECF) - 20-25% of

body weight

1.) Plasma water - 5%

Altered by dehydration,
anemia, polycythemia, heart failure,
abnormal plasma osmolality,
hypoalbuminemia
FLUID COMPARTMENTS

• Extracellular Fluid (ECF) - 20-25%

of body weight

2.) Interstitial fluid - 15%

Increases in heart failure,
protein-losing enteropathy, liver
failure, nephrotic syndrome, sepsis,
pleural effusions
FLUID COMPARTMENTS

• Intravascular volume regulation:

Due to balance between hydrostatic
and oncotic forces

critical for tissue perfusion

v

FLUID COMPARTMENTS

• Intravascular fluid has higher

albumin than the interstitial fluid
(depends on the limited
permeability of albumin)

Oncotic force draws water into the

intravascular space
FLUID COMPARTMENTS

• Hydrostatic pressure of the

intravascular space
(due to the pumping action of the
heart)

Drives fluid out of the intravascular

space,
favors movement into the interstitial
space
FLUID COMPARTMENTS

• Net movement of fluid out of the

intravascular space to the interstitial
space

Returned to the circulation via the

lymphatics
PLASMA OSMOLALITY
- Normal range: 285 – 295 mOsm/L
- Regulated by the kidney and hypothalamus via ADH secretion and
thirst mechanism
ELECTROLYTE
COMPOSITION
ECF
- Sodium, Chloride

ICF
- Potassium, proteins,
phosphate
PARENTERAL FLUID THERAPY

1. Assess the ability to take in oral hydrating fluids

If unable to tolerate, initiate parenteral fluid therapy

PARENTERAL FLUID THERAPY
Prior to initiation of parenteral fluid therapy:
Assess the hydration status

% Degree of fluid deficit:

Pre-illness wt (kg) - admisssion wt (kg) x 100

Pre-illness wt (kg)
PARENTERAL FLUID THERAPY
2. Assess the antecedent fluid deficit if pre-illness
weight data is unknown.
Antecedent fluid deficit
PARENTERAL FLUID THERAPY

3. Measure serum sodium and blood glucose concentrations:

- prior to initiation of parenteral fluid therapy
- at least 24 hours after
PARENTERAL FLUID THERAPY

Other initial laboratory examinations as necessary:

CBC
BUN, serum creatinine, potassium, chloride
Urinalysis
Urine electrolytes
Chest x-ray
PARENTERAL FLUID THERAPY

MONITORING:
Pre-breakfast weight at least every 24 hours
Input, output, fluid balance at least every 8 hours
PARENTERAL FLUID THERAPY

- Use pre-illness weight in calculating for maintenance water and

electrolyte requirements and fluid deficit.

- If pre-illness weight no known:

Oral rehydration therapy vs Intravenous therapy
RESUSCITATION
- For previously healthy individual:
Dextrose-free crystalloid solution with sodium of 130-154
mmol/l
Give as a bolus of 20ml/kg in 5-20 minutes via “push-pull”
technique using the largest bore catheter possible.
RESUSCITATION
- After three unsuccessful peripheral IV catheter placements,
secure an intraosseous line.
RESUSCITATION
- Hypoglycemia – use 5% dextrose-containing IVF with similar
sodium content as single bolus dose of 20 ml/kg

- Jaundiced patient or with suspected liver insufficiency - Avoid

lactate-containing solutions

- Colloids - alternative solutions if with poor response to crystalloids.

RESUSCITATION
- Reassess frequently after administration of fluid bolus.
- Evaluate the physiologic indicators of perfusion:

Quality of central and peripheral pulses

Skin perfusion (CRT < 2sec)
Mental status
Urine output (More than or equal to 1ml/kg/hr)
Blood pressure
RESUSCITATION
- If within an hour or despite a total volume of 60ml/kg and
individual is still in shock

- refer to specialist
REHYDRATION and REDISTRIBUTION
- Previously healthy and well patient:
Dextrose-containing crystalloid solution with sodium of 77-
140 mmol/l

- Daily total volume computed as:

antecedent net deficit fluid loss + maintenance water
requirement
REHYDRATION and REDISTRIBUTION
- Risk of water-retention associated with non-osmotic
vasopressin secretion, use dextrose-containing solution with
sodium in the range of 130-140 mmol/l

- States with non-osmotic vasopressin release:

- ECF contraction
- Hypoxia
- Perioperative states
- Neurologic disorders
- Pulmonary diseases
- Hematologic-oncologic conditions
- Anesthetics, and anti-cancer drugs
- Fever, stress, pain and nausea
REHYDRATION and
REDISTRIBUTION
- Antecedent net deficit fluid loss:
= Approximated Fluid Deficit (based below) - Initial resuscitation
fluid boluses
REHYDRATION and
REDISTRIBUTION
- First 8 hours:
50% of net fluid deficit + 1/3 of the estimated maintenance
requirement

- Next 16 hours:
Remaining volume
 REHYDRATION and
REDISTRIBUTION
In infants and children with AGE, give net fluid deficit as rapid hydration in
6 hours.
1. Mild deficit
Computed fluid deficit loss using a dextrose-containing crystalloid solution
with sodium 51-77mmol/l in 6 hours.

2. Moderate to severe deficit

First hour: 1/4 to 1/3 of the computed net fluid deficit using dextrose-
containing crystalloid solution with sodium of 130 mmol/l

Next 5-6 hours: 3/4 to 2/3 fluid deficit using dextrose-containing crystalloid
solution with sodium 51-77 mmol/l
 Daily Maintenance Water Requirement
Holliday-Segar
- Estimates caloric expenditures in fixed weight categories
- It assumes that for every 100 calories metabolized, 100ml of water will be
required.
Daily Maintenance Water Requirement
Holliday-Segar Computation

Ex: 22kg child

Daily Maintenance Water Requirement
Ludan (Modified Finberg) Basal Caloric Expenditure Method

Ex: 22kg
Daily Maintenance Water Requirement
Crawford Body Surface Area Method

1500 ml/m2, where m2 =

- For critically-ill, obese, with acute kidney injury, known chronic kidney
disease, malignancy, or severe sepsis.
Daily Maintenance Water Requirement
Maintenance fluid replacement therapy

- Ensures adequate blood and oxygen to at-risk organs

- Prevents subsequent organ dysfunction and failure from hypoperfusion and

tissue edema

- Restores continued daily losses of water and electrolytes from insensible

losses - urine, sweat, stool, respiration

- Prioritizes water balance

Maintenance fluid replacement therapy
- In a previously healthy, well-nourished patient with on-going fluid losses,
attempt replacement via the enteral route first using reduced osmolarity
ORS (210-268 mOsm/l) to be given volume per volume every 1-4 hours:

- Avoid sports drinks/non-physiologic solutions

Maintenance fluid replacement therapy
- If the enteral route is not feasible or tolerated:
Dextrose-free IVF with sodium 130-154 mmol/l given volume per
volume every 1-4 hours or until ongoing losses cease.
Fluid therapy on removal
- On parenteral fluid for > 24 hours, assess the need for continued IVF
therapy
- Stop fluid therapy:
- Signs of circulatory improvement
- Signs of fluid overload (worsening respiratory status, rales, gallop
rhythm, hepatomegaly, etc.)

- Stop parenteral therapy:

- Able to tolerate at least 75% of the maintenance water requirement via
enteral fluids
- Able to eat or has an appetite.
Fluid therapy on removal
- Base succeeding parenteral fluid prescription on the weight, blood
pressure, serum sodium, and blood glucose

- Increase in pre-illness weight > 5%, hypertension, edema:

Decrease sodium content of parenteral fluid

- Euvolemic with serum sodium <135 mmol/l

Decrease drip rate to 50-80% of maintenance water requirement

- Euvolemic with serum sodium >145 mmol/l

Decrease sodium content to <77 mmol/l and infuse maintenace rate
plus 30-50ml/kg for 48 hours
Fluid therapy on removal
- If blood glucose is abnormal, adjust dextrosity.
Maximum volume to be given in 24 hours:
Male = 2500 ml
Female = 2000 ml