MAINTENANCE

&
REPLACEMENT
FLUID THERAPY

Moderated By Dr.Madhuri Engade

Presented By Dr.Akshay

OBJECTIVES

To know the difference in physiology of children.

To know the Goals of maintenance fluid therapy.

Able to Calculate total fluid requirement & do

monitoring of the patient.
To know Variations in maintenance water &
electrolytes.
To order Replacement fluids in common
situations.

WHY THE INFANTS ARE MORE

VULNERABLE?*

Physiological inability to concentrate urine.

Higher metabolic rate & larger surface area.

Cant express thirst for more fluids.

Larger turnover.

*IAP text book of Pediatrics 5th edition

WHOM TO GIVE MAINTENANCE

FLUIDS?

Infants who are sick & whose oral intake is

uncertain.
Babies who are kept NBM for the surgery, with
respiratory distress etc.
neonates kept under radiant warmer.

GOALS OF MAINTENANCE FLUIDS*

Prevent dehydration

Prevent electrolyte disturbance

Prevent ketoacidosis

Prevent protein degradation

*Nelsons Text book of pediatrics 19th edition

AT BIRTH
75 % of the total body weight
Next 2 3 Days

Obligatory diuretic phase

65 % of the total body weight

At the end of Ist year

60 % of the total body weight

BACK TO PHYSIOLOGY
Total Body Water 60%*
Intra cellular fluid
(ICF)
40%

Extra cellular fluid

(ECF)
20%
Interstitial
15%

Intravasular
5%

*IAP text book of Pediatrics 5th edition

What osmolarity means

What tonicity means

DISTRIBUTION OF BODY WATER

Intravascular (5%)
ECF

Na+
Cl-

ICF

K+

Interstitial (15%)

Intracellular (40%)

ELECTROLYTE CONCENTRATIONS

ECF

Component

ICF

Na+

High

Low

K+

Low

High

Ca++

Low

Low (higher
than ECF)

Proteins

High

High

KEY LEARNING POINT*

Sodium is the Principle electrolyte in ECF

[140mEq/L (+/- 5)]
Potassium is the Principle electrolyte in ICF
[150mEq/L (+/- 5)]

*IAP text book of Pediatrics 5th edition

Maintenance fluids consists ofWater

ii.
Glucose
iii. Sodium
iv. Potassium
i.

Advantages
.

Simplicity, long shelf life, low cost, compatibility.

Prototypical maintenance therapy fluid doesnt

provide calcium, phosphorus, magnesium or
bicarbonate.*

*Nelsons Text book of pediatrics 19th edition

FLUID LOSSES IN INFANTS

LUNGS

URINE, FECES

SKIN

CONCEPT OF MAINTENANCE OF
WATER

Crucial component of maintenance fluid therapy.

Maintenance water = Measurable loss of water 65%
(Urine 60%, stools 5%) + Insensible of water 35%
(skin & lungs)

FOR NEONATES

Day 1 60 ml/kg/day

Day 2 90 ml/kg/day

Day 3 120 ml/kg/day

Day 4 150 ml/kg/day (maximum for term infants)

Day 5 to 3 months 150 ml/kg/day

MAINTENANCE REQUIREMENTS*

Weight

Requirement

0-10 kg

100cc/kg/24hr

11-20 kg

1000 +
50cc/kg/24hr

>20 kg

1500 +

Upper limit 2400cc/24hrs

20cc/kg/24hr
*Nelsons Text book of pediatrics 19th edition

Maintenance Fluids
Hourly Maintenance Fluid Requirement*
4 - 2 -1 rule
WEIGHT
0 - 10 kg

FLUID
4 ml/kg/hr

10 - 20 kg

40ml/hr + 2 ml/kg/hr

> 20 kg

60ml/hr + 1 ml/kg/hr

Upper limit 100cc/hr

*Nelsons Text book of pediatrics 19th edition

CONCEPT OF MAINTENANCE OF
ELECTROLYTES

Insensible water loss contains no electrolytes*

So, sodium & potassium present in the urine,
stools & sweat would be the amount to be
replaced plus the sodium & potassium required
for normal metabolism of the body.

3mEq of sodium in 100 cc of fluid

&
2mEq of potassium in 100 cc of fluid

*IAP text book of Pediatrics 5th edition

CONCEPT OF MAINTENANCE OF
GLUCOSE*

Maintenance fluids usually contains 5% dextrose

(5 gm/100ml) providing 17 calories/ 100 ml of
fluid.

Which is approx. 20% of the daily caloric needs.

Prevents ketone production.

*Nelsons Text book of pediatrics 19th edition

COMMONLY USED FLUIDS FOR

MAINTENANCE*
I.

0.9% Normal Saline Think of it as Salt and

water

Principal fluid used for intravascular resuscitation and

replacement of salt loss e.g diarrhoea and vomiting

Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l; K+ - Absent,

But K+ is often added

IsoOsmolar compared to normal plasma

Distribution: Stays almost entirely in the Extracellular space

Does not provide free water or calories. Restores NaCl deficits.

*The Harriet Lane Handbook 19th edition

CONTENTS OF IV FLUID
PREPARATIONS*
Na

(mEq/L)

(mEq/L)

Cl

(mEq/L)

NS

154

154

DNS

154

154

NS

77

77

5%D +
1/2NS

77

77

HCO3

(mEq/L)

Dextrose
(gm/L)

mOsm/L

308
50

564
143

D5W

50

350

50

278

Ringers
Lactate
(RL)

130

109

28

50

273

Iso P

23

20

23

30

50

367

*The Harriet Lane Handbook 19th edition

COMMONLY USED FLUIDS FOR

MAINTENANCE
II.

Lactated Ringers (RL): Isotonic, 273 mOsm/L.

Contains

130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate, and 4

mEq/L K+, 3 mEq/L Ca++

Lactate

is used instead of bicarb because it's more stable in IVF

during storage.

Lactate

is converted readily to bicarb by the liver.

Has

minimal effects on normal body fluid composition and pH. More

closely resembles the electrolyte composition of normal blood serum.

Does

not provide calories.

HOW TO CHOOSE?*
0.9% sodium chloride

Suitable for initial volume resuscitation in

hypovolaemia and for ongoing fluid therapy in older
children with normal serum glucose. Fluid of choice
in patients with head injury

5% dextrose + 0.9%
sodium
chloride

Suitable for ongoing fluid therapy in infants and

children, including post-operative cardiac patients.
Use in head injured patients with hypoglycaemia.

5% dextrose + 0.45%
sodium
chloride

Suitable for ongoing fluid therapy in infants and

children, including post-operative cardiac patients

10%dextrose + 0.45%
sodium
chloride

Suitable for ongoing fluid therapy in neonates or

older infants who are hypoglycaemic, including postoperative cardiac patients
*Leeds Teaching Hospitals NHS Trust Paediatric Intensive Care Units

MONITORING WHILE
ADMINISTERING FLUIDS*

Child should be weighed prior to the commencement of

therapy, and daily afterwards.
Children with ongoing dehydration/ongoing losses may
need 6 hourly weights to assess hydration status
All children on IV fluids should have serum electrolytes
and glucose checked before commencing the infusion
(typically when the IV is placed) and again within 24
hours if IV therapy is to continue.

*Royale Childrens Hospital Melbourne Guidelines

MONITORING WHILE
ADMINISTERING FLUIDS*

For more unwell children, check the electrolytes and

glucose 4-6 hours after commencing, and then according
to results and the clinical situation but at least daily.
Pay particular attention to the serum sodium on
measures of electrolytes. If <135mmol/L (or falling
significantly on repeat measures) If >145mmol/L (or
rising significantly on repeat measures)
Children on iv fluids should have a fluid balance chart
documenting input, ongoing losses and urine output.

*Royale Childrens Hospital Melbourne Guidelines

MAINTENANCE FLUIDS &

HYPONATREMIA*

Production of ADH leading to water retention

leading to water intoxication.
Patients producing ADH due to subtle volume
depletion can be safely treated with fluids
containing higher sodium concentration, decrease
in fluid rate or the combination of both.
Persistent ADH production due to underlying
disease requires less than total maintenance fluids
Individualization & careful monitoring is must.
*Nelsons Text book of pediatrics 19th edition

VARIATIONS IN MAINTENANCE
WATER & ELECTROLYTES

Source

Skin

Causes of increased water

Causes of decreased water

needs

needs

Radiant warmer

Incubator

Phototherapy
Fever
Sweat
Burns
lungs

Tachypnea

Humidified ventilator

Tracheastomy
GI tract

Diarrhea
Vomiting
Nasogastric secretion

renal

Polyuria

Oligo/anuria

REPLACEMENT FLUIDS*

In addition to normal maintenance fluid

requirements, unwell children may need:
Fluid

resuscitation for shock

Replacement

of pre-existing fluid losses

Replacement

of ongoing fluid losses

*Royale Childrens Hospital Melbourne Guidelines

REPLACEMENT FLUIDS*

GI losses are accompanied with loss of potassium,

bicarbonate leading to metabolic acidosis.
Impossible to predict the loses for next 24 hrs, so
measure & replace excess GI losses as they occur.
So each ml of the diarrheal stool or the vomitus
should be replaced by the same amount every 1
to 6 hourly.
*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Diarrhea*
Average composition of Diarrheal stools (except cholera)
Na 55 mEq/l
K 25 mEq/l
Bicarbonate 15 mEq/l
Approach to Replacement of Ongoing Losses
D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl
Replace stools ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Emesis or Nasogastric losses*
Average composition of Gastric Fluid
Na 60 mEq/l
K 10 mEq/l
Chloride 90 mEq/l
Approach to Replacement of Ongoing Losses
NS + 10 mEq/l KCl
Replace Output ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria / Anuria
Place patient on insensible fluids (25 to 40% of maintenance)
Replace Urine output ml/ml by half NS
Polyuria
Place patient on insensible fluids (25 to 40% of maintenance)
Measure urine electrolytes
Replace Urine output ml/ml by solution based on measured urine
*Nelsons Text book of pediatrics 19
electrolytes

th

edition

CASE I

5 day old baby boy weighing 3 kg having total

billirubin 18.0 is to be kept under phototherapy.
Baby having no other risk factors & accepts DBM
well.
What fluid at what rate should we prescribe?

Rate Day 5 (150 ml/kg/day)

Weight 3 kg

So,
150 * 3 = 750 ml is the total maintainence.

For the babies under phototherapy we should give

half of the maintainence.

So 375 ml/24 hrs i.e 125 ml / 8hrly

Fluid of choice is 5% dextrose + 0.45% NS or iso P
will also be suitable.

CASE II

7 year old girl (weight 20 kg) admitted for

bronchopneumonia with respiratory rate of
44/min & fever of 102 F. later developed 4
episodes of vomiting (each of 25 ml quantity) &
loose stools 3 episodes (each of 80 ml quantity)

Weight 20 kg.
So, Total maintenance fluid will be

(100*10) + (50*10) = 1500 ml/ day i.e 500 ml / 8 hrly

Choice of fluid will be 0.45% DNS + 20mEq/L KCl

Replacement fluid for vomiting (each of 25 ml

quantity) = 25 * 4 =100 ml of NS + 10 mEq/l KCl
Replacement fluid for loose stools (each of 80 ml
quantity) = 80 * 3 =240 ml of 0.2% DNS + 20 mEq/l
sodium bicarbonate + 20 mEq/l KCl.

TACHYPNEA
Respiratory

Alkalosis

Increase

in rate and
depth of breathing
Loss

of CO2

Causes of hyperventilation (tachypnea): Fear, pain, fever, CHF,

anemia

FEVER

Each

degree of fever increases basal

metabolic rate (BMR) 10%, with a
corresponding fluid requirement

VOMITING
Metabolic Alkalosis
Loss of acid from stomach

pH

HCO3

H+

Treatment: Prevent further losses and replace lost

electrolytes

DIARRHEA
Metabolic

Acidosis
loss of HCO from G.I. Tract
3

Treatment:

pH
HCO3

Correct base
deficit, replace losses of
with NaHCO3

TAKE HOME MESSAGE

Fluid is like prescription so give it with caution.

Children are more vulnerable for rapid fluid loss.

Maintenance calculation by 4-2-1 rule or Holliday Segars formula.

Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM

SODIUM CONCENTRATION while giving fluid is must.
As far as possible try to give maintenance fluid requirement orally.
0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children
requiring maintenance therapy.
Replacement of fluids should be prompt & appropriate.

!! THANK YOU !!