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823 Full PDF
823 Full PDF
FLUID THERAPY
By Malcolm A. Holliday, M.D., and William E. Segar, M.D.
Department of Pediatrics, Indiana University Medical Center
O NE OF THE MAJOR objectives of parent per kilogram from a simple formula relat
eral fluid therapy is provision of ing calories per kilogram to age.
water to meet physiologic losses. These The following scheme was devised to
losses, tile insensible and urinary losses, permit an estimate of total expenditure of
have 1)eehl extensively studied and defined energy from weight alone using a relation
for iiifants and adults. It is established from ship between weight and expenditure of
these studies that both insensible loss of energy that may be easily remembered
water and urinary water loss roughly paral (Fig. 1). The lower line in Figure 1 defines
id energy metabolism and do not parallel basal caloric expenditure at the various
body mass (weight). Therefore, any values weight levels and the upper line defines
which are applicable to all ages must be estimated caloric expenditure for normal
derived from some function of energy activity.' The line in between indicates the
metabolism. calculated expenditure of energy for hos
Initially, and to a large extent even today, pitalized patients. It is calculated from the
needs for water have been determined on simple equations illustrated below the graph
the basis of weight in infants and on the and is necessarily arbitrary. Tile course of
basis of total amounts in adults. Although tile calculated line for infants implies that
tilis serves well for infants and adults, the hospitalized infants are more active and
hapless individual between these two more nearly approach normal expenditure
groups receives, at best, a rough estimate than is the case with adults. Hospitalized
of his requirement for water. children and adults are assumed to have an
Darrow and Pratt' have referred water energy expenditure roughly midway be
needs directly to energy expenditure, com tween basal and normal levels. Using this
puted from a set of tables2 utilizing 100 system, expenditure of energy ranges from
calories as a I)asis of reference. This latter 100 to 3000 calories. Table I illustrates the
figure is well chosen since it is equivalent weight comparable to each of these 100-
to 1 kg in the infallt and ready transfer of calorieincrements.
familiarIlumbers is possible.However, the Since losses of water are a function of
necessity for using a table and for making expenditure of energy, needs for water
computations has probably served as a must he computed from some function of
barrier to its widespread acceptance. energy metabolism. In Table II require
Crawford and his associates3 have re ments for water at various weights are com
ferred needs for water, and a variety of pared using the different systems referred
drug dosages as well, to a unit of surface to previously. Close agreement of needs for
area (S.A.) since surface area closely paral water as determined by the various
lels basal energy metabolism. In this sys methods is apparent. There is one excep
tem surface area is computed from a height tion which merits comment. In computing
weight nomogram. needs for water per unit of surface area,
Wallace4 has recently devised a scheme the values in the 6 to 15 kg range are sig
for computing requirement for calories nificantly less than the others calculated in
3000
2500
C
0
@ 2000
0
1500
U
1000
500
30 40
WEIGHT kg.
Fic. 1. The upper and lower lines were plotted from data of Talhot.3 \Veights at the 50th
percentile level were selected for converting calories at various ages to calories related to weight.
The computed line was derived from the following equations:
1. 0-10 kg100cal/kg.
2. 10-20 kgbOO cal + 50 cal/kg for each kg over 10 kg.
3. 20 kg and upi500 cal + 20 cal/kg for each kg over 20 kg.
that range, a finding related to the fact cordingly, a figure comparable to the others
that energy expenditure, either basal or would be obtained if this adjustment is
total, is higher per unit of surface area for made.
the child of intermediate weight than for It may be appropriate to examine the
the small infant or for the adult. An in two major components of loss of water,
crease of about 50% in needs for water per urinary and insensible, in terms of their
unit of surface area for this group would relation to these systems.
make them comparable to the other groups.
With this exception, the four systems give INSENSIBLE WATER LOSS
similar results. With respect to insensible loss of water,
The higher figure in the adult range com Newburgh and Johnston6 and Levine and
puted from the system of Darrow and Pratt Wheatley7 have demonstrated that, for au
results from the use of a constant percentage ages, insensible loss of water in tile resting
of basal metabolism as an estimate of activ state in a comfortable environment is a
ity. As noted by Darrow and Pratt, a lower constant function of basal energy expendi
percentage would more probably describe ture. The figures average 45 ml of water
the actual activity of hospitalized adults. Ac expended for each 100 cal of energy. At
l'ABLEII
NEEDS FOR WATER IN RESPE('T TO WEIGHT (oMPI'TED FROM \ARIOI'S SYSTEMS
(nil/24 hr)
JVeig/it
Sfet/wd of
Estimation S kg 6 kg JO kg 15 kg 20 kg So kg 6() kg
2300S.A.t
Cal. 3(K) 60() 1000 1250 1500 1700
255t)Cal.4-@
(Crawford et a!.') 300 450 660 900 1200 1500
3000Cal4(l)arrow el a'.') 240 600 975 1291) 1530 1950
24004(Wallace4) 300 600 1000 1360 1640 2100
text.t
Xeeds for water estimated to be 100 ml/l00 (alsee
forthat
Nee(lS for water estimated to be 1500 1111/11,2
for each weight computed and assuming 50th percentile height
weight.4*
ofTalhot.5
Needs for water estimated to be 120 iiil/100 cal as given by the author. l'asal calories fronl the table
increaseover
Activity assumed to be 30%, specific dynamic action 1.5%, an(l growth 5%. This results in a 50%
likely.)Needs
basal rate. (For adults a total increase of 30% is more
follows:cal/kg
for water estimated to be 100 1111/100cal as given by the author. (aloneiieed estithiated as
100 (SXage in years). Total calories tlieii equal weightXcalculated calories per kilogram.
TABLE III
RELATION OF INSENSIBLE Loss OF WATER TO SURFACE AREA AND TO ESTIMATED
CALORIc EXPENDITURE FOR VARIOUS AGE Gaou@s
yr1150591241183
03
yr95049102Ithi816
8
yr@m)0457390All
ages93050
* Data of Ileeley and Talbot8 recalculated from weight, estimated caloric expenditure and observed insensible loss.
t Mean for all ages taken as 100% and mean for each age group expressed as per cent of this figure.
centage deviation of each of the various age these limits by the intake of water. In dis
groups from the over-all average may be ease states requiring parenteral fluid ther
calculated. Repeating the same calculation apy the limits of concentration may be con
using the data expressed in terms of 100 siderably narrowed. In addition, the intake
cal of estimated expenditure, a similar but of water is no longer controlled by the
less marked influence of growth is demon patient in response to his own stimuli and,
strated (Table III). Using surface area as finally, administration of drugs as well as
the standard reference, infants have a 24% other stimuli may influence factors control
increase over the group average. Using esti ling excretion of water, i.e., secretion of
mated expenditure of energy as the stand antidiuretic hormone, independent of water
ard reference, the increase is 18%. Similarly, intake. Accordingly, a definition of the
values for adults by the first system are 25% average solute load during parenteral fluid
below average for the group and by the therapy, along with some knowledge of
second are 10% below. Therefore, 50 rnl/100 its range, is essential in ascertaining the
cal/day represents a figure that approxi volume of water needed. It is furthermore
mates insensible loss of water for all ages. desirable to consider those factors which
This figure agrees well with previously re might influence excretion of water other
ported estimates.1 than intake of water and load of solutes.
Such considerations would assist in ascer
URINARYWATERLOSS taining the safest concentration range and
The problem of urinary water loss is the factors which may dictate exception to
best considered in terms of total excretion the average figure for water needs.
of solutes. The excretion of water is largely A theoretic approach to the problem of
a function of the amount of solute requir requirements for water, in terms of excre
ing excretion and of the factors which con tion of solutes, during parenteral fluid ther
trol the concentration at which the solute apy has been applied by Gamble et a/IC and
is to be excreted. Talbot et ai.12 using data obtained from
These factors have been discussed in adults receiving glucose. In Table IV rates of
detail by Gamble,@Welt, and Talbot. excretion of solutes are illustrated for in
Under usual conditions, solute concentra fants receiving glucose and water.1' Two
tions may be varied from a low of 75 infants were shifted from a cow's milk feed
mOsm/l to a high of 1200 rnOsm/l so that ing to the glucose and water feeding for a
each milliosrnol may be excreted in as much 5-day period. Later glucose and water were
as 13.5 ml of water or as little as 0.8 ml, and administered to these infants for 10 days.
the concentration is determined within The data depict the average excretion of
concentration would require 66.7 ml (40/ To test this concept, the concentration of
600 X 1000 = 66.7). The minimum solute solutes in the urine was determined in in
load excreted at 150 mOsm/l requires the fants, children and adults who had been
same volume of water as the maximum receiving pareiiter@t1 fluid therapy for at
solute load excreted at 600 mOsm/l. This least 12 hours. The subjects were OIl vari
of course derives from the fact that the high ous hospital services and tileir intake of
concentration of solutes is four times the fluid was dictated by the individual ser@'
low and the maximum solute load is four ice. A random, untimed specimen of urine
times the minimum. The average solute was obtained. Urine was collected and Pre
load, 25 mOsm/l excreted in 66.7 ml of served with thymol. Concentration of
water would be excreted at a concentra soluteswas determined in a Fiske osmome
tion of 375 mOsrn/l (25/66.7 X 1000 = 375 ter and concentration of creatinine1w the
mOsm/l). Providing 66.7 ml of water for method of Folin and \Vu.1@
renal excretion for patients receiving par The data, with respect to concentration
enteral fluid therapy permits the predicted of solutes, are represented in Figure 2 in
solute loads of 10 to 40 mOsm/100 cal/day the form of a frequency distribution. This
to be excreted between the concentrations figure is subdivided into three categories
of 150 and 600 mOsm/l, and the average arbitrarily defined, as indicated, to repre
solute load of 25 mOsm/100 cal/day to be sent values pertaining to infants, children
excrete(I at a concentration of 375 mOsm/l. and adults. Concentrations of solutes were
20
I 15
I
I 10
C
C
C
0
<100 100.-iSO 150-300 300-000 000-1000 >1000
SOLUTE CONCENTRATION - mOs/L
47 15
20 61 2$
25 [@JCRILDRzN.1oo0-20ooCAL.(10-4skg.)
Fic.. 2.
TABLE V
AN EXAMPLE ILLUSTRATING METHOD OF CALCULATION OF TOTAL I)AILY ExrhiETIoN (IF SOLITES
300 ml (100 ml/100 cal) and a total daily 116.7 ml/100 cal/day. It is fair to assume
excretion of solutes of 75 mOsm (25 mOsm/ that the water of oxidation will provide
100 cal). The rate of excretion of solutes nearly 16.7 ml. The balance, 100 ml/100
would then be about 3 mOsm/hr. At maxi cal/day, must be provided parenterally.
mal urinary dilution (75 mOsm/l) the maxi Fortuitously then, average needs for water
mal rate of excretion of water would be 40 expressed in milliliters equals estimated
ml/hr (13.3 mI/mOsm). Should half the daily energy expenditure in calories.
need for water, 150 ml, be given in a 1-hour
period, the excretion could then be but MAINTENANCE ELECTROLYTENEEDS
40 ml. The insensible loss of water in that With respect to maintenance needs for
hour would account for an additional 6 ml. electrolyte, less precise data are available,
The balance, 104 ml, would be retained. and figures considerably in excess of the
The total quantity of water in the body is minimum requirements are readily handled.
estimated to be 1800 ml (60% of the body This fact is apparent in comparing the
weight). The addition of 104 ml of water electrolyte intake of infants receiving
would represent a dilution of body fluid of human milk and cow's milk. The intake of
nearly 6% and would result in a drop of electrolytes in relation to the intake of
approximately 8 mEq in the concentration calories for babies receiving each type of
of sodium in the serum. Such an abrupt milk is indicated in Table VI. Also pre
decrease in concentration of sodium is suffi sented are the figures recommended by
cient to produce symptoms. Furthermore, Darrow' for infants and adults, and by
under stimulus for maximal excretion of Welt for adults, recalculated in terms of
water the administered water would be 100 cal. Close agreement of the various sys
excreted in a 4-hour period and, unless this tems is evident. It is also apparent that
were taken into account, a period of rela these values fall between the intakes pro
tive water deficit would then ensue. vided by human milk and cow's milk and
Daily administration of water is then should therefore be acceptable as main
best provided continuously, but certainly tenance needs for electrolyte.
it should be provided over a period of at
least 12 hours. This is especially true in the TABLE VI
infant. The significant number of infants INTAKE OF ELECTROLYTES PROVIDED PER ESTIMATED
excreting urine at concentrations less than 100 CALORIES ON VARIOUS REGIMENS
100 mOsm/l indicates that the above con
siderations are often ignored. Excessive cal/dayNa(IKHuman
RegimenmEq/100
amounts of glucose and water are fre
quently given to maintainan infusion.
The inherent danger of such practices is milk*1.01.22.0Cow'srnilk3.54.56.0Recommendedt3.02.02.0Recommended
evident from the foregoing consideration.
Equally apparent is the fact that insuffi
(Darrow)3.02.03.0Recommended
cient amounts of water were provided in adult**3.03.01 .0
6 of the 28 infants, and a fairly extreme de
gree of concentration of solutes in the urine * Computed assuming an intake of 150 @@l/100 cal/
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1957 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/19/5/823
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1957 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.