Fluids and Electrolytes (Part 2)

2.3b
October 10, 2016
DR. VICTOR DOCTOR

 Failure to replace these losses leads to a child who is

PATTERNS OF INTRAVENOUS THERAPY
thirsty, uncomfortable, and, ultimately, dehydrated
 What is the type of loss?
 What is the degree or extent of loss?
 The goal of maintenance water is to provide
 What is the duration needed to correct the loss?
enough water to replace these losses.
(See First Trans)  Although urinary losses are approximately 60% of
MAINTENANCE AND REPLACEMENT THERAPY the total, the normal kidney has the ability to
 Maintenance intravenous fluids are used in a child markedly modify water losses, with daily urine
who cannot be fed enterally. volume potentially varying by more than a factor of
 Along with maintenance fluids, children may 20.
require concurrent replacement fluids if they  Maintenance water is designed to:
have continued excessive losses such as may occur: o Provide enough water so that the kidney does not
o With drainage from a nasogastric (NG) tube need to significantly dilute or concentrate the
o With high urine output due to nephrogenic urine. It also provides a margin
diabetes insipidus
 If dehydration is present, the patient also needs to
receive deficit replacement.
MAINTENANCE THERAPY
 Healthy children can tolerate significant variations in
intake because of the many homeostatic
mechanisms that can adjust absorption and
excretion of water and electrolytes.
 Maintenance fluids are most commonly necessary
in:
o Preoperative and postoperative surgical patients
o Many nonsurgical patients also require A system for calculating maintenance water on the
maintenance fluids basis of the patient’s weight and emphasizes the high
 It is important to recognize when it is necessary to water needs of smaller, less mature patients.
begin maintenance fluids
 Infants become dehydrated more quickly than older  An overweight child:
patients. o Better to base the calculations on the lean body
 Maintenance fluids are composed of a solution weight, which can be estimated by using the 50th
of: percentile of body weight for the child’s height.
o Water  It is also important to remember that there is an
o Glucose upper limit of 2.4 L/24 hr in adult-sized patients.
o Sodium  Intravenous fluids are written as an hourly rate.
o Potassium
 This solution has the advantages of:
o Simplicity, long shelf life, low cost, and
compatibility with peripheral intravenous
administration.
 Goals of Maintenance Fluids:
o Prevent dehydration
o Prevent electrolyte disorders
o Prevent ketoacidosis
o Prevent protein degradation Enable rapid calculation of the rate of maintenance
 Patients lose water, sodium, and potassium in their: fluids
o Urine and stool INTRAVENOUS SOLUTIONS
 Water is also lost from the skin and lungs ELECTROLYTE COMPOSITION OF PLASMA AND
 The glucose in maintenance fluids provides COMPARISON TO EACH FLUID PREPARATION
approximately 20% of the normal caloric needs of Na K Cl HCO3
the patient, prevents: NSS 150 0 150 0
o Development of starvation ketoacidosis LRS 130 4 100 28
o Diminishes the protein degradation that would NR 150 5 109 28
occur if the patient received no calories. Plasma 140 4 100 28
 Glucose also provides added osmoles, thus avoiding Blood 140 4 109 27
the administration of hypotonic fluids that may cause Oresol* 75 20 65 20
hemolysis D5 0.3% 50 0 50 0
 Maintenance fluids do not provide adequate NaCl
calories, protein, fat, minerals, or vitamins. D5 0.45% 75 0 75 0
 A patient receiving maintenance intravenous fluids is NaCl
receiving inadequate calories and will lose 0.5-1% of
weight each day.
 Prototypical maintenance fluid therapy does not
provide electrolytes such as:
o Calcium
o Phosphorus
o Magnesium
o Bicarbonate

MAINTENANCE WATER
 Normal saline (NS) and Ringer lactate (LR) are
 Water is a crucial component of maintenance fluid
isotonic solutions; they have approximately the same
therapy because of the obligatory daily water losses.
tonicity as plasma.
 These losses are both:
 Isotonic fluids are generally used for the acute
o Measurable (urine, stool)
correction of intravascular volume depletion.
o Not measurable (insensible losses from the skin
 The usual choices for maintenance fluid therapy in
and lungs)
children are half-normal saline (1/2NS) and

0.2NS.
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o These solutions are available with 5% dextrose Diarrhea 80 20 60 20

(D5). Vomiting 50 100 150 0
o In addition, they are available with: Plasma 140 4 109 27
 20 mEq/L of potassium chloride, leak
 10 mEq/L of potassium chloride
 No potassium.  Diarrhea
 Custom-made solutions has: different Give oresol if the patient can drink. If not, give D5
concentrations of glucose, sodium, or potassium 0.45% NaCl instead.
 Other electrolytes, such as calcium, magnesium,  Why D5 0.45% NaCl?
phosphate, acetate, and bicarbonate, can be added First, look at the electrolyte losses in diarrhea. Then
to intravenous solutions. compare it with the electrolyte composition of the
 Custom-made solutions take time to prepare and are different replacement therapies. Choose the best
much more expensive than commercial solutions. replacement solutionthat will help correct the
 The use of custom-made solutions is necessary only deficits.
for:
o Patients who have underlying disorders that cause  Dengue
significant electrolyte imbalances. Before giving plasma, cross-match first
 The use of commercial solutions saves both time and Go for LRS first while waiting for the result of the
expense. cross-matching
 A normal plasma osmolality is 285-295 mOsm/kg. If you lose plasma, give a plasma substitute that is
 Infusing an intravenous solution peripherally with a readily available.
much lower osmolality can cause water to move Blood is best replaced by blood while plasma is best
into red blood cells, leading to hemolysis. replaced by plasma but sometimes there are
 Thus, intravenous fluids are generally designed to constraints.
have an osmolality that is either close to 285 or  Vomiting
greater (fluids with moderately higher osmolality do D5 0.3% NaCl + KCl
not cause problems).
Thus, 0.2NS (osmolality = 68) should not be VOLUME FOR REHYDRATION
administered peripherally, but D5 0.2NS (osmolality= Young Older child
346) or D5 1/2NS+ 20 mEq/L KCl (osmolality = 472) infants (up (above 20
can be administered. to 10 kg) kg)
 One approach to avoid water intoxication is to reduce Mild (5%) (3%) 50 cc/kg 30 cc/kg
the rate of infusion of fluids containing 0.2NS or Moderate (10%) (6%) 100 cc/kg 60 cc/kg
1/2NS.
Severe (15%) (9%) 150 cc/kg 90 cc/kg
STAGES OF MANAGEMENT
Time for correction: 4-8 hours
1st Mild Rehydrate **The first percentages in parenthesis are for the
stage 0-8 hours young infants and the second % in parenthesis are for
Moderate - Resuscitate (IV) the older child
Severe 0-1 hour
2nd stage Rehydrate (IV/oral) Examples:
2-8 hours 1) 5 kg infant
3rd stage Maintain and replace on- Goal:
going losses (IV/oral)  Na = 15
9-24 hours  K = 10
RESUSCITATE Urgent – prevent death  Cl = 10
Precise – enhance  5kg x 100cc/kg = 500 ml
Adequate – survival and  What fluid are you going to give? Give 500 mL of D5
recovery IMB
1.Isotonic solution  Why D5IMB?
2.Approximate volume for circulation Na = 25/2 = 12.5
20 cc/kg K = 20/2 = 10
3.Rapid circulatory access Cl = 22/2 = 11
bolus (15-20 minutes)  Why did we divide by 2? Because the electrolyte
ELECTROLYTE COMPOSITION OF PLASMA AND values were approximated per liter of solution. Since
COMPARISON TO EACH FLUID PREPARATION we are only giving 500 ml for the patient, 1 liter of D5
Na K Cl HCO3 IMB must be divided by 2 to attain our goal of giving
NSS 150 0 150 0 the patient 500 ml of solution. Thus, the electrolyte
LRS 130 4 100 28 values were also halved.
NR 150 5 109 28
Plasma 140 4 100 28 2) 20 kg older child
Blood 140 4 109 27 Goal:
Oresol* 75 20 65 20  Na = 60
D5 0.3% 50 0 50 0  K = 40
NaCl  Cl = 40
D5 0.45% 75 0 75 0  20kg x 75cc/kg = 1500 ml
NaCl 
*Oresol has no control for patients with shock  What fluid are you going to give? Give 1.5 L of D5NM.
 20 cc/kg isotonic solution is given in 15 – 20  Why D5 NM?
minutes Na = 40+20 = 60
 Ex. 10 kg patient  you will administer 200 cc IV in K = 13 + 6.5 = 19.5
15 to 20 minutes Cl = 40 + 20 = 60
 Isotonic - the same tonicity of plasma
 280 – 300  If, for example, you chose to give 2L of D5 IMB
Tonicity of plasma Excess of 500 in volume
 NSS (with a tonicity of 308) and NR (292) have a  Since the patient is already in maintenance and can
little higher tonicity than plasma. On the other hand, eatalready, D5NM is better. Even if there is little
LRS (271) has a little lower tonicity than plasma.
potassium, you can supplement by eating.
Even so, all 3solutions are considered as isotonic.
 Rehydrate
 NSS isotonic
Na -you can already say normal due to little
Match volume and quality of losses
difference
Cl -big difference (1/3)
ELECTROLYTE LOSSES IN SOME SELECTED
K - None
CONDITIONS
HCO3 - None
Na K Cl HCO3
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 LRS  Thirst
Low on Na but all the other components are better  Normal physical
 If you have metabolic acidosis examination
Do not give potassium-containing solution because  Infant has few clinical
of hyperkalemia. Use NSS instead. signs or symptoms
 NSS Moderate 7-  Tachycardia
First discovered solution, oldest, used in the first dehydration 10%  Little or no urine output
world war  Irritable/lethargic
METABOLIC ACIDOSIS  Sunken eyes and
fontanel
 When you have a critical patient, the compensatory
 Decreased tears
mechanism is almost 0.
 Dry mucous membranes
 Mild tenting of the skin
Na K Cl HCO3
 Delayed capillary refill
Plasma 140 4 100 28  Cool and pale
Acidotic 140 7 100 10  Infant has clear physical
NSS 150 0 150 0 signs and symptoms
 Interpretation:  Intravascular space is
Na = 140 + 150 = 290  290/2 = 145 depleted
K = 7 + 0 = 7  7/2 = 3.5 (improves) Severe 10-  Rapid and weak pulse
Cl = 100 + 150 = 250  250/2 = 125 (worsen) Dehydration 15%  Decreased blood
HCO3 = 10 + 0 = 10  10/2 = 5 (worsen) pressure
 Vital organs may be
Na K Cl HCO3 receiving inadequate
Plasma 140 4 100 28 perfusion
Acidotic 140 7 100 10  No urine output.
LRS 130 4 109 28  Very sunken eyes and
 Interpretation: fontanel
Na = 140 + 130 = 270  270/2 = 135 (normal)  no tears
K = 7 + 4 =11  11/2 = 5.5 (improve)  Parched mucous
Cl = 100 + 109 = 200  200/2 = 100 (improve) membranes
HCO3 = 10 + 28  38/2 = 19 (improve)  Tenting of the skin
 LRS does not aggravate the hyperkalemia and it  Very delayed capillary
improves the acidosis. Therefore, the statement “do refill
not give K-containing solution for acidosis” is not  Cold and mottled
always true.  Infant is gravely ill
 Immediate and
aggressive intervention is
 NSS may induce or aggravate metabolic
necessary
acidosis
 LRS will not aggravate metabolic acidosis.
 For older children and adult:
 LRS may also alleviate metabolic acidosis.
 Mild dehydration 3% body weight loss
Electrolyte Content Moderate dehydration 6% body weight loss
When LRS is Added to Normal Plasma Severe dehydration 9% body weight loss
Na+ K+ Cl- HCO3-
Normal 140 4 100 28  This difference is because water is a higher
Plasma percentage of body weight in infants
LRS 130 4 100 28  In hypernatremic dehydration - the degree of
Average 135 4 100 28 dehydration tends to be underestimated because the
movement of water from the intracellular space to
the extracellular space helps to preserve the
Electrolyte Content
intravascular volume.
When LRS is Added to Acidotic Plasma
 The neonate with dehydration due to poor intake of
Na+ K+ Cl- HCO3-
breast milk hypernatremic dehydration
Acidotic 140 4 100 10
Plasma
Hypernatremic Hyponatremic
LRS 130 4 100 28
Dehydration Dehydration
Average 135 4 100 19
 Losses of hypotonic fluid  Child with diarrhea who
and poor water intake is taking in large
Electrolyte Content  Diarrhea quantities of low salt
When LRS is Added to Hyperkalemic Plasma  Poor oral intake due to fluid such as water or
Na+ K+ Cl- HCO3- anorexia or emesis diluted formula.
Hyperkalemic 140 7 100 10
Plasma DEHYRATION FEATURES
LRS 130 4 100 28 Isotonic  Serum Na+:135-145 mEq/L
Average 135 5.5 100 19  Serum osmolality- 280-300
mOsm/L
DEHYDRATION AND SHOCK  Almost all cases of viral and
 There are many modifications of fluid and electrolyte bacterial diarrheas
management. Hypottonic  Serum Na+:<130 mEq/L
 In 4 hours’ time, if you think what you give is not
 Serum osmolality: <260 mOsm/L
enough, you can just add more.
 WHO  Malnourished children and some
Does not use mild, moderate, and severe Instead, breastfed infants with diarrheal
no dehydration, some dehydration, severe dehydration
dehydration is used.  Salt-losing states like salt-losing
 The classification of dehydration is appropriate only nephritis
for diarrhea. Do not use this for other existing  Rapid administration of electrolyte-
disease. free IV fluid like plain D5W
Hypertonic  Serum Na+: >150 mEq/L
DEHYDRATION % FEATURES  Serum osmolality: >300 mOsm/L
Mild dehydration 3-  Normal or increased  Excessive water loss which is out of
5% pulse proportion to electrolyte loss
 Decreased urine output  Conditions presenting

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hyperventilation such as asthma, o Leak of plasma from capillaries all over the body
pneumonia, and encephalitis →hypovolemia
 Babies who are given skimmed milk  Infections like Sepsis
or high solute formula or those who o Dysfunction and inflammation of the capillaries →
have received excessive parenteral escape of plasma
fluid of pure saline or Ringer’s  Burns
Lactate solution o Plasma seepage from the capillary
APPROACH TO DEHYDRATION  Anaphylactic reaction
 The child with dehydration requires restoration of the o Leak of plasma
intravascular volume with an isotonic solution such o Vasodilatation → relatively big compartment ->
as normal saline (NS) or Ringer lactate. low volume of plasma
 The child is given a fluid bolus, usually 20 mL/kg, FLUID AND ELECTROLYTE LOSS
over about 20 min. ACUTE DIARRHEA
 Blood transfusion is indicated in the child with  One of the top 5 causes of mortality among children
significant anemia or blood loss.  Water and electrolyte losses
 Plasma is useful for children with a coagulopathy.  Most common:
 The child with hypoalbuminemia may benefit from o Enteral diarrhea
5% albumin, although there is evidence that albumin o Cholera
infusions increase mortality in adults. Losses from Diarrhea (per 1000mL of plasma)
 In Isotonic dehydration Na+ K+ Cl- HCO3-
o The entire fluid deficit is corrected over 24 hr. Enteral 70-80 20 50-60 20
 Calculate maintenance water Diarrhea
 Calculate deficit water Cholera 100-140 20 80 20
o The child receives normal maintenance fluids and  Loss of fluid hypovolemia and weight loss
the fluid deficit.  Loss of HCO3  metabolic acidosis
o The total amount of water and electrolytes are SAMPLE CASE: DIARRHEA
added together and then an appropriate fluid is Which is an appropriate solution?
selected. NSS No!
o D5 ½ normal saline with 20 mEq/L KCl is usually  Na and Cl – too high
an appropriate fluid.  K and HCO3 – lacking
Half of the total fluid is given over the first 8 hr; LRS No!
previous boluses are subtracted from this volume. The  Na and Cl – too high
remainder is given over the next 16 hr  K – insufficient
 HCO3 – high

D5%W No!
 Only volume will be replaced, not the
electrolytes
D5%NM No!
 Not satisfying enough to replace
electrolytes
1/2NSS No!
 Na – satisfied
 Cl – too high
 K and HCO3 – lacking
ORS Yes!
 A patient is unable to tolerate oral feeding:
o Severe dehydration
 Child is estimated to die within 10-15 minutes
FLUID AND ELECTROLYTE TREATMENT OF  If the patient cannot tolerate oral feeding:
SPECIFIC DISORDERS o Administer intravenously.
 Management of fluid and electrolyte disorders in o Closest choice is D5NM.
pediatrics requires understanding of the dynamics  ORS cannot be used for IV administration due
of the body fluid, physiologic disturbances and to problems of sterility and stability.
recognition of the clinical manifestations which  What are the advantages of ORS?
usually serve as the main basis for the clinical o Cheap
management of these problems o Most practical to advise parents
DISTRIBUTION OF BODY FLUID o Does not need hospitalization
 Total Body Water (TBW) = ICF + ECF WHO – DENGUE
 ECF = Interstitial Fluid (ISF) + Plasma volume  One of example of Plasma Loss Syndromes
o Losing lots of plasma hypovolemia
OLDER TBW 65% OF LEAN BODY MASS o Examples:
INFANT ECF 25% ICF  Dengue – leakage of plasma
AND ISF PV 40%  Sepsis – plasma loss from capillaries due to
CHILDREN 16% 9% overwhelming infection  death is due to
hypovolemia and shock
 In disorders affecting the composition of the body  Burns – yellowish fluid inside the blister is
fluids, plasma volume and interstitial fluid are plasma
primarily distributed with secondary changes  Peritonitis – infectious or non-infectious
occurring in the ICF
 If the patient has signs of shock
NEWBORN TBW 75-80% OF LEAN BODY MASS Give 20 cc/kg bolus
ECF ICF  If the patient improves
30-35% 40% Give 7-11cc/kg (1-2 hours)
 If the patient is doing well
 Larger TBW is due to an expanded extracellular
reduce to5-7cc/kg (2 hours)
water (almost same as ICF)
 If the patient further improves
 “Excess water” is lost during the physiologic
reduce to3-5cc/kg (2-4 hours)
adjustment of the neonate in the first 2 weeks of
postnatal life  If the patient is stable
 Reason for expected initial weight loss of the reduce to2-3cc/kg and maintain as such
newborn *If there is new sign of shock 7-11 or 20cc/kg
depending on the situation
PLASMA LOSS DISEASES
COMPARISON OF THE OLD AND THE NEW TREATMENT
 Dengue

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PROTOCOLS o V = (100cc/kg) x (15kg) = 1500cc

OLD NEW o Na+ = (3mEq/kg) x (15kg) = 45mEq
Shock 20cc/kg bolus o K+ = (2mEq/kg) x (15kg) = 30mEq
90/8 = Severe 7-11 o Cl- = (2mEq/kg) x (15kg) = 30mEq
11.25  Per 1000cc:
60/8 = 7.5 Moderate 5-7 o 1500cc/1000cc = 1.5
30/8 = 3.75 Mild 3-5 o Na+= 45mEq/1.5 = 30mEq
75? Maintenance 2-3 o K+ = 30mEq/1.5 = 20mEq
o Cl- = 30mEq/1.5 = 20mEq
o Values are nearest to D5 IMB
 In dengue, most of the time we’re dealing with an older
child Example:
 Why? Because the one with subsequent dengue will 30kg 14-year-old child
have more reaction  Computation:
 Treatment for shock: o V = (75cc/kg) x (30kg) = 2250cc
Isotonic solution o Na+ = (3mEq/kg) x (30kg) = 90mEq
20cc/kg o K+ = (2mEq/kg) x (30kg) = 60mEq
15-20 minutes o Cl- = (2mEq/kg) x (30kg) = 60mEq
 Rehydration:  Per 1000cc:
4-8 hours o 2250cc/1000cc = 2.25
Volume o Na+ = 90mEq/2.25 = 40mEq
 Dengue – plasma model o K+ = 60mEq/2.25 = 26.7mEq
 Why is isotonic solution used for resuscitation? o Cl- = 60mEq/2.25 = 26.7mEq
Procedure o Values are nearest to D5 NM
System (faster to administer IV) VOMITING
 Resuscitation  Vomiting of gastric content (acidic)
Isotonic  Opposite of diarrhea
16-24 hours  Na+ content is relatively lower than K+
 Small child – D5 IMB  HCO3- is zero because it is acidic
 Older child – D5NM MANAGEMENT
 Higher content butless H20  General Principle: Intake = Output
 Adult – 60% H20 o Volume – address hypovolemia
o Quality
 Newborn – 80% H20
o Duration – time of administration or infusion (fast
SAMPLE CASE: DENGUE SHOCK SYNDROME drip or slow drip)
A 14-year-old male presented with fever of four days
duration. Patient was apparently in shock. Always remember this table!
BP=80/60mmHg, WBC=4000/μL, platelet=60/μL. MANAGEMENT PROTOCOL
1. RESUSCITATION (to treat patient in shock) RESUSCITATE  Must be:
What?  LRS (isotonic solution) o Urgent: prevent death
 NSS (if LRS is not available) o Precise: enhance
Amount?  20cc/kg o Adequate: survival and
Duration?  15 to 20 minutes recovery
 Steps:
 Signs of effective resuscitation: 1.Rapid circulatory access: Bolus
o Improvement in sensorium 15-20 minutes
o Increase in blood pressure 2.Isotonic solution
o Patient will urinate (most important) 3.Physiologic solution: To re-
 If the patient does not urinate: establish cellular function
o Resuscitation is still not enough 4.Approximate volume for
o Repeat the procedure (LRS 20cc/kg 15-20min) circulation: 20cc/kg
o Patient will usually respond REHYDRATE  Match the volume and quality of
2. REHYDRATION (to normalize the patient) losses
What?  LRS (isotonic solution)  Time for correction: 4 to 8 hours
Amount?  Classify first if dehydration is:  Aimed at the immediate
o Mild - 5% weight loss correction of abnormal losses of
o Moderate - 10% weight loss fluid and electrolytes
o Severe - 15% weight loss
 Should be accomplished either by
 Young children (<3yo):
oral rehydration or IV therapy
o Mild - 50cc/kg
 Deficit portion of fluid therapy
o Moderate - 100cc/kg
which results from previous
o Severe - 150cc/kg
abnormal losses of fluid and
 Older children (>5yo):
electrolytes such as diarrhea,
o Mild - 30cc/kg
vomiting, and other dehydrating
o Moderate - 60cc/kg
conditions
o Severe - 90cc/kg
Duration?  4 to 8 hours
 Acute conditions: exclusively loss
of water and minerals without loss
 Remember 30-60-90! Why?
of tissue fluids
o DSS occurs among patients who already had
previous dengue infection. Thus, it is more  In the management of the deficit
likely to occur among older children. therapy during the rehydration
 Remember 30-60-90! Why? phase, the following should be
o DSS occurs among patients who already had corrected:
previous dengue infection. Thus, it is more o Fluid loss
likely to occur among older children. o Osmolality or sodium iron
disturbance
3. MAINTENANCE (to maintain being normal)
o Other electrolyte disturbances
What?  Young children: D5 IMB
like potassium, magnesium,
 Older children: D5 NM
calcium, etc.
Amount?  Young children: 100cc/kg
o Acid-base imbalance
 Older children: 75cc/kg
MAINTENANCE  After rehydration
Duration?  16 to 24 hours
Example:  Duration of maintenance: 16 to
15kg 5-year-old child 24 hours
 Computation:  Intended to stabilize the internal
milieu after it has been restored

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to normal during the rehydration Infants 100 cc/kg

phase Older child 75 cc/kg
 Normal daily requirement of fluid
and electrolytes 2.Compute for the individual’s electrolyte content
 Includes the provision of the based on weight
normal daily requirement of water
and electrolytes and the active
replacement and continuing losses mEq/kg Na K Cl
due to persistent diarrhea and Patient's 3 2 2
other dehydrating conditions. electrolytes
 The normal daily requirement of
water and electrolytes is the 3.Match the obtained electrolyte content with the
amount that an infant or child appropriate fluid
normally losses per day as a
result of caloric expenditure PER LITER SOLUTION Na K Cl
 Loss of water and electrolytes is D5 0.3% NaCl 50 0 50
largely in the form of urine and D5 Nm 40 13 40
insensible loss from the skin and D5 IMB 25 20 22
lungs
Example:
INTRAVENOUS FLUIDS 1. Infant 10kg
Version 1
FLUID Na K Cl HCO3
NSS 150 0 150 0 Na: 30
LRS 130 4 100 28 K: 20
NR 150 5 100 28 Cl: 20
Plasma 140 4 100 27  Give D5 IMB
2. Child 20kg
Blood 140 4 100 27
D5 0.3% 50 0 50 0
NaCl
Na: 60
D5 0.45 NaCl 75 0 75 0
K: 40
ORS (Oresol) 75 20 65 20 Cl: 40
H2O 0 0 0 0  Give D5 Nm
3. Infant 5kg

Version2
FLUID Na K Cl HCO3 Na: 15
ORS 75 20 65 20 K: 10
NSS 150 0 150 0 Cl: 10
1/3 NSS 50 0 50 0  Give D5 IMB
LRS 130 4 100 28 REQUIREMENTS IN ELECTROLYTE THERAPY
MT 50 16 39 16  Resuscitation therapy (1st hour)
½ NSS 75 0 75 0 o Requirement = 20cc/kg
IMB 25 20 22 16  Rehydration therapy (4-6 or 4-8 hours)
NM 40 13 40 16  Maintenance therapy (within 24 hours)
Plasma 140 4 100 27
*IMB and NM are usually maintenance fluid

RESUSCITATE Problem: 10 kg child, with mild dehydration. What is

 Must be: the total volume replacement?
o Urgent: prevent death 1. 10 kg X 20 cc/kg = 200 cc for Resuscitation
o Precise: enhance Therapy
o Adequate: survival and recovery 2.10 kg X 50 cc/kg = 500 cc for Hydration Therapy
 Steps: 3.10 kg X 100 cc/kg = 1000 cc for Maintenance
1.Rapid circulatory access: Bolus 15-20 minutes Therapy
2.Isotonic solution Total Volume Replacement = 1700 cc
3.Physiologic solution: To re-establish cellular
function
4.Approximate volume for circulation: 20cc/kg
REHYDRATE
VOLUME FOR REHYDRATION
DEHYDRATION Young Older child
infants (up (above 20
to 10 kg) kg)
Mild (5%) (3%) 50 cc/kg 30 cc/kg

Moderate (10%) (6%) 100 cc/kg 60 cc/kg

Severe (15%) (9%) 150 cc/kg 90 cc/kg
MAINTENANCE AFTER REHYDRATION
 Volume/Type/Quality
 Na (3) K (2) Cl (2) mEq/kg
 Infants 100cc/kg
 Older child 75 cc/kg
 Duration of maintenance = 16 – 24 hours

STEPS FOR COMPUTING FOR FLUID

MAINTENANCE (AFTER REHYDRATION)
1.Compute for the volume needed/required based on
the specific age group

AGE GROUP VOLUME REQUIREMENT

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