Fluid and Electrolyte

Disorders

Janice F. Bacani- Carandang, MD, DPPS

 Composition of Body Fluids

n Total Body Water

n Fluid Compartments

n Electrolyte Composition
 WATER
n the most plentiful constituent of the human
body

n Total body water (TBW) as a percentage of

body weight varies with age

n At birth: 75% of birthweight

n 1st yr of life: TBW ↓to 60% until puberty

 WATER
n What happens during puberty?
n Fat content in females increases
n Males acquire more muscle mass

n Since fat has very low water content, TBW in

males remains at 60% while TBW in females
decrease to 50%.

n Also, during dehydration: TBW is ↓

 FLUID COMPARTMENTS
n TBW is divided into 2 main compartments:
n Extra-cellular fluid (ECF)
nPlasma water- 5%

nInterstitial fluid- 15%

n Intra-cellular fluid (ICF)

 FLUID COMPARTMENTS
n Fetus and newborn: ECF > ICF
post-natal diuresis: ↓ ECF
continued expansion of ICF (cellular growth)

n By 1 year of age: ECF: ICF ratio approaches

adult levels

n ECF: 20-25% of body weight

n ICF: 30-40% of body weight
 FLUID COMPARTMENTS
n Plasma water- 5%

nAltered by dehydration, anemia,

polycythemia, heart failure,
hypoalbuminemia
 FLUID COMPARTMENTS
n Interstitial fluid- 15%

nIncreases dramatically in diseases

associated with edema
nHeart failure, protein- losing
enteropathy, liver failure, nephrotic
syndrome and sepsis
 FLUID COMPARTMENTS
n Hydrostatic and oncotic forces
n Depends on the limited permeability of
albumin across the capillaries
n Over-all, there is a net movement of fluids
out of the intravascular space to the
interstitial space.
n This fluid is returned to the circulation via
the lymphatics.
 FLUID COMPARTMENTS
n Osmotic Equilibrium
maintains ECF and ICF balance because
the cell membrane is permeable to water.

n 285- 295 mOsm/kg

n Can also be measured by calculating glucose

and blood urea nitrogen (BUN)
Dehydration and Fluid
Management
Definition of DEHYDRATION
n Excessive loss of water from the body or
from an organ or a body part, as occurs
during illness or fluid deprivation.

n The process of removing water from a

substance or a compound.

The American Heritage® Stedman's Medical Dictionary

Copyright © 2002, 2001, 1995 by Houghton Mifflin Company.
 Dehydration
n frequently the result of DIARRHEA

n a common problem in children

n continues to be a serious problem in many

areas of the world

n Especially lethal when superimposed on

malnutrition
 Approach to Dehydration
n FIRST STEP:
Assess Degree of Dehydration
↓
dictates both the urgency of the
situation AND the volume of fluid
needed for rehydration

↓
either 1. Minimal/ None;
2. Moderate or
3. Severe
Symptoms Associated with Dehydration
SYMPTOM MINIMAL/ NONE MILD – MODERATE SEVERE
(<3% of Body Weight) (3-9% of Body Weight) (>9% of Body Weight)
Mental Status Well, alert Normal, fatigued or Apathetic, lethargic,
restless, irritable unconscious
Thirst Drinks normally; might Thirsty, eager to drink Drinks poorly; unable
refuse liquids to drink
Heart Rate Normal Normal to increased Tachycardia
Quality of pulses Normal Normal to decreased Weak, thready or
impalpable
Breathing Normal Normal; fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and Moist Dry Parched
Tongue
Skin fold Instant recoil Recoil in <2 sec Recoil in >2 sec
Capillary refill Normal Prolonged Prolonged; minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal to decreased Decreased Minimal
 Clinical Evaluation of Dehydration
MILD MODERATE SEVERE
(3-5%) (7-10%) (10- 15%)
Normal/ increased Tachycardia Rapid and weak pulse,
pulse decreased BP

Decreased urine output Little or no urine output No urine output

Thirsty
Normal PE Irritable, lethargic
Sunken eyes & fontanel Very sunken eyes & fontanel
Decreased tears No tears
Dry mucous membranes Parched mucous membranes
Mild tenting of the skin Tenting of the skin
Delayed capillary refill Very delayed capillary refill
Cool and pale skin Cold and mottled skin
 REMEMBER!
n Clinical assessment of dehydration is
only an estimate and based on range

n The patient must be continually re-

evaluated during therapy (hydration
rounds)

n PE findings are usually proportional to

the degree of dehydration (refer to table of symptoms
shown earlier)
 Approach to Dehydration
n SECOND STEP:

Treat dehydration accordingly

(depends on the degree of dehydration where
you classified your patient)
 NO DEHYDRATION
n Rehydration therapy is NOT applicable
(because patient is NOT dehydrated, no need to rehydrate)

n Ongoing losses should be continually replaced

with Oral Rehydration Solution (ORS)
WHO Recommendations:
Sodium: 75 mEq/L Chloride: 65 mEq/L
Glucose: 75 mEq/L Potassium: 20 mEq/L
Citrate: 10 mEq/L

n Emphasize 3 F’s to the watcher:

Fluids, Food, Follow- up
 NO DEHYDRATION
n How to replace ongoing losses?
If patient weighs:
<10 kg: 60- 120 ml ORS for each diarrheal stool
or vomiting episode
>10 kg: 120- 240 ml ORS for each diarrheal
stool or vomiting episode

* If stool volume can’t be measured, 10- 15

ml/kg/hr ORS is appropriate
 2 yr/Male; 12 kg
WITH NO DEHYDRATION

n Rehydrate or not? NO
n Replace ongoing losses? YES
n How?
>10 kg: 120- 240 ml ORS for each
diarrheal stool or vomiting
episode
 MILD DEHYDRATION
n Rehydrate with ORS 50 ml/kg body weight
over 3-4 hrs

n Replace ongoing losses:

If patient weighs:
<10 kg: 60- 120 ml ORS for each diarrheal stool
or vomiting episode
>10 kg: 120- 240 ml ORS for each diarrheal
stool or vomiting episode

* If stool volume can’t be measured, 10- 15

ml/kg/hr ORS is appropriate
 2 yr/Male; 12 kg
WITH MILD DEHYDRATION
n Rehydrate or not? YES
n How?
50 ml X 12 kg= 600 ml in 3- 4 hrs OR
150- 200 ml/hr
n Replace ongoing losses? YES
n How?
>10 kg: 120- 240 ml ORS for each
diarrheal stool or vomiting
episode
MODERATE DEHYDRATION
n Rehydrate with ORS 100 ml/kg body weight
over 3-4 hrs

n Replace ongoing losses the same way as in

NO or MILD Dehydration

* ORS therapy is less expensive than IV therapy

and has a lower complication rate
 2 yr/Male; 12 kg
WITH MODERATE DEHYDRATION
n Rehydrate or not? YES
n How?
100 ml X 12 kg= 1,200 ml in 3- 4 hrs OR
300- 400 ml/hr
n Replace ongoing losses? YES
n How?
>10 kg: 120- 240 ml ORS for each
diarrheal stool or vomiting
episode
Emphasize NUTRITION while treating
Dehydration:

n Continue breastfeeding

n Resume age- appropriate normal diet after

initial hydration, including adequate caloric
intake for maintenance

n Vomiting may occur during the first 2 hrs of

giving ORS → lessens over time
 Limitations to Giving ORS
1. Shock
2. Ileus
3. Intussusception
4. Carbohydrate intolerance
5. Severe emesis
6. High stool output (> 10 ml/kg/hr)
 Risk Factors Necessitating IV
Resuscitation (instead of oral route):
1. Age < 6 months
2. Prematurity
3. Chronic illness
4. Fever > 38C if < 3 mos, or > 39C if 3- 36 mos
5. Bloody diarrhea
6. Persistent emesis
7. Poor urine output
8. Sunken eyes
9. Depressed level of consciousness
 SEVERE DEHYDRATION
n Intravenous (IV) therapy is required
immediately and oral therapy is not even
considered.
n In addition, IVF is required in those:
1. with uncontrollable vomiting;
2. those unable to drink because of
extreme fatigue, stupor, or coma; or
3. those with gastric or intestinal
distention
 FLUID MANAGEMENT OF
SEVERE DEHYDRATION
1. Restore intravascular Normal saline or Lactated Ringer’s solution:
volume 20 mL/kg over 20 min
(Repeat until intravascular volume is restored)
2. Rapid volume Normal saline or Lactated Ringer’s solution:
repletion 20 mL/kg over 2 hours
3. Calculate 24- hr water nCalculate maintenance water
needs nCalculate deficit water

4. Calculate 24-hr nCalculate maintenance sodium and potassium

electrolyte needs nCalculate deficit sodium and potassium

5. Select an appropriate Administer half the calculated fluid during the first
fluid 8 hrs, first subtracting any boluses from this
amount
Administer the remainder over the next 16 hrs
 MAINTENANCE WATER
n Body Weight Method:
0-10 kg: 100 ml/kg
11- 20 kg: 1000 ml + 50 ml/kg for each
kg > 10 kg
> 20 kg: 1500 ml + 20 ml/kg for each
kg > 20 kg
 DEFICIT WATER
Percent dehydration × weight
Mild: 3- 5 %
Moderate: 7-10%
Severe: 10- 15%

n Any value may be used, either the lower

or higher, as long as it is within the
given range.
 Laboratory Exams to Request:
n Serum electrolytes (Na, K, Ca, Mg, Cl)
n BUN and Serum creatinine

n Urinalysis (specific gravity)

n CBC (Hemoconcetration)
 2 yr/Male; 12 kg
WITH SEVERE DEHYDRATION
1. Restore intravascular 20 ml X 12 kg= 240 ml over 20 mins
volume (20 mL/kg)
2. Rapid volume 20 ml X 12 kg= 240 ml over 2 hours
repletion (20 mL/kg)
3. Calculate 24- hr water Maintenance: 1000 ml + 50(2 kg)= 1,100 ml
needs Deficit: 15% X 12 kg= 1,800 ml
(Maintenance + Deficit) TOTAL: 2,900 ml
4. Calculate 24-hr may use 10-15%
electrolyte needs
5. Select an appropriate 2,900 ml divided by 2= 1,450 ml
fluid
1,450 ml- 480 ml= 970 ml in 8 hrs (121.5 ml/hr)
(Give half in 8 hrs, less
the bolus given; then The remaining 1,450 ml will be given in 16 hrs
give remaining in 16 hrs (90 ml/hr)
 CORNERSTONES OF
MANAGEMENT

n Oral Rehydration Solution

n Continued feeding
n Zinc (recommended by WHO and UNICEF)
< 6 mos: 10 mg/ day for 14 days
> 6 mos: 20 mg/ day for 14 days
 MONITORING THERAPY
n Vital signs
Pulse, Blood pressure

n Intake and output

Fluid balance, Urine output & specific gravity

n Physical Examination
Weight, clinical signs of depletion or overload

n Electrolytes
Serum Electrolyte
Imbalance
ELECTROLYTE COMPOSITION
n Extra-cellular fluid (ECF):
n Sodium (Na+)
n Chloride (Cl-)

n Intra-cellular fluid (ICF):

n Potassium (K+)
n Proteins, organic anions and phosphorus

n The difference in electrolyte compositions are

important in the evaluation and treatment of
electrolyte disorders.
 SODIUM (Na+)
n The dominant cation in the ECF
n Normal values: 135- 145 mEq/L
n Intake:
n Determined by the child’s diet
n Readily absorbed by the GIT

n Co- transport system with Glucose

n Excretion:
n Through stool and sweat
n Through the kidney- RAS
 Hypernatremia
n Sodium concentration of > 145 mEq/L
n3 Basic mechanisms:
n Excessive sodium
Iatrogenic, intentional salt poisoning, hyperaldosteronism
n Water deficit
Diarrhea, emesis, lactulose, burns
n Water and sodium deficits
GI losses, renal losses, cutaneous losses
 Hypernatremia
n Clinical manifestations:
n Signs of dehydration
n Irritable, restless, weak and lethargic

n Very thirsty, even with nausea

n Brain hemorrhage- most devastating

consequence; decrease in brain volume causes
tearing of blood vessels → seizures and coma
n Thrombotic complications due to hypercoagulability:
strokes, peripheral thrombosis, RVT
 Hypernatremia
n Diagnosis:
n History and PE
n Urine osmolality

n Treatment:
n Important NOT to correct too rapidly.
n Rate: <12 mEq/L in 24 hrs, or 0.5 mEq/L per
hour
n Restoration of intravascular volume with isotonic
fluid
Review of the Tonicity of IV Fluids
and their respective actions:
HYPOTONIC ISOTONIC HYPERTONIC
(Pulls fluid out of the (Primarily remains in the (Returns fluid to the
intravascular space) intravascular space) intravascular space)
D5NM D5LR D10W
D5IMB PLR D50W
D5W D5NSS
D5 0.3NaCl PNSS
 Hyponatremia
n Sodium concentration of < 135 mEq/L
n Classification of Hyponatremia:
* Based on the patient’s volume status
nHypovolemic hyponatremia
Excess hypotonic IV, child abuse, diluted formula
nEuvolemic hyponatremia
SIADH, water intoxication
nHypervolemic hyponatremia
CHF, cirrhosis, Nephrotic syndrome, renal failure
 Hyponatremia
n Treatment:
Important to avoid “overly rapid” correction
→ leads to CPM (Central Pontine
Myelinolysis) → neurologic symptoms like
confusion, agitation, flaccid or spastic
quadriparesis, death

n Based on the pathophysiology of the specific

etiology
 Computation of Sodium Deficit
n Eg. 2.5 kg child with Na+ of 123
n Deficit: (Desired- Actual) X Weight X 0.6
(135- 123) X 2.5 X 0.6
= 18 mEqs
n Maintenance: 2-4 mEq/kg
2 mEq X 2.5 kg = 5 mEqs

n Total: 18 mEqs + 5 mEqs = 23 mEqs

 Composition of IV Solutions
*Choose the IV Fluid with the highest Na content to correct the deficit

Na K Cl
D5 LR 130 4 109
D5 0.3NaCl 51 51
D5 0.45NaCl 77 77
D5 0.9NaCl (NSS) 154 154
D5 NR 140 5 98
D5NM 40 13 40
D5 IMB 25 20 23
* mEqs per liter of solution
Computation of Sodium Deficit
n Having chosen NSS with Na of 154 meqs/L,
compute using ratio and proportion.

154 mEqs = X (X is the mEqs given during initial hydration)

1000 cc 100 cc (volume given during initial hydration)

where did this come from?

 2.5 kg child with Na+ of 123
1. Restore intravascular 20 ml X 2.5 kg= 50 ml over 20 mins
volume (20 mL/kg)
2. Rapid volume 20 ml X 2.5 kg= 50 ml over 2 hours
repletion (20 mL/kg)
3. Calculate 24- hr water Maintenance: 100 (2.5 kg)= 250 ml
needs Deficit: 10% X 2.5 kg= 0.25L or 250 ml
(Maintenance + Deficit) TOTAL: 500 ml
4. Calculate 24-hr
electrolyte needs
5. Select an appropriate 500 ml divided by 2= 250 ml
fluid
250ml- 100 ml= 150 ml in 8 hrs (18.75ml/hr)
(Give half in 8 hrs, less
the bolus given; then The remaining 250 ml will be given in 16 hrs
give remaining in 16 hrs (9.3 ml/hr)
Computation of Sodium Deficit
n Use NSS (154 mEqs/L), using ratio and
proportion:
154 mEqs = X (mEqs given during initial hydration)

1000 cc 100 cc (volume given during initial hydration)

n Then, cross- multiply:
X= 154(100) divided by 1000 = 15.4 mEqs
n BUT.. remember that your total computed Na
deficit is 23 mEqs…. How do you give the
remaining deficit?
 Computation of Sodium Deficit
n Give remaining as D5IMB (the usual IV fluids used in the
ward) with 25 mEqs/L of Na:
25 mEqs = X (mEqs Na given during 24 hr correction)

1000 400 cc (volume given during 24 hr correction)

n Then, cross- multiply:
X= 25 (400) divided by 1000 = 10 mEqs

n Total: 15.4 mEqs + 10 mEqs = 25.4 mEqs

(which is close to total deficit of 23 mEqs)
 POTASSIUM (K+)
n The dominant cation in the ICF
n Normal values: 3.5- 5.1 mEqs/L
n Majority is in the muscle
n Maintained by the Na+K+ATPase system
n Necessary for the electrical responsiveness of
nerve and muscle cells, and for the contractility
of cardiac, skeletal and smooth muscles
 Hyperkalemia
n Potassium concentration of > 5.1 mEq/L
n One of the most alarming electrolyte abnormalities
because of the potential for lethal arrythmias
n Basic mechanisms:
n Spurious hyperkalemia (pseudohyperkalemia)
n Increased intake

n Transcellular shifts

n Decreased excretion
 Hyperkalemia
n Clinical manifestations:
Most important effects are on membrane
polarization, esp in the cardiac conduction system
- ECG changes: peaking of T waves
- ventricular fibrillation, asystole
- paresthesias, weakness, tingling
 Hyperkalemia
n Treatment has two basic goals:
(1) to stabilize the heart to prevent life-threatening
arrhythmias and,
(2) to remove potassium from the body.
n Hyperkalemic regimen: (to remove K from the body)
n Calcium gluconate- stabilizes the cell membrane
n Salbutamol/ Albuterol nebulizations

n Sodium polystyrene gluconate (Kayexalate)-

exchange resin
n Insulin

n Dialysis
 Hypokalemia
n Potassium concentration of < 3.5 mEqs/L
n Common in children, most cases related to
gastroenteritis
n Basic mechanisms:
n Spurious

n Transcellular shifts
n Decreased intake

n Extra-renal losses

n Renal losses
 Hypokalemia
n Clinical manifestations:
ECG changes: flattening of T-waves,
depressed ST segment, appearance of a u-wave
Muscle weakness and cramps, paralysis
Chronic: kidney damage

n Treatment:
n Oral or IV potassium
Computation of Potassium Deficit
* E.g. 10 kg child with K+ of 2.44

nDeficit:
(Desired- actual) X weight X 0.4
( 4.5 – 2.44) X 10 X 0.4
= 8.4 mEq
nMaintenance: weight X 3

10 kg X 3 = 30 mEq

n Total: 8.4 mEqs + 30 mEq = 38.4 mEq

 Composition of IV Solutions
*Choose the IV Fluid with the highest K content to correct the deficit

Na K Cl
D5 LR 130 4 109
D5 0.3NaCl 51 51
D5 0.45NaCl 77 77
D5 0.9NaCl 154 154
D5 NR 140 5 98
D5NM 40 13 40
D5 IMB 25 20 23
* mEqs per liter of solution
Computation of Potassium Deficit
n Observe the table of IV Solutions (previous slide)
n Notice that some fluids do not contain K

n These are the fluids used for resuscitation- why do

they not have K?
n Because you don’t know yet if the kidney is
functioning or not. If not, excess K cannot be
eliminated from the body → hyperkalemia →
DEATH!
n Therefore, IV fluids for resuscitation are non- K
containing.
 Computation of Potassium Deficit
* D5 IMB has 20 mEq/L
nEx: Child is already up at the ward, hooked to
D5IMB at a given rate of 45 cc/hr:
45 cc/hr X 24 hrs = 1080 cc
n Then, multiply total fluid with mEqs K in IVF:

1080 cc X 20 mEqs/L = 21.6 mEq

nBut remember: TOTAL DEFICIT is 38.4 mEq
- 21.6 mEq = 16.8 mEq
nTherefore, you still need 16.8 mEqs to correct the
total deficit.. WHAT WILL YOU DO NEXT?
 Correction of Potassium Deficit
n Two choices: give IV or oral Potassium
n Computation is via TRIAL and ERROR

n If through IV: Just remember to keep the Potassium

Infusion Rate (KIR) at 0.1- 0.3 mEq/kg/hr
So, incorporate pure K to D5IMB as follows:
20 mEq + 16.8 mEqs X 45 cc/hr ÷ weight
1000
= 0.16 mEq/kg/hr KIR
Therefore, your K+ correction is within limits.
 Correction of Potassium Deficit

n For trial and error, you may adjust either the

amount of K (eg. 20 mEq) that you will
incorporate (comes in a vial from which you
extract K and inject to the IV fluid), or the IV
running rate (eg. 45 cc/hr) so that you fall
within the KIR.
 Correction of Potassium Deficit

n OR you may opt to give oral supplementation of

KCl (10 mEqs per tab) at a dose of 2- 4 meqs/ kg/
day BID- QID, provided patient is able to take in
oral prep and will not vomit it, or fully conscious
and will not aspirate. In this case, you may give
1 tablet BID.
 Magnesium (Mg+)
n 4th most common cation in the body;
n 3rd most common intracellular cation
n 50- 60% is in bone (serves as a reservoir)
n Normal values: 1.5- 2.3 mg/dL
n A necessary co-factor for hundreds of enzymes
n Important for membrane stabilization and nerve
conduction
n Needed by ATP and GTP
 Magnesium
n Intake
n Green vegetables, cereals, nuts, meats, milk (30- 50%
is absorbed)
n Human milk (35 mg/L) < formula milk (40-70 mg/L)

n Small intestine- major site of absorption (passive)

n Excretion
n Renal excretion- principal regulator of Mg balance;
70% in the TAL of the Loop of Henle
 Hypomagnesemia
n Relatively common in hospitalized patients, but
mostly asymptomatic.
n Causes:
n GI Disorders
n Diarrhea: 200 mg/L Mg; Gastric contents: 15 mg/L
n NGT suctioning, IBD, Celiac disease

n Renal disorders
n Meds: Loop diuretics, mannitol, aminoglycosides
n Diabetes, ATN, chronic kidney diseases

n Miscellaneous causes
n IUGR, infants of diabetic mothers, exchange transfusion
 Hypomagnesemia
n Clinical manifestations:
n Secondary hypocalcemia (impaired release of PTH
by the parathyroid gland; blunting the tissue
response to PTH)
n Tetany, seizures

n Treatment:
n Parenteral Mg (Mg sulfate: 25- 50 mg/kg slow IV)
n Oral Mg (long-term therapy)
 Hypermagnesemia
n Almost always secondary to excessive intake
n Mg present in high amounts in certain laxatives,
enemas, cathartics used in drug overdose
n Usually asymptomatic unless > 4.5 mg/dL
n Inhibits acetylcholine release at the NMJ →
hypotonia, hyporeflexia and weakness, paralysis
n Other S/S: lethargy, sleepiness, poor suck
n ECG changes will also be present
 Hypermagnesemia
n Treatment:
n IV hydration and loop diuretics
n Dialysis, exchange transfusion in severe cases

n Excess Mg rapidly cleared if renal function is intact.

n Acute emergencies: IV calcium gluconate

 Phosphorus
n Most phosphorus is in bone or is intracellular
n Phosphate is the most plentiful intracellular anion,
although the majority is part of a larger
compound (ATP)
n ↑ in childhood: facilitate growth
n Diurnal variation: peak during sleep
n With ATP: Critical for cellular energy metabolism
n With calcium: for skeletal mineralization
 Phosphorus
n Intake
n Milk and milk products (best sources); meat, fish
n Vegetables > fruits and grains

n Small intestine: site of absorption

n Excretion
n Kidneys- regulate phosphorus balance (proximal
tubules)
 Hypophosphatemia
n Age- dependent
n Causes of hypophosphatemia:
n Trans-cellular shifts- insulin, refeeding, tumor
growth
n Decreased intake- nutritional, preterms

n Renal losses-kidney transplant, hyperparathyroidism

n Multi-factorial- alcoholism, sepsis, dialysis

 Hypophosphatemia
n Clinical manifestations:
n Rickets, muscle weakness & atrophy, rhabdomyolysis

n Diagnosis
n Investigate nutrition, medications, familial disease

n Treatment:
n Oral or IV phosphorus
n Increasing dietary phosphorus
 Hyperphosphatemia
n Renal insufficiency- most common cause
n Causes:
n Trans-cellular shifts
n tumor lysis syndrome, DKA
n Increased intake
n enemas, laxatives, treatment of hypophosphatemia
n Decreased excretion
n renal failure
 Hyperphosphatemia
n Clinical manifestations:
n Hypocalcemia, systemic calcification

n Diagnosis:
n Plasma creatinine and BUN
n Hx: intake of phosphorus, chronic diseases

n Treatment:
n Phosphorus binders
STUDY HARD!
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