FLUIDS AND ELECTROLYTES

FOR PEDIATRICS
Natharina Yolanda

FLUIDS
Maintenance Fluid
Replacement Fluid and Deficit
Therapy
Resuscitation Fluid

Maintenance Fluid
Quantity if IV fluids required to maintain
hydration in an euvolemic child without
abnormal ongoing fluid loss
Composed of: water, glucose, sodium, potassium
Do not provide adequate calories, protein, fat,
minerals, or vitamins only for few days
Goals:
Prevent
Prevent
Prevent
Prevent

dehydration
electrolyte disorders
ketoacidosis
protein degradation

Maintenance Fluid (2)

Calculation are based on patients
dry/baseline weight
Solution with 0.45% saline or 0.9%
saline is the preferred maintenance
solution for ill child
Potassium should be withheld until the
patients has satisfactory urine output
The amount of KCl should be
individualized

Maintenance Water

Maintenance Glucose
Mainttenance fluid usually contain
D5 (17 cal/100 mL) or 20% of caloric
needs
Enough to prevent ketoacidosis and
protein degradation

Selection of Maintenance
Fluid
For children with normal homeostatic
mechanisms:
< 10 kg: D51/4NS + KCl 20 mEq/L
Children > 10 kg: D51/2Ns + KCl 20 mEq/L
Surgical patients:
Isotonic fluids during surgery and 6-8 hr
postoperatively
Rate is 2/3 calculated maintenance rate

Variations
Source of water loss: urine 60%, IWL 35%, stool
5%
Fever: 10-15% increase in maintenance water
for each 1C increase temp above 38C
Adjustments
Skin: radiant warmer, phototherapy, fever, sweat,
burns
Lungs: tachypnea, tracheostomy
GI: diarrhea, emesis, nasogastric suction
Renal: polyuria
Etc: surgical drain, third spacing

Replacement Fluids for Ongoing

Loss
Average composition of diarrhea
Sodium: 55 mEq/L
Potassium: 25 mEq/L
Bicarbonate : 15 mEq/L

Deficit Therapy
To replace dehydration
Assess degree of dehydration first
(estimation)
Laboratory adjuncts:
Bicarbonate serum
Anion gap
Electrolytes
Ureum, creatinine
Hb, Ht

Examination

Older Child
3% (30 mL/kg) 6% (60 mL/kg) 9% (90 mL/kg)
Infant
5% (50 mL/kg)
10% (100
15% (150
mL/kg)
mL/kg)

Dehydration
Skin turgor
Skin (touch)
Buccal
mucosa/lips
Eyes
Tears
Fontanelle
CNS

Mild
Normal
Normal
Moist

Moderate
Tenting
Dry
Dry

Severe
None
Clammy
Parched/cracked

Normal
Present
Flat
Consolable

Deep set
Reduced
Soft
Irritable

Pulse rate

Normal

Sunken
None
Sunken
Lethargic/obtund
ed
Increased

1 % dehydration

Slightly
=increased
10 mL/kg

WHO

 Ongoing-loss replacement

An Example of Approach
Restore intravascular volume: NS 20 mL/kg over
20 min
Rapid volume repletion: 20 mL/kg NS or RL over
2 hr (max 1 L)
Calculate 24-hr fluid needs: maintenance +
deficit volume
Subtract isotonic fluid already administered from
24-hr fluid needs
Administer remaining volume over 24 hr using
D51/2NS + 20 mEq/L KCl
Replace ongoing losses as they occur

Monitoring
Vital signs
Pulse
Blood pressure

Intake and output

Fluid balance
Urine output

Physical examination
Weight
Clinical signs of depletion or overload

Electrolytes

Resuscitation Fluid
Start 20 ml/kg NS 0.9% as quickly as possible
(<20 min)
Consider colloid if more than 40 60 ml/kg are
required to normalize perfusion
Smaller (5-10 ml/kg) and slower bolus in
neonates, severe anemic shock, or cardiogenic
shock
Frequent monitoring
Infants at risk of hypoglycemia dextrosecontaining fluids after initial resuscitation
DONT: infuse fluid bolus over 1 hour

Resuscitation Fluid in Shock

Regardless of the type of shock,
some degree of hypovolemia is
usually present IV fluid should
always be considered

FLUID THERAPY IN
SPECIAL CONDITIONS

Rehydration in Malnutrion
REDUCED WHO ORS

ReSoMal

Glucose (mmol/L)

75

125

Sodium (mEq/L)

75

45

Potassium (mEq/L)

20

40

Chloride (mEq/L)

65

70

Citrate (mmol/L)

10

Osmolality (mOsm/L)

245

224

Magnesium/Zinc/Copp
er (mmol/L)

3/0.3/0.45

Dengue

Neonates
Initial Fluid Therapy
Fluid Rate (mL/kg/day)
Birth
Weight

Dextrose

< 24 hr

24-48 hr

>48 hr

<1 kg

5-10

100-150

120-150

140-190

1 1.5 kg

10

80-100

100-120

120-160

> 1.5 kg

10

60-80

80-120

120-160

ELECTROLYTE
ABNORMALITIES

Electrolyte Abnormalities Sodium

Hyponatremia
Serum Na < 135 mEq/L
water intake, water retention, sodium
loss
Euvolemia, hypervolemia, or hypovolemia
Symptoms: irritability, poor feeding, nausea,
vomiting, lethargy, seizure, coma, death
Urgent treatment in:
Neurological changes
Seizure
Level < 120 mEq/L

Electrolyte Abnormalities Sodium

(2)
Goal: raise serum Na level to 120 125 mEq/L
or until seizure stop
First Step (fast correction)
NaCl 3% via central line over 15 20 min
1.2 mL/kg NaCl 3% (0.6 mEq/kg) will raise Na
serum by 1 mEq/L
4 mL/kg NaCl 3% resolution of symptoms

Second Step (slower correction)

Raise the Na level an additional 12 mEq over the
next 24 hr from the current 120 mEq/L
0.6 x (weight in kg) x (delta Na)

Electrolyte Abnormalities Sodium

(3)
Hypernatremia
Serum Na > 145 mEq/L
Too much salt ingestion or free water
loss
Infant, toddler, critically ill patients
Sings: irritability, high-pitched cry,
lethargy, seizures, fever, renal failure,
rhabdomyolisis
Correct slowly, no more than 0.5
mEq/L/hour or 12 mEq/L/day

Electrolyte Abnormalities Sodium

(4)
The amount of free water to correct hypernatremia:
Free water deficit =
(weight in kg x 0.6) x 1 (desired Na/actual Na) (1000 mL/L)

4 mL/kg of free water will drop the Na by 1 mEq/L

Free water deficit = 4 x (weight in kg) x (delta Na)

Free water = water without sodium

NS = no free water, 1/2NS = 50% free water, water
= 100% free water
1 L of D5 NS will provide 400 mL of free water
and is good starting point

An Approach to Hypernatremic
Dehydration
Restore intravascular volume: NS 20 mL/kg over
20 min
Determine time for correction
Na
Na
Na
Na

145-157
158-170
171-183
184-196

:
:
:
:

24
48
72
84

hr
hr
hr
hr

Administer fluid at constant rate over time

D51/2NS + KCl 20 mEq/L
Rate: 1.25 1.5 times maintenance

Follow-up sodium concentration

 Adjust
Sign of fluid depletion: NS
Sodium decrease too rapidly
Increase sodium concentration of IV fluids
Decrease rate of IV fluids

Sodium decrease too slowly

Decrease sodium concentration of IV fluids
Increase rate of IV fluids

Electrolyte Abnormalities
Potassium
Hypokalemia
Potassium level < 3.5 mEq/L
Inadequate intake, renal loss, GI loss,
metabolic alkalosis
Signs: fatigue, parasthesias, ECG
changes
Asymptomatic dietary replacement
Supplement of 1 3 mEq/kg/day orally in 34 divided dose

Electrolyte Abnormalities
Potassium (2)
Conservative protocol for IV replacement
K 3 3.5 mEq/L 0.25 mEq/kg IV KCl over 1 hour
K 2.5 3 mEq/L 0.5 mEq/kg IV KCl over 2 hours
K < 2.5 mEq/L 0.75 mEq/kg IV KCl over 3 hours

Administer KCl IV in single replacement dose

of no more than 0.5 mEq/kg/hour, max dose
10 mEq over 1 hour
Via central line or large-bore IV with ECG
monitoring

 Total Potassium Replacement:

deficit+maintenance
Deficit= (delta K) x weight x 0.1 x 50
Maintenance = 2 mEq/kg
Maximal concentration
Peripherally: 6 mEq/100 ml
Central: 8 mEq/100 ml

Potassium Infusion Rate

((mEq x fluid rate): weight):100
Normal: 0.2 0.3

Electrolyte Abnormalities
Potassium (3)
Hyperkalemia
K level > 5.5 mEq/L
Can be life-threatening
Renal failure, hypoaldosteronism,
adrenal insufficiency, metabolic
acidosis, rhabdomyolisis, burn, crush
injury, tumor lisis syndrome
Common cause of false elevation of K:
hemolysis from heel-stick blood
sampling or tourniquet use
Sign: arrhythmias, weakness,

Electrolyte Abnormalities
Potassium (4)
Symptomatic hyperkalemia urgent therapy
Cardio monitor and obtain 12-lead ECG
Recheck to confirm hyperkalemia
Discontinue any exogenous potassium
Administer one of the following:

Calcium gluconate
Sodium bicarbonate
Insulin-dextrose infusion
Albuterol
Sodium polystyrene resin
Or emergency hemodyalisis

Electrolyte Abnormalities Calcium

Hypocalcemia
Total calcium < 2.12 mmol/L or ionized calcium
< 1 mmol/L
Low dietary intake, lack of vitamin D or PTH
Common in critically ill pt, whom also tend to
hypoalbuminemic
If available, evaluate ionized calcium
Signs: tetany, irritability, hyper-reflexia,
weakness, paresthesias, fatigue, stridor,
laryngospasm, hypotension, bradycardia,
arrhythmias

Electrolyte Abnormalities Calcium

(2)
Therapy
Large-bore IV or central venous
Do not administer via scalp veins, IM, or SC
Indications for IV calcium: hypocalcemia,
hyperkalemia, ca-channel blocker overdose,
hypermagnesemia, and post-arrest stabilization
Ca Gluconate 10% = 0.45 mEq/mL of ionized ca
Neonate: 50 200 mg/kg IV over 5 10 minutes
Infants and children: 50 125 mg/kg IV over 5 10
minutes

Electrolyte Abnormalities Calcium

(3)
Hypercalcemia
Total calcium > 2.75 mmol/L or ionized
calcium > 1.3 mmol/L
Prolonged immobility,
hyperparathyroidism, malignancies,
excessive vit A or D, granulomatous
disease
Hypertension, decreased level of
consciousness, irritability, lethargy,
seizure, coma, nausea, vomiting,
abdominal pain

Electrolyte Abnormalities Calcium

(4)
Hydration with IV isotonic saline at
200 250 mL/kg/day + furosemide
induced diuresis 1 mg/kg IV every 6
hours
Calcitonin
Alternatives: aspirin, indomethacin,
glucocorticoids