FLUIDS AND ELECTROLYTES

Physiology of Fluids and Electrolytes

Scope:

ELECTROLYTES
❖ Sodium
❖ Potassium
❖ Calcium
❖ Magnesium
❖ Chloride
❖ Phosphorus
ACID BASE BALANCE
Why are children more prone to fluid and electrolyte problems?

1. Higher metabolic rate relative weight (2x over adult)

2. Larger skin surface area to body weight ratio
3. Immaturity of kidneys
4. Higher respiratory rates
5. Tend to loss more, proportionate to body weight
General Considerations

❖ Total amount of water and electrolytes as a whole

❖ Water and solutes in various compartments
❖ Water is largest single component of the body making up
to 45-75% of total body mass
❖ Concentration of solutes within its compartment
 Neonate Infant 1 year old Adolescent
(% body weight) (% body (% body weight) (% body weight)
weight)
TBW 23-37 wk AOG-85-90
28-32 wk AOG-82-85 ≈ 70 ≈ 60 ≈ 60 male
36-40 wk AOG- 71-76 ≈ 55 female

Extracellular fluid 23-37 wk AOG-60-70

28-32 wk AOG-50-60 ≈ 70 ≈ 55 ≈ 30
36-40 wk AOG- ≈ 40 ( 75%-interstitial)
( 25%-
intravascular)
Intracellular fluid 23-37 wk AOG-30-40
28-32 wk AOG-40-50 ≈ 30 ≈ 45 ≈ 70
36-40 wk AOG- 60

Transcellular fluid ≈2.5 ≈2 ≈ 1.8 ≈ 1.7

Fluid Balance

❖ 2 barriers separate ICF, interstitial fluid and plasma

❖ Plasma membrane separates ICF from
surrounding interstitial fluid
❖ Blood vessel wall divide interstitial fluid from plasma
❖ Body is in fluid balance when required amounts of water
and solutes are appropriately present and correctly
proportioned among compartments
 Intracellular
(30-45%)
Fluid Compartments
– Infant 1 year old

Interstitial
(45-35%) Extracellular
( 70-55%)

Plasma
(25-20%)
Fluid Balance

❖ Electrolyte- an inorganic substance that dissociates

into ions in solution is called an
❖ Processes of filtration, reabsorption, diffusion, and
osmosis make continuous exchange of water and
solutes among compartments
ICF differs considerably from ECF

❖ ECF most abundant cation is Na+, anion is Cl-

❖ ICF most abundant cation is K+, anion are proteins and
phosphates
❖ Na+ /K+ pumps play major role in keeping K+ high
inside cells and Na+ high outside cell
ECF

❖ Sodium (Na+)
❖ Most abundant ion in ECF
❖ 90% of extracellular cations
❖ Plays pivotal role in fluid and electrolytes balance because it account for
almost half of the osmolarity of ECF
❖ Level in blood controlled by
❖ Aldosterone- increases renal reabsorption
❖ ADH-if sodium too low, ADH release stops
❖ Atrial Natriuretic Peptide- increases renal secretion
ECF

❖ Chloride Cl-

❖ Most prevalent anions in ECF

Regulate osmotic pressure, forming HCl in gastric
acid
❖ Controlled indirectly by ADH and processes that
affect renal reabsorption of sodium
ICF

❖ Potassium K+
❖ Most abundant cations in ICF
Key role in establishing resting membrane potential in neurons and muscle
fibers
❖ Maintain normal ICF fluid volume
❖ Regulate pH of body fluids when exchanged for H+
❖ Controlled by aldosterone
ICF

❖ Bicarbonate HCO3-
❖ Important plasma ion
❖ Major member of the plasma acid-base buffer
system
❖ Kidneys reabsorb or secrete it for final acid-base
balance
ICF

❖ Calcium Ca2+
❖ Structural component of bones and teeth
❖ Used for blood coagulation, neurotransmitter release, muscle
tone, excitability of nerves and muscles
❖ Level in plasma regulated by parathyroid hormone
ICF

❖ Phosphate
❖ Occurs as calcium phosphate
❖ Used in the buffer system
❖ Regulated by parathyroid hormone and calcitriol
ICF

❖ Magnesium
❖ An intracellular cation
❖ Activates enzymes involved in carbohydrates and protein
metabolism
❖ Used in myocardial function, transmission in the CNS and
operation of the sodium pump
Regulation of Osmolality and Volume
Regulation of Osmolality

• PLASMA OSMOLALITY = 275-295 mOSM/ kg

• Involved: osmoreceptors primary osmoles:
volume receptors Sodium

hypothalamus Glucose
posterior pituitary Urea
collecting ducts of nephron
Osmolality

• Hyperosmolality: • Hypo-osmolality:
– intake= decreased – excess water
– excretion= increased – body solutes
– a combination of the two
– solute
• Causes:
• Causes: – SIADH
– diabetes insipidus – salt-losing nephropathy
– osmoreceptor dysregulation – diuretic use
– acute tubular necrosis – mineralocorticoid deficiencies
– burns – GI illnesses
– GI-illness – nephrotic syndrome
– heart failure
– iatrogenic causes
– cirrhosis
Body Water Regulation

❖ THIRST
❖ Conditions that generate thirst
❖ Plasma osmolality raised by 1-2 %
❖ Volume depletion
❖ Renin-angiotensin stimulation
Body Water Regulation

Sources of water loss

Excretion
Urine: 60%
Insensible losses: 35% (Skin and lungs)
Stool: 5%
BODY WATER REGULATION

Volume of urine is regulated by:

1. Plasma osmolality (neuro-hypophyseal-renal
axis)
2. GFR
3. Renal tubular epithelium
4. Plasma adrenal steroids
 Electrolytes

and

Acid-base Balance
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Sodium - Dominant 135 to 145 mEq/L - Dehydration - Brainstem

cation of the ECF - CNS herniation
- Principal symptoms and apnea
determinant of - Irritable, - Lethargy
extracellular restless, - Confusion
osmolality weak and - Agitation
- Maintenance of lethargic - Seizures
intravascular - High- - Muscle
volume pitched cry cramps
- Hyperpnea and
- Brain weakness
hemorrhage - rhabdomyolys
is

Electrolytes
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Potassium - Principal intra- 3.5 to 5.5 mEq/L - Paresthesia - Ventricular

cellular cation - Fasciculation fibrillation
- Weakness - Torsades de
- Necessary for - Ascending pointes
electrical paralysis - Digitalis-
responsiveness of - Peak T waves induced
nerve and muscle - ST-segment arrythmias
cells and depression - Flattened T-
contractility of - Increased PR wave
interval - Depressed ST
cardiac, - Flattening of P segment
skeletal and wave - Presence of U
smooth muscle - QRS wave
widening - Muscle
weakness
&paralysis

Electrolytes
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Calcium - Supports the - 4-7days: 2.25 – 2.73 - Bone pain - Irritability

mmol/L - Paresthesia
structure and - Child: 2.20 - 2.70 - Arrythmia
- Seizures
hardness of mmol/L - Cardiac -
- Thereafter: 2.10 to 2.55 Broncho-
bone and teeth mmol/L arrest spasm
- Nerve and - Kidney - Laryngo-
muscle function stone spasm
- Cardiac - Muscle - Heart
automaticity weakness failure
- Muscle
- Excessive cramps
urination
- Short QT
interval

Electrolytes
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Magnesium - Protein- 1.7 to 2.2 mg/dL - Lethargy - Tetany

synthesis 0.85 to 1.10 - Sleepiness - Chvostek
mmol/L
- Nerve & muscle - Poor suck and
function - Hypotension Trousseau
- Blood glucose - Prolonged PR signs
control interval, QRS - Seizures
- Blood pressure interval and QT - Arrythmia
regulation interval - Flattening of
T wave
- Lengthening
of ST
segment

Electrolytes
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Chloride - Major extra- 98 to 106 mmol/L - Severe - Diarrhea

cellular anion dehydration - Weakness
- Maintenance - Kidney - Difficulty of
osmotic failure
pressure, acid base - Traumatic breathing
balance and brain injury - Tachy-
electrical neutrality cardia
- Involved in - Hypotension
chloride shift - vomiting

Electrolytes
 Electrolytes Function Normal values Excess s/sx Deficit s/sx

Phosphorus - Cell signaling & 3.4 to 4.5 mg/dL - Hypoxia - Rickets

nucleic acid 1.12 to 1.45 mmol/L from - Proximal
muscle
synthesis pulmonary
weakness &
- Skeletal calcification atrophy
mineralization - Renal - Rhabdomyolysis
failure from - Cardiac
nephron- dysfunction
- Tremor
calcinosis - Paresthesia
- Ataxia
- Seizures
- Delirium
- Coma

Electrolytes
Acid-base Balance

❖ Chronic, mild derangement – interfere with normal growth and

development
❖ Acute, severe derangement – fatal
❖ Control of acid-base balance:
❖Kidneys
❖Lungs
❖Intracellular fluids
❖Extracellular fluids
Acid-base Balance

❖ Arterial blood gas

❖Values:
❖ pH: 7.35 – 7.45

❖ pCO2: 35 to 45 mmHg

❖ HCO3: 22 to 28 mEq/L

❖ pO2: 80 to 100 mmHG

Acid-base Disorders

❖ Metabolic Acidosis
❖ Metabolic Alkalosis
❖ Respiratory Acidosis
❖ Respiratory Alkalosis
MAINTENANCE DEFICIT THERAPY
 Goals:
1. To correct fluid loss
2. To correct osmolality = sodium
3. To correct other electrolyte losses
4. To correct acid-base imbalance
Fluid Therapy

MAINTENANCE
 Normal maintenance - replace normal losses
 Active maintenance - replace ongoing abnormal losses
DEFICIT
 Replaces PREVIOUS losses
 This is when the patient develops the signs and
symptoms of dehydration
Maintenance (Normal and Active)
Goal: Maintain normal body water content
 How?
1. Replace normal obligatory losses
2. Replace ongoing abnormal losses
3. Prevent dehydration from occurring even in the presence of ongoing abnormal losses
 Additional goals of maintenance fluids therapy:
1. Prevent electrolyte disorder
2. Prevent ketoacidosis
3. Prevent protein degradation
 Composition of a good maintenance fluid:
1. Water
2. Glucose
3. Sodium
4. Postassium
* Glucose in D5 concentration provides 17 calories/100ml and nearly 20% of
the total daily caloric need enough to prevent ketone production and protein
degradation

A patient receiving maintenance intravenous fluids is receiving inadequate
calories and will lose 0.5 - 1% of weight each day
Methods in computing maintenance fluid
❖ Holiday-Segar
❖ Ludans
❖ Crawford
Normal Maintenance Therapy - Holiday-Segar Method

For row 2: If a child is 10.5 kg, use ROW 2. Thus,1000 ml/24 hrs + (50 ml x 0.5).
The result is 1025ml/24 hrs for a 10.5 kg child
Normal Maintenance Therapy - Holiday-Segar Method

Reminder:
For obese patients, there might be an overestimation of the normal maintenance volume
Instead, base calculation on:
a. Lean body weight: 50th percentile weight for height OR
b. Median Z-score of the weight for length/height OR
c. Use the ceiling: 2400 ml/24 hrs
Sample Case

❖ A 4 year old female is admitted for an appendectomy and

was placed on NPO. Weight is 16kg and height is 103cm.
Patient has no signs of dehydration

❖ Calculating DAILY NMF:

❖ 1000mL + (6 x 50mL/kg) = 1300mL/Day

❖ Calculating HOURLY NMF:

❖ 40mL/hr + (6 x 2mL/kg/hr) = 52mL/hour
END