pedia Alhamdollilah Fluids

8/6/2019 pedia Alhamdollilah Fluids

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Gimnaste Glenn Paquit Adajar

Medicine III


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TBWTBW ICFICF ECF ( ISF + PV)ECF ( ISF + PV)

NewbornNewborn 7575 80 %80 % 40 %40 % 3030 35%35%

Infants/Infants/

ChildrenChildren

65%65% 40%40% 25 % ( 16 + 9)25 % ( 16 + 9)

AdultAdult 60%60% 40%40% 20%20%


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The infant is more prone to suffer from

disturbances of hydration and acid-base

balance due to the ff.:

1. Infant has higher metabolic rate

which results in a greater turnover of

water


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2. Infant has a larger skin surface area (2-3x

the adult) in relation to the volume of his

total body water. Infants body water isdepleted more rapidly.

3. Infant is more prone to greater loss offluid.


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4. Immaturity of the infants kidneys

predisposes to hydration, and acid-

base balance.


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Non-ionized molecules:

Glucose

Urea

Lipids

Electrolytes:

Cations Anions


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SERUM INTERSTITIALFLUID

INTRACELLULARFLUID

CATIONS

Sodium 140 mEq/L 138 mEq/L 9mEq/LPotassium 5 8 155

Calcium 5 8 4

Magnesium 4 6 32

Total 154 mEq/L 160mEq/L 200mEq/L

ANIONS

Chloride 100mEq/L 119mEq/L 5 mEq/L

Bicarbonate 26 26 10

Protein 19 7 65

Organic Acids 6 6 -

HPO4 2 1 95

SO4 1 1 25

Total 154mEq/L 160mEq/L 200mEq/L


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Multiply serum sodium concentration by 2

Example: 145 mEq/L Na x 2 = 290 mOsm/L

Normal: 280-300mOsm/L

.: approximately 10mOsm/L come from bloodglucose and urea nitrogen contributing

5mOsm/L each


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HYPERTONIC- Na > 150 mmol/L

HYPOTONIC Na < 130 mmol/L

ISOTONIC Na = 135-145 mmol/L


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Cell shrinkage

Negative pressure in the cranium

increases Subarachnoid vessels rupture

Hyperirritability

Convulsions Residual neurological damage


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Cell edema in the CNS Somnolence Coma Convulsions

Shock


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There is an equal or

proportional loss of waterand electrolytes without a

change in the waterdistribution between the twofluid compartments


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Rehydration phase Deficit therapy

Immediate correction of the abnormal losses offluid and electrolytes

Accomplished within 6 hours Maintenance phase

Normal maintenance and active replacementtherapy

Stabilize the internal milieu after it has beenrestored to normal during the rehydration phase


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Is employed to maintain or restore the

normal volume & composition of body

fluids Goal: to normalize the intracellular &

extracellular chemical environments

that optimize cell & organ function


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Dimensions offluid therapy

Maintenance Phase

NormalMaintenance(Normal daily

requirement of water)

Active Replacementtherapy ( activereplacement of

continuing losses)

Rehydration Phase

Deficit therapy


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Following should be corrected:

1. Fluid loss

2. Osmolality or sodium ion disturbance3. Other electrolyte disturbances like potassium,

magnesium, calcium, etc.

4. Acid-base imbalance


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In most instances, computation of weightloss is difficult due to no record of infantor childs previous weight.

However, estimation to the degree ofdehydration can be assessed based onfairly evident clinical criteria.

FLUIDLOSS

WeightLOSS


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Degree of

Dehydration

Infant

(%

weight

lo

ss)

Children

(% weight

loss)

Clinical Features

MILD 5% 3% Sunken eyes; depressed

anterior fontanelle; dry skin,

lips, and tongue; mild oliguria

MODERATE 10% 6% Early shock: loss ofskin

elasticity and turgor (+ skin fold

test): pale, mottled skin;

collapsed neck veins; marked

enophthalmos; markedoliguria; unstable vital signs

SEVERE 15% 9% Late shock: patient is dying or

moribund


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ISOTONIC HYPOTONIC HYPERTONIC

SKIN Cold and dry; poor

elasticity and turgor

Cold and clammy;

very poor elasticity

and turgor

Warm, velvety, and

doughy normal to

slightly poor

LIPS &TONGUE

dry Clammy or moist;

presenceof

hypersalivationand

sheddingoftears if

serum sodium is 110mEq/L or less

Parched; patient

complainsofextreme

thirst

CNS lethargic comatose,;occasionallywith

generalized

convulsions

Lethargicwhenundisturbed;

hyperirritable when

aroused; focal or

generalized seizures;increase muscle tone

and tendon reflexes;meningismus

VITAL SIGNS Normal to low

temperature; normal to

low BP rapid PR

Very low

temperature; BP;

in shock; threadypulse

Febrile temperature;

normal BP; normal to

slightly increased PR


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Degreeofdehydration

MILD

Volumeoffluid

Mannerofadministra

tion

Isotonic Hypotonic Hypertonic

INFANTS

CHILDREN

5%wt. loss

3%wt. loss

50mL/kg

30mL/kg

1st 6hours

0.3%NaClin D5W

(50mmol/L NaCl)

0.45%NaCl in

D5W(75mmol/

L NaCl)

Deficit,maintenance and

replacement are

combinedand givenand given

in 48

hours as0.15%

NaCl inD5W


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Degreeofdehydration

MODERATE

Volumeoffluid

Mannerofadministra

tion


INFANTS

CHILDREN

10% wt. loss

6% wt. loss

100mL/kg

60mL/kg

1st hour. oftotal

Next 5-6

hours: orremainder

ofdeficit

Ringerslactate or

acetate in

D5W

After the

initialhydrating

solutionfollowwith

IV fluid asabove:

0.3% NaClin D5W

Ringerslactate or

acetate in

D5W

Follow

with 0.45%NaCl

(mix 1 partof0.3%

NaCl to 1

part plain

D5W tomake

0.15% NaClin D5W)


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Degreeofdehydration

SEVERE

Volumeoffluid

Mannerofadministra

tion


INFANTS

CHILDREN

15%wt. loss

9% wt. loss

150mL/kg

90mL/kg

1st hour.1/3 oftotal

Next 5-6

hours: 2/3or

remainderofdeficit

Ringerslactate in

D5W

0.3% NaCl

in D5W

Ringersacetate in

D5W

0.45%

NaClIn D5W

(mix 1 partof0.3%

NaCl to 1

part plain

D5W tomake

0.15% NaClin D5W)


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After the patient has voided, add 20-

30mEq/L ofKCl to IV fluid for maintenance

po

tassium requirement. In hypernatremiaand in the presence ofhypokalemia (ileus,

muscle weakness, and ECG changes)

administer 40-50 mEq/L ofKCl. For

hypokalemia, maintain a constant

concentration ofpotassium for 3-4 days.


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Basal caloric expenditure

(calories/kg/24hrs) x bodyweight (in kg) x 1.5 mL/calorie

= total amount


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Goals:

Prevent dehydration

Prevent electrolyte disorders Prevent ketoacidosis

Prevent protein degradation


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-designed to replace usual losses of fluid &

electrolytes

-based on measured or estimatedcontinuing abnormal losses

F

luid is continually lost from the body inthe form ofinsensible water losses (skin

and lungs) and urinary loss.


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Replaces urine, water and sweat lossand therefore avoid the developmentof dehydration and deficiencies ofsodium and potassium

Maintenance Fluid Requirement

amount ofFluid required to keep thebody fluid in BALANCE .


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Newborn = 45-50 calories/kg/24hrs

3-10 kg = 60-80

10-15 kg = 45-6515-25 kg = 40-45

25-35 kg = 35-40

35-60 kg = 30-35over 60 kg = 25-30


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Estimate Fluid Deficit

(Mild, Moderate, Severe = % weight loss)

FindType ofDehydration

(Isotonic, Hypotonic, Hypertonic)

Give daily Maintenance


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A 5kg infant developed severe diarrhea withvomiting. On physical examination, the followingclinical features were noted: weak and lethargic butarousable; deeply depressed anterior fontanelle andsunken eyes; pale and mottled skin which felt coldand dry with positive skin fold test indicating poorskin turgor and elasticity; collapsed neck veins.Patient had no urine output for over 12 hours andthe V/S showed temperature of36.8C, pulse rate of160/min,BP ofless than 60mmHg (flush method)and respiratory rate of45/min describes as deep andrapid.


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Degreeofdehydration

MODERATE

Volumeoffluid

Mannerofadministra

tion


INFANTS

CHILDREN

10% wt. loss

6% wt. loss

100mL/kg

60mL/kg

1st hour. oftotal

Next 5-6

hours: orremainder

ofdeficit

Ringerslactate or

acetate in

D5W

After the

initialhydrating

solutionfollowwith

IVfluid asabove:

0.3% NaClin D5W

Ringerslactate or

acetate in

D5W

Follow

with 0.45%NaCl

(mix 1 partof0.3%

NaCl to 1

part plain

D5W tomake

0.15% NaClin D5W)


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1ST 6 HOURS

TOTAL FLUIDVOLUMETO BEGIVEN =

100mL/kg for 10% weight loss Fluid deficit = 100mL/kg x 5kg = 500 mL

Given: 25 ml/kg or 125 mL in 1 hr as Ringerslactate or acetate solution

75 mL/kg or 375mL as 0.3% NaCl inD5W inthe next 5 hours (ISOTONIC)


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After the patient has voided, add20-30mEq/L of potassium to theparenteral fluid or in the presence ofhypokalemia, 40-50mEq/L of

potassium ion to be maintained for3-4 days.


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A 32 kg child with moderatedehydration, from several

diarrheal episodes. Computethe deficit and maintenance

therapy.

EXAMPLE 2


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child, 32 kg, moderate dehydration

Estimated fluid loss:6% Fluid to Administer:

(60 mL) (32 kg)

1, 920 mL in 6 hours

First hour: 1,800 mL/4 = 480 mL/hour

120 gtts/min Next 5-6 hours:

1, 920 mL- 480 mL = 1, 440 mL 1, 440 mL/5 hours = 288 mL/hour

72 gtts/min


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Holiday-Segar Method:

F

irst 10 kg = 1000 mL/kg Second 10 kg = 500 mL/kg

Above 20 kg = 20/mL/kg; thus,

First 20 kg = 1,500 mL

Above 20 kg: 32 kg-20 kg = 12 kg

(12 kg) (20 mL/kg)

240 mL

For 24 hour maintenance: 1,500 mL + 240 mL = 1, 740 mL

1, 740 mL/24 hours

73 mL/ hr----18 gtts/min


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Weight Method for Calculating Daily Maintenance Fluid VolumeWeight Method for Calculating Daily Maintenance Fluid Volume

BodyBody

WeightWeight

Fluid per dayFluid per day

00--10 kg10 kg 100 mL/kg100 mL/kg

1111--20 kg20 kg 1,000 mL + 50 mL/kg for each kg>10 kg1,000 mL + 50 mL/kg for each kg>10 kg

>20 kg>20 kg 1,5001,500 mLmL + 20+ 20 mLmL/kg for each kg>20 kg/kg for each kg>20 kg

*maximum fluid per day is normally 2, 400*maximum fluid per day is normally 2, 400 mLmL


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ACTUAL BODY WEIGHT

(KG)

TFR

1st 10 kg ofBW 100mL/kg/day, plus

2nd 10kg ofBW 50mL/kg/day, plus

Body weigh >20kg 20ml/kg/day

e.g. 25 kg child: (1000 + 500 + 100) = 1600 mL/day


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MILD MODERATE SEVERE

< 5 , < /o 5 cc/ 5

> 5 , > /o 3 6 9

D5 .3% in 6-

8 hours

hr: PLRS 1st hr: 1/3

PLRS

Next 5-7 hrs:

D5LRS

Next 5-7 hrs:

/3 D5 .3%

IVF Dextrose Na Cl K Lactate Others


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IVF Dextroseg/L

NamEq/L

ClmEq/L

K

mEq/LLactatemEq/L

OthersmEq/L

LRS 130 109 4 28 Ca 3

NSS 154 154

D50.15%NaCl

50 25 25

D50.3%NaCl

50 51 51

D50.45%NaCl

50 77 77

D50.9%NaCl

50 154 154

D5IMB 50 25 22 20 23 Mg-3;PO4-3

D5LRS 50 130 109 4 28 Ca-3

D5NM 50 40 40 13 Mg-3; Acetate-26

D5NR 50 140 98 5 Mg-3;Acetate-

27;gluconate-23


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SODIUM (135-150mEq/L or 3-4 mEq/kg/day

HYPONATREMIAmEq Na deficit = (desired-actual) xTBW

Where:TBW (in L) = 0.6 x body weight (kg)

Initial goal: 120mEq/L;subsequent:130 in 24-3 hrs

Correct only up to 15 mEq/L/day (2.5mEq/L/hr)

to avoid pontine myelinolysis


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Hypovolemic hyponatremia Replace the sodium deficit and any water deficit

1st, restore the intravascular volume withisotonic saline

Hypervolemic hyponatremia Water and sodium restriction

Diuretics Isovolumic hyponatremia Acute: Hypertonic saline

Chronic: child needs to receive an appropriateformula and excess water intake should beeliminated


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HYPERNATREMIA

Water deficit = plasma[Na] 140 xTBW140

Correct only 10-15 mmol/L/day


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HYPOKALEMIA

mmol K deficit = (desired-actual) x 0.3xwt (kg) or

Deficit = wt (kg) x 50 x estimated % deficit

KSerum Level Estimated deficit

3-3.5mEq/L 5% deficit

(appro

x 200-400mmo

l)2-2.5mEq/L 10% deficit

1-2.0mEq/L 20% deficit

(approx 600mmol and up)


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If asymptomatic: oral replacement 2-3mEq/kg/d

IV replacement guidelines:1. Rate: 0.2-0.3 mmol/kg/hr not to exceed 1 mmol/kg/hr

2. If via peripheral vein, not >40mmol/L

3. If via central vein, not >80mmol/L; continuous ECG


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HYPERKALEMIA

First action: STOP all sources ofpotassium

ECG changes: peaked/tentedT waves,

At > 7.0mEq/L: prolonged PR, ST, wide QRS

At >8.0mEq/L: P wave disappears, QRS merges w/T


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TREATMENT:

1. Reverse membrane effects: Ca gluconate 10% at

0.5-1.0ml/kg IV over 2-10 mins2.Transfer K into cells (redistribute): 2-agonists; or

regular insulin 10-20 U + glucose 25-50g; or

NaHCO3 3amp/L D5W

3. Enhance renal excretion of K:

Kayexalate 1g/kg PO diluted with 2-4mL sorbitol


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HYPOCALCEMIA

Ca gluconate 10% (8.9 mg/mL elemental Ca):0.5-1.0mL/kg IV bolus over 20-30mins with

cardiac monitoring x3 doses

Maintenance: 500 mg/kg/24hr PO


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HYPOMAGNESEMIA

For symptomatic children

4-7 kg: 0.5mL of 50% MgSO4 (1mmol Mg)

> 7 kg: 1mL of 50% MgSO4 (2mmol Mg)


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Hypophosphatemia

Oral maintenance doses:2-3 mmol/kg/day in divided doses

For severe deficiency or who cannot tolerate oralmedications:

0.08-0.16 mmol/kg over 6 hours


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Oral Rehydration

Principle

Glucose absorption (enterocytes) facilitates water

and electrolyte absorption.


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CHOCHO NaNa Cho:Cho:NaNa

KK BaseBase OsmolalityOsmolality

NaturalyteNaturalyte 140140 4545 3.13.1 2020 4848 265265

PediatricPediatric

electrolyteelectrolyte140140 4545 3.13.1 2020 3030 250250

PedialytePedialyte 140140 4545 3.13.1 2020 3030 250250

InfalyteInfalyte 7070 5050 1.41.4 2525 3030 200200

RehydralyteRehydralyte 140140 7575 1.91.9 2020 3030 310310

WHO ORSWHO ORS 111111 9090 1.21.2 2020 3030 310310


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Com ositio of ral e y ratio

Sol tio ( . .S)

303520452.5Pedialyte

308020902.0W.H.

sol tio

mmol/Lmmol/Lmmol/Lmmol/Lgram %

BaseCl-

K+

Na+

l cose


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treatment is aimed at providing adequate

fluids and continuing an age-appropriate diet

use of ORS should be encouraged (1 mL offluid should be administered for each gram of

output )


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When losses are not easily measured, 10 mLof additional fluid can be administered perkilogram body weight for each watery stool or2 mL/kg body weight for each episode ofemesis

Alternative: children weighing 10 kg should be administered 120--240 mL(4--8 ounces)


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Oral Rehydration Solutions Acceptable Pedialyte Infalyte (Ricelyte) WHO/UNICEFORS

Suboptimal Apple juice Coca-ColaGatorade

Tea Chicken broth


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GOAL: Usual diet + replace ongoing losses

Formula-fed infants should continue their usualformula immediately upon rehydration

Children receiving semisolid or solid foods should

continue to receive their usual diet during episodesof diarrhea. Encourage starchy foods, clear brothsoups, yogurt, fresh fruits and vegetables.

Foods high in simple sugars should be avoidedbecause the osmotic load might worsen diarrhea

practice of withholding food for >24 hours isinappropriate.


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Highly specific diets (e.g., the BRAT [bananas,

rice, applesauce, and toast] diet) have been

commonly recommended


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hemodynamic shock

abdominal ileus

Intestinal intussusception

Stool output in excess of 10 mL/kg bodyweight/hour has been associated with a lower

rate of success of oral rehydration


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Diarrhea causes:

increased stool zinc loss,

negative zinc balance reduced tissue levels of zinc


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An additional 10 ml/kg of ORS is given

for each stool. Fluid intake should be decreased if the

patient appears fully hydrated earlier

than expected or if periorbital edemadevelops.

ORS should be given in small amounts at

short intervals: 1-2 tsp every 1-2

minutes


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MildMild ModerateModerate

InitialInitial

DoseDose

5050 mLmL/kg over 4 hrs/kg over 4 hrs 100 mL/kg over 6100 mL/kg over 6

hourshours

SubsequentSubsequent Resume feeding 10Resume feeding 10 mLmL/kg/kg

ORS/diarrheic stoolORS/diarrheic stool


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Oral Hydrating SolutionPreparationPreparation Contents (mEq/L)Contents (mEq/L)

Formulated ORSFormulated ORS 1/3 tsp1/3 tsp NaClNaCl, baking, bakingsoda,soda, KClKCl; 1 L water; 1 L water

NaNa++ 50, K50, K++ 20, Cl20, Cl-- 50, HCO50, HCO33-- 20, Glucose 2020, Glucose 20gg

Glucolyte 60Glucolyte 60 1 sachet/ 250 mL1 sachet/ 250 mL NaNa++ 60, K60, K++ 20, Cl20, Cl-- 50, Mg50, Mg2+2+ 5, Gluconate 5,5, Gluconate 5,Citrate 10,Glucose 100 gCitrate 10,Glucose 100 g

HydriteHydrite ORS 45: 1 tab/ 200 mLORS 45: 1 tab/ 200 mL NaNa++ 90, K90, K++ 20, Cl20, Cl-- 80, HCO80, HCO33-- 30, Glucose 11030, Glucose 110gg

Oresol (DOH)Oresol (DOH) 1 sachet/1 L1 sachet/1 L NaNa++ 90, K90, K++ 20, Cl20, Cl-- 80, HCO80, HCO33-- 3030

OrhydrateOrhydrate

Concentrate SyrupConcentrate Syrup

60 MmL in 940 water or60 MmL in 940 water or

5 mL in 78 mL water5 mL in 78 mL water

NaNa++ 45, K45, K++ 20, Cl20, Cl-- 35, Mg35, Mg2+2+ 2.5, Gluconate2.5, Gluconate

2.5, Citrate 30,Glucose 10 g, Sucrose 20 g2.5, Citrate 30,Glucose 10 g, Sucrose 20 g

Pedialyte 45Pedialyte 45 PremixedPremixed NaNa++ 45, K45, K++ 20, Cl20, Cl-- 35, Citrate 30, Dextrose 2535, Citrate 30, Dextrose 25g, Calories 100g, Calories 100

Pedialyte 90Pedialyte 90 PremixedPremixed NaNa++ 90, K90, K++ 20, Citrate 30, Dextrose 25 g,20, Citrate 30, Dextrose 25 g,

Calories 100Calories 100


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MaintenanceTherapy:

MildDiarrhea: treated at home with100 mL of ORS/kg/24 hours until diarrhea

stops

ReplacementTherapy: volume/volume replacement; or

each episode = 10-15 ml/kg/hr is

appropriate


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