Pediatric Fluids and Electrolytes

Rachel Sykes, PharmD, BCPS

Clinical Assistant Professor Ernest Mario School of Pharmacy Rutgers University Saint Barnabas Medical Center

September 27, 2007

Objectives
Describe how pediatric body composition changes over time Identify the three main components of fluid therapy Calculate the maintenance fluid rate for a child using the Holliday -Segar Method Determine appropriate fluid components for a hospitalized child

Objectives
Calculate fluid rates for a child with dehydration Determine a 3% saline volume and rate for a child with severe hyponatremia Recommend an oral rehydration regimen for a child with mild dehydration

Body Fluids
Total Body Water = Extracellular Fluid (ECF) + Intracellular Fluid (ICF) ECF = Plasma + Interstitial Fluid Total Body Water expressed in terms of % body weight (adolescent or adult): Plasma (5%)

ICF (30-40%)

Interstitial (15%)

Changes in Body Water

Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 17 th Ed. Philadelphia, PA: Elsevier Science; 2004.

Change in Body Composition

Miller RD. Millers Anesthesia . 6 th Ed. Philadelphia, PA: Elsevier Science; 2005.

Babies are like bags of water Full-term: 75% water

http://chfs.ky.gov/dph/ach/ecd/newbornscreening.htm http://www.inmagine.com/rubberball-single-image-set-photos/Rubberball-rbv005

Premature babies: 83% water

http://www.sciencemuseum.org.uk/antenna/babybrainscans/ http://www.jupiterimages.com/popup2.aspx?navigationSubType=itemdetails&itemID =22684522

Regulating Water and Electrolytes

What makes someone thirsty?
Increase in serum osmolarity Volume depletion

Dehydration causes increased serum osmolarity

Antidiuretic hormone (ADH) released SIADH ADH is released even when the serum osmolarity is low

Fluid Therapy
Three types of fluid therapy
Maintenance fluid Deficit Replacement Fluid to compensate for ongoing normal losses

Fluid to compensate for ongoing losses during medical treatment

Fluid to compensate for fluid loss prior to medical treatment

Case #1
A 5 year-old boy is admitted to the hospital after a bike accident where he lost a significant amount of blood. During his hospital stay he has a chest tube placed for a few days. The patient is treated in the hospital for one week and is then discharged home. What types of fluid therapy does he need?

Maintenance Fluid
Where does the body lose fluid?
Urine Insensible losses
Respiratory, skin, feces

Intrinsic losses
By -product of metabolism

What makes kids different?

Higher metabolic rate and evaporative losses

Insensible Losses
Factors affecting insensible losses
Respiratory rate
Age Pain Ventilator

Environmental temperature
Phototherapy

Congenital skin defects

Gastroschisis

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9028.htm

Omphalocele

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9030.htm

Respiratory Rates
Age Group Infant Toddler Preschool Age School Age Adolescent Respiratory Rate (per minute) 30-60 24-40 22-34 18-30 12-16

HazinskiMF. Anatomic and physiologic differences between children andadults.

Deficit Fluids
Causes of dehydration
Inadequate intake Blood loss Fever Catabolic state
Extra solutes, need extra fluid in order to excrete

Replacement Fluids
Type of fluids replaced depends on what s being lost
Cerebrospinal fluid drains
Generally replaced with normal saline

Chest tube drains

Generally replaced with albumin, particularly after heart surgery

Calculating Maintenance Fluids

Holliday-Segar Method Fluid per day 1st 10 kg Next 10 kg Weight > 20 kg 100 mL/kg/day 50 mL/kg/day 20 mL/kg/day Rate per hour 4 mL/kg/hr 2 mL/kg/hr 1 mL/kg/hr

This method assumes that 100 kcal expended requires 100mL water

Maintenance Fluid Example Calculations

Calculate the maintenance fluids in mL/day and mL/hr for the following patient weights: 25kg 4kg 16kg

Electrolyte Maintenance Requirements

Sodium Potassium Chloride 2 - 3 mEq/kg/day 1 - 2 mEq/kg/day 3 - 5 mEq/kg/day

Chloride needs are generally met by meeting sodium and potassium requirements with NaCl and KCl

What is the usual maintenance fluid for a child?

28 kg, well-hydrated child - What fluid would you recommend? FIRST - calculate the amount of fluid you need NEXT - calculate how much sodium and potassium you need FINALLY - pick a fluid based upon what is commercially available if you can

Increased Maintenance Requirements

Fever Vomiting Hyperventilation Hypermetabolic states High environmental temperature Intestinal losses Burns

Decreased Maintenance Requirements

Increased environmental humidity Hypothermia Hypometabolic states

Dehydration

Clinical Signs of Dehydration

Weight loss Babies - sunken fontanelle Decreased urine Thirst production Decreased skin turgor Increased urine Dry mucous specific gravity membranes Increased heart rate Lack of tears Decreased blood pressure What are the implications of dehydration for drug therapy?
Weigh children frequently

Anterior Fontanelle

http://commons.wikimedia.org/wiki/Image:Human_anterior_fontanelle_1_month_dscn1449.jpg

Degree of Dehydration
Need to accurately monitor patient weights frequently Fluid deficit (L) = PIW (kg) IW (kg)
PIW = Pre-illness weight IW = Illness weight

% Dehydration = PIW (kg) IW (kg) x 100% PIW (kg)

Degree of Dehydration

Mild Older Child Infant 3% (30 mL/kg) 5% (50 mL/kg)

Moderate 6% (60 mL/kg)

Severe 9% (90 mL/kg)

10% 15% (100 mL/kg) (150 mL/kg)

Degrees of Dehydration
Clinical Signs Weight Loss (%) Behavior Thirst Mucous membranes Tears Anterior Fontanelle Mild 5 Normal Slight May be normal Present Flat Moderate 10 Irritable Moderate Dry Severe 15 Hyperirritable to lethargic Intense Parched Absent Sunken

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Degrees of Dehydration
Clinical Signs Eyes Skin Turgor Blood Pressure Skin color Pulse Urine output Mild Normal Normal Normal Normal Full, normal rate Decreased Moderate Deepset Normal Pale Rapid Markedly decreased Severe Sunken Increased Decreased Gray / mottled Rapid, weak Anuria

Types of Dehydration
Isotonic
Serum Na = 130-150 mEq/L 80% of dehydrated patients

Hypertonic
Serum Na > 150 mEq/L 15% of dehydrated patients

Hypotonic
Serum Na < 130 mEq/L 5% of dehydrated patients

Dehydration Developing a Plan of Action

1. 2. Estimate the degree of dehydration Determine the type of dehydration This will lead you to your Plan! Plan will have 3 phases

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Phase I Rapid phase

Goal: Restore circulation, reperfuse brain, kidneys Mild-Moderate
10 20 mL/kg bolus given over 30 60 minutes

Severe
May repeat bolus as needed

Fluids something isotonic such as NS or lactated ringers (LR)

Hypotonic / Isotonic Dehydration

Phase 2 Replacement Phase

Goal: Replace deficit of fluids and electrolytes Amount:
1/3 daily maintenance + deficit

Fluids:
D5 NS + 20-30 mEq KCl
Add KCl only if patient has voided

Time: Over 8 hours

Hypotonic / Isotonic Dehydration

Phase 3 Stabilization Phase

Goal: Transition to maintenance fluids Amount:
2/3 daily maintenance + deficit

Fluids:
D5 NS + 20-30 mEq KCl

Time: Over 16 hours

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Hypertonic Dehydration

Phase 2 Replacement Phase

Goal: Replace deficit of fluids and electrolytes and daily maintenance Amount:
Deficits + daily maintenance

Fluid:
D5 NS + 20-30 mEq/L KCl

Give over 24-48 hours IMPORTANT: Lower serum Na by no more than 10-12 mEq/L/day

Hypertonic Dehydration

Phase 3 Replacement Phase

Goal: Replace ongoing losses and transition towards maintenance fluid therapy Amount:
Replacement + daily maintenance

Fluid:
D5 NS + 20-30 mEq/L KCl

Acute Severe Hyponatremia

Serum Na < 120, CNS symptoms Administer 3% saline Total volume =
[(130 - serum Na)(0.6)(wt in kg)] x 2

Give 1/2 total in < 1 hr and remainder over the next 2 hours if symptoms persist

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Oral Rehydration
Effective, safe, inexpensive Indications
Replacement fluid for mild dehydration Following Phase I volume resuscitation in moderate dehydration

Contraindications
Severe dehydration Electrolyte abnormalities Ileus or gastric obstruction

www.rehydrate.org

Rehydration Solutions
Recommendation: Glucose 2 - 2.5 g/dL Sodium 50-75 mEq/L Glucose (g/dL) Pedialyte Gatorade Apple Juice Milk Water 2.5 5.9 11.9 4.9 Sodium Potassium (mEq/L) (mEq/L) 45 21 0.4 22 3 20 2.5 26 36 0.5

http://almostgirl.coffeespoons.org/?p=1131 http://www.yummy.com/subcategorylist.aspx?cGw8n4AckUu5BAvSiFaUNV n9hS91DEsEXmQyGJauVHM=

Oral Rehydration
Patient vomiting
5-10mL Q 5-10 minutes and increase as tolerated

Mild Rehydration
Deficit replacement: 50 mL/kg over 4 hours

Moderate Rehydration
Deficit replacement: 100 mL/kg over 4 hours

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Hyperkalemia
Can cause life-threatening arrhythmias
Bradycardia Ventricular dysrhythmias

First determine why the serum level might be high

Heel stick? KCl in fluids?

Blood Collection in Newborns

http://health.state. ga. us/programs/nsmscd/screening_form.asp http://www.nlm.nih.gov/medlineplus/ency/imagepages/2961.htm

Hyperkalemia
Treatment
Calcium Bicarbonate Insulin (with glucose) Albuterol

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Case #3
JW, a 16 month old boy (11kg), is brought into your pharmacy by his mother. JWs mom says that he had a mild bout of diarrhea a few days ago, and she is still noticing fewer wet diapers. Otherwise, he has no symptoms. JWs mother would like to know what she should do. What do you recommend?

Case #4
DR is a 4 year old girl (16kg) who presents to the emergency room with fatigue, headache, generalized malaise, and severe gastrointestinal distress. The ER team gets a chem-7 and discovers her sodium to be 118. They would like to give 3% NS and ask you for a recommendation on how much to give, and at what rate.

Case #5
LM is a 4 month old, 7kg (preillness) girl who presents to the ER with a sunken fontanelle, dusky skin, lethargy, and is not crying. She has not urinated in several hours. Current weight is 6kg. Her sodium is 137. What type and degree of dehydration does she have? How do you recommend treating her?

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Case #5
How do I double-check my answer?
Its easy! Just add up all the fluid you gave. It should equal the deficit + the daily maintenance requirement.

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