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Maintenance requirements
Management of dehydration
Normonatremic
Hyponatremic
Hypernatremic
A few little pearls
Maintenance requirements
Chapter 10, Harriet Lane, p. 233
At normal activity
Infants approx. 100 kcal/kg/d
4-6yo approx. 90 kcal/kg/d
7-10yo approx. 70 kcal/kg/d
Teens approx. 50 kcal/kg/d
Caloric needs are based on resting energy expenditure and activity
Resting energy expenditure (REE) is based on size
Energy needs increase with injury, fever, growth, etc.
First 10 kg 100 4
Second 10 kg 50 2
Each additional 20 1
kg
Ex: 25 kg 1600 cc/d 65 cc/h
(1000+500+100)
Holliday-Segar Method
Electrolyte Requirements
Na 3 MEq per 100 cc water
K - 2 MEq per 100 cc water
Initial resuscitation
Determining deficit
Adding in maintenance
Ongoing losses (dont forget!)
Estimating degree of
dehydrationtraditional teaching
Recent weight changes
Physical exam findings
Dehydration Mild (5%) Moderate (10%) Severe (15%)
Turgor Normal Tenting None
Cap refill Brisk (< 2 sec) 2-4 sec >4 sec
Mucus membranes Moist Dry Parched/cracked
Eyes Normal Deep set Sunken
Tears Present Reduced None
Fontenelle Flat Sunken
CNS Consolable Irritable Lethargic/obtunded
Pulse Regular Slight increase Increase
Urine output Normal Decreased Anuric
Caveatstraditional teaching
The previous chart applies to babies. For adults
it should be scaled back to 3%, 6%, and 9%.
Older kids show symptoms at a lower % dehydration
Hyponatremic dehydration looks worse clinically
exaggerated hemodynamic instability
Hypernatremic dehydration looks better clinically
circulation maintained at the expense of
intracellular volume
Systematic Review of the
Published Data on History, PE,
and Labs in Dehydration
Limitations:
Inter-rater agreement only slight to fair
Kappa 0.01-0.35
Site of application, lighting and ambient
temperature
Abnormal Skin Turgor
Sensitivity Specificity LR Positive LR Negative
Limitations:
Inter-rater agreement fair to moderate
Kappa 0.36-0.55
Hypernatremia increases false negatives
Abnormal Respirations
Sensitivity Specificity LR Positive LR Negative
Limitations:
Inter-rater agreement of only chance to fair
Kappa 0.04 to 0.40
Varying measurements and definitions
Less Useful Signs
Sign Comment
Sunken Eyes Pooled LR of 1.7
Dry MM Pooled LR of 1.7
Weak Pulse LR ranged from not significant to 3.1
sensitivity low (0.04-0.25), specificity high (0.89 to 1)
Cool Extremity LR ranged from not significant to 18.8
Absent tears Pooled LR CI crosses 1.0
Abnormal overall Pooled LR CI crosses 1.0
appearance
Tachycardia Pooled LR CI crosses 1.0
Weak Cry CI for LR crosses 1.0.
Sunken fontanelle LR actually below one, CI crosses 1.0
Combinations of Signs
Vega evaluated the standard dehydration
table
Severe classification
LR 3.4 for 5% dehydration
Mild or Moderate classification
No increase in likelihood of dehydration
Gorelick found an LR of 4.9 when 3/10
signs of dehydration present
Results: Laboratory Tests
BUN
Study of hospitalized patients with gastroenteritis
BUN >45, specificity: 1.00, LR positive of 46.1
D5W 5 170
NS 154 154
(0.9%
NaCl)
LR 0-10 0-340 130 4 109 28 3
Rehydration
First resuscitate out of shock restore perfusion
Calculate maintenance, including ongoing losses,
and deficit
Run maintenance as usual
Replace ongoing losses
Typical is to replace deficit over 24 hours
Half in first 8 hours
Other half over 16 hours
Where the dehydration comes
fromtraditional teaching
In a brief duration of illness (<3 days), 80% of
the deficit is typically from the ECF
More than 3 days of illness and the deficit from
the ICF increases to about 40% (therefore 60%
from ECF)
This matters because ECF contains a lot of
sodium (135-145 mEq), and intracellular fluid
contains a lot of potassium (150MEq)
But rememberNo walls, no sparks
Example Calculations, normal Na
(See table 10-7 in Harriet Lane on page 237.)
7 kg infant with 10% dehydration that accumulated over >3d.
24 Hours H2O Na K
Maintenance 700 21 14
(Hol.-Seg.)
Deficit 700
(10% of 7 kg)
ECF (60%) 61
420 (145MEq/L x
0.42L)
ICF (40%) 42
280 (150MEq/L x
0.28L)
Total 1400cc 82MEq 56MEq
First 8 hours
MIVF for 8 hours plus 50% of the deficit
H2O Na K
1/ Maint 233 7 5
3
Deficit 350 31 21
Total 583 38 26
583/8=73 cc/h; 38/0.583=65MEqNa/L = 0.42NS
(65/154); 26/0.583=45MEqK/L
Roughly D5halfNS plus 40 KCl at 75 cc/h
Next 16 hours
MIVF for 16 hours plus other 50% of the deficit
H2O Na K
2/ Maint 467 14 9
3
Deficit 350 30 21
Total 817 44 30
817/16=51 cc/h; 44/0.817=54MEqNa/L =
0.35NS (54/154); 30/0.817=37MEqK/L
Roughly D5halfNS plus 40 KCl at 50 cc/h
Simplified what fluid, normal Na
(Roberts method)
Usually after boluses with NS or LR, D5halfNS is
an appropriate rehydration fluid
After urine output is assured, give K as 20
MEq/L
That is usually safe
Often you dont need to fully replete K losses acutely
Watch the rate of fluids regarding K and dont give
more than 1 MEq/kg/h
Simplified what rate
(Roberts method)
If a child is 10% dehydrated -
Give a 20 cc/kg bolus of NS
Restores hydration 2%
Next give 10 cc/kg/h of D5halfNS with 20 KCl for
8 hours
Restores hydration 8%
Next give 1.5 times MIVF using D5quarterNS
with 20KCL for 16 hours
That days maintenance
Example, the Roberts method
Make a table!
Component H2O Na K
(mL) (mEq) (mEq)
Mainenance Na=3mEq/100ml 700 21 14
K=2mEq/100ml
Deficit 700
60% ECF x 700 61
= 420
40% ICF x 700 = 42
280
Excess Na (135-115) x .6 x 84
deficit 7kg
24 hour 1400 166 56
totals
First 8 hours, hyponatremia
MIVF for 8 hours plus 50% of the deficit
H2O Na K
1/ Maint 233 7 5
3
Deficit 350 72 21
Total 583 80 26
583/8=73 cc/h; 80/0.583=137MEqNa/L =
0.89NS (137/154); 26/0.583=45MEqK/L
Roughly D5halfNS plus 40 KCl at 75 cc/h
Next 16 hours, hyponatremia
MIVF for 16 hours plus other 50% of the deficit
H2O Na K
2/ Maint 467 14 9
3
Deficit 350 72 21
Total 817 86 30
817/16=51 cc/h; 86/0.817=105MEqNa/L =
0.68NS (105/154); 30/0.817=37MEqK/L
Roughly D5halfNS plus 40 KCl at 50 cc/h
Practical Interpretation,
Hyponatremia
In adults, rapid correction of hyponatremia may
be associated with central pontine myelinoysis.
Correct the Na fast only if the patient is
symptomatic (seizing or particularly irritable)
For asymptomatic patients, the goal should be
to increase the Na no faster than 1 MEq/L per
hour
Start with NS boluses and then D5NS or
D5halfNS
Follow Na carefully
Hypernatremia
MIVF 700 21 14
Free water
deficit = 140
280cc/2 days
Def remaining
(solute) =420cc
(700-280=420)
ECF (60%)
252 37
ICF (40%)
168 25
Total, 24 hr 1260 58 39
Fluid choice, Hypernatremia
Need in 24 hours,
1260 cc water
58 Meq Na
39 MEq K
1260/24 = 52.5 cc/h
58/1.260 = 46 MEqNa/L = 0.3 NS (46/154)
39/1.260 = 31MEqK/L
Roughly D5halfNS with 30KCl at 50 cc/h could
also use D5quarterNS half is more
conservative
Practical Interpretation,
Hypernatremia
Still bolus the hypernatremic patient with NS if
needed
You want to lower the Na slowly so you can
start with D5halfNS and remeasure
The calculations almost always come out to
something near quarter NS, and you should not
give more dilute fluid than that, so that is also a
reasonable starting point
The important thing is to follow the sodium
carefully and adjust as necessary
Practical Approach,
Replacing the Deficit
Isotonic dehydration
1/2 NS
Hyponatremic dehydration
3/4 or NS
Hypernatrmic dehydration
1/4 NS
Follow I/Os, weights, lytes carefully q 4
hours, you can follow on VBGs
Even EasierRun Maintenance
and Deficit Separately
Maintenance (calculate using Holliday-Segar)
Y in Deficit
Ongoing losses (calculate by shift or anticipate)