Dr.

Nzemeke Chukwuemeke
STATE HOUSE MEDICAL CENTRE, ABUJA

FLU ID A N D ELEC TR O LY TES

O U TLIN E
Introduction
Body Water distribution
Adult VS Pediatric Fluid balance
Body water osmolality
Homoestasis
Fluid therapy
IV Solution
Fluid imbalance/correction
Electrolyte imbalance/correction

INTRODUCTION

From Adult M edicine

Distribution of total body water (TBW)
60% of adult body weight is fluid

Gender, body mass & age

considerations
Intracellular (ICF, within cells = 40% of

body weight)
Extracellular (ECF, plasma, interstitial &
lymph =20% of body weight)

1 Litre water = 2.2lb or

1 kg

Body W ater D istribution

Body W ater D istribution

D evelopm entalD iff

erences
Infants & young children
Four areas of immature functioning

Increased fluid intake and output relative to

size
Total body fluid is 20% more than adults
Greater surface area relative to size: >
water loss through skin
Increased metabolic rate up to 2 years
Immature kidney function
requires more fluid to excrete wastes

In Pediatrics
Total body water (TBW)
It is higher in children than adults
Preterm 80% of body weight
Term 75% of body weight
At one year 60%
After puberty in girls 50%

Body W ater D istribution

At birth ECF is lager than ICF
Post natal diuresis leads to drop in ECF

At one year The ratio approximate adult value

ECF 25-20% of TBW
ICF 30-40% of TBW

ECF consist of interstitial and intravascular

fluid
Relation between these 2 compartment is maintained

by the oncotic , hydrostatic and osmotic pressure

Body W ater O sm olality

Normal osmolality = 285 295 mOsm/kg
Change in ECF osmolality leads to

change in ICF osmolality

Calculated from E&u and glucose conc.
2(Na+K) + Glucose (mmol/L) + Urea (mmol/L)
Glucose mg/dl 18 = glu mmo/L
Urea mg/dl 2.8 = urea mmol/L
Calculated value usually slightly less

than measured value

Calculation is also useful in

differentiating DKA from HONK

Physiology ofbody w ater regulation

Regulation is in response to 2 stimuli
Volume change
Osmolality change

Volum e change

Hypovolaemia or hypotension is sensed by the

juxtaglomerular cells of the afferent arterioles

in the glomerular apparatus of kidneys
Renin is released which cleave angiotensinogen

to angiotensin I.
Released angiotensin I is acted on by ACE to
produce angiotensin II
Angiotensin II is a vasopressor which act on the

adrenal medulla to release aldosterone

 Aldosterone stimulate re-absorption

of Na with secondary re-absorption

of water in the distal nephrone
Volume overload
Release of atrial natriuretic peptide

(ANP)
Sodium and water is loss in the
collecting duct

Change in O sm olality
Stimulation of osmoreceptor in the

hypothalamus
Release of antidiuretic hormone in

posterior pituitary
ADH act on V2 receptors in the collecting

duct to cause water re-absorption

This mechanism is distorted by SIADH

and diabetes insipidus

Fluid Therapy

1. Oral: Safer and best route. Include

use of Table water, Carbonated

drinks, soups, ORS etc
2. Intravenous: Although not as safe as
oral fluid therapy (higher risk of
overhydration and sepsis),
bioavailability and rapid onset of
action is its greatest advantage

O RS
Glucose-electrolyte solution
For mild to moderate dehydration
Deficit corrected over 4hrs
Maintenance 100mls/kg/24hrs
Ongoing loss 10mls/kg/loose stool
Low osmolar fluid lead to reduction in loose

stools
Some now come in sachets to be diluted in
500mls

Types ofIV Fluids solution

A. Isotonic solution
B. Hypertonic solution
C. Hypotonic solution

Fluid
Imbalance

O verhydration
Rare
Most commonly caused by excessive

and rapid IV fluid therapy

Tx- Stop IVF medication
If severe, then , Give Diuretics (Frusemide at
1mg/kg)

D ehydration
Its the negative fluid balance, resulting in

reduction of total body water

Children, especially those <4 years old,
are more susceptible to volume depletion
as a result of vomiting, diarrhea or
increases in insensible water losses.

Categories ofdehydration
A] According to osmolarity: Amount of solute per
kg solvent.
1. Isonatremic (isotonic): Most common (80%).
Fluid loss is similar in Na+ conc. to plasma.
130-150mEq/L. As in most vomiting and
diarrhea
2. Hyponatremic (hypotonic): Less common(510%). Fluid lost has more Na+ conc. than
plasma i.e relatively more sodium than water is
lost, thus water moves from intravascular to
extravascular space exaggerating intravascular
fluid loss. <130mEq/L. As in diuretic therapy

3. Hypernatremic (hypertonic): Less

common(5-10%). Fluid lost has less Na+
than water. Shifting extravascular water
into intravascular space, minimizing
intravascular volume depletion. As in
osmotic diarrhea.
Correction should be slower (e.g over
48hrs) as rapid correction can cause
cerebral edema. Watch out for
hyperglycemia and hypocalcemia

Categories ofdehydration
B] According to severity: based on how
much body fluid is lost.
1. Mild
2. Moderate
3. Severe
When severe, dehydration is a life-

threatening emergency.

Causes ofdehydration
The commonest causes are vomiting or

diarrhea.
A] Vomiting may be caused by any of the
following systems or processes:
CNS (eg, infections, space-occupying lesions)
GI (eg, gastroenteritis, obstruction, hepatitis,

liver failure, appendicitis,

peritonitis,intussusception, volvulus, pyloric
stenosis, toxicity [ingestion, overdose, drug
effects])

Causes ofdehydration
Endocrine (eg, DKA,congenital adrenal

hypoplasia, Addisonian crisis)

Renal (eg, infection,pyelonephritis, renal

failure, renal tubular acidosis)

Psychiatric (eg, psychogenic vomiting) - This is

not seen in infants and is rare in children

compared with adults.

Causes ofdehydration
B] Diarrhea may be caused by any of the
following systems or processes:
GI (e.g., gastroenteritis, malabsorption,

intussusception, irritable bowel, inflammatory

bowel disease, short gut syndrome)
Endocrine (eg, thyrotoxicosis, congenital

adrenal hypoplasia, Addisonian crisis, diabetic

enteropathy)
Psychiatric (eg, anxiety)

W H O Classifi
cation O fD ehydration
No signs of dehydration :

are <5 percent dehydrated

Some dehydration :
5 to 10 percent dehydration
Severe dehydration :
>10 percent dehydration

Assessm ent ofD ehydration

Prior guidelines, including CDC's 1992
recommendations and the American
Academy of Pediatrics (AAP) 1996
guidelines, divide patients with
dehydration into subgroups for:
mild (3%-5% fluid deficit)
moderate (6%-9% fluid deficit)
severe (>10% fluid deficit, shock, or near

shock)

 Of these,
The most accurate in identifying the

level of dehydration are capillary refill,

BP, skin turgor, and breathing.
The least accurate are mental status,

heart rate and fontanelle

appearance.

Types ofFluid Therapy(in D ehydration)

1. Maintenance therapy: Maintenance
therapy is usually undertaken when the
individual is not expected to eat or drink
normally for a longer time
2. Replacement therapy
Deficit
Ongoing losses

M aintenance fl
uid therapy
Composition
Water This provide for daily urine and

insensible water loss

Glucose provide euglycaemia and prevent
ketosis and protein breakdown
Does not provide more than 20% of
required calories
Sodium 2-3mEq/kg/day
Chloride
Potassium 1-2mEq/kg/day

Water quantity
First 10kg = 100mls/kg/24hr
Next 10kg = 1000mls + 50ml/kg/24hrs
Next 10kg = 1500mls + 20mls/kg/24hrs
Max = 2400ml/24hr
Rate
0 10kg = 4mls/kg/hr
10 20kg = 2mls/kg/hr
>20kg = 1ml/kg/hr

Condition requiring > 100% of

m aintenance fl
uid
Sickle cell crises
Fever
Radiant heater
Presence of a surgical drainage
Cancer chemotherapy
Polyuria
Burns

Condition requiring reduction in m aintenance

fl
uid

Oliguria or anuria
Acute or end stage renal failure
Give insensible water loss 400mls/m2 (or

1/3 maintenance fluid) + previous day

urine output

SIADH
Congestive cardiac failure

Replacem ent therapy

Depends on level of dehydration

A]Therapy of Minimal Dehydration

Minimal dehydration (<5% loss of body
wt)
Encourage use of ORS
Nutrition should not be restricted

Replacem ent therapy

B] Therapy of Moderate Dehydration
Mild to moderate (3-9% loss of body wt)
ORS: 50-100 cc/kg over 2-4 hrs
Small, frequent feedings

A randomized trial of ORS versus IV

rehydration demonstrated shorter stays

in A/E and improved parental
satisfaction with oral rehydration

Replacem ent therapy

C] Therapy of Severe Dehydration
-Infants <10kg; (<1yr)- Correct over
6hrs
IVF 30mls/kg over 1hr, then 70mls/kg
over next 5hrs
-Children >10kg; (>1yr)- Correct over
4hrs
IVF 30mls/kg over 30mins, then
70mls/kg over next 3hrs 30mins.

Alternatively,Replacem ent
therapy
% fluid loss in different types of dehydration
Mild <3-5%
Moderate 6-10%
Severe 10-15%
These values are less in older children
Fluid deficit is calculated from degree of dehydration
Fluid deficit (ml) = % dehydration x wt(kg) x 10mls

Fluid is replace over 6 to 8hrs, then, Continue

maintenance fluid therapy

Electrolyte replacem ent

The electrolyte composition of

replacement fluid is based on the

type of fluid loss
It is preferred to measure the
electrolyte in the fluid loss (E/U/Cr)
Major electrolytes:
ICF = K+
ECF = Na+, Cl-

 Zinc supplementation reduces the

severity and duration of diarrhea

Reduces the incidence of subsequent

episodes of diarrhea for several months

WHO recommends zinc for children under

5 years of age with diarrhea :

10 mg/day for under 6 months and 20
mg/day for 10 days for 6 months to 5
years.

Electrolyte
imbalance

Introduction
Electrolytes play a vital role in

maintaining homeostasis within the

body.
They help to regulate myocardial and
neurological function, fluid balance,
oxygen delivery, acid-base balance
and much more.

Causes
Electrolyte imbalances can develop by

the following mechanisms:

1. Excessive ingestion;
2. Diminished elimination of an electrolyte;
3. Diminished ingestion
4. Excessive elimination of an electrolyte.

The most common cause of electrolyte

disturbances is renal failure

H yponatrem ia
(N a+ < 135 m Eq/L)
Low sodium determined by blood

chemistry
Sodium supports neuron transmission

Mechanism and examples

Free water gain
Deficient sodium intake
Renal sodium loss in excess of water
Water in excess of sodium gain

 Manifestations
Water excess rapid weight gain
Na+ loss neurological symptoms
irritability, seizures, < LOC

Muscle cramps
Anorexia/ Nausea/Vomiting (subtle signs)

Treat water excess

Fluid restriction (I&O)

Treat sodium loss

Oral or IV sodium

H ypernatrem ia
(N a+ > 145 m Eq/L)
Etiology
Water loss or sodium gains
Comatose patients
Na+ intake > water intake
Diabetes insipidus (excessive fluid loss) <

production of ADH
Damage to hypothalamic thirst center?
Tumor or CVA?

Manifestations

Thirst, dry tongue

Restlessness;
Decreased LOC; Coma;
Weight changes

Treatment (Rx)
Dilute Na+ and promote secretion
Fluids (5% D/W) and diuretics
Always check LOC
loose alertness & orientation

sepsis, head injury, intracranial bleed

Sodium pulls fluid to cause blood vessels
to burst

Potassium (K+ )Norm al-3.5-5.0 m Eq/L

Primarily an intracellular ion; small

amount in plasma is essential for normal

neuromuscular an cardiac function
Maintained by the cellular sodiumpotassium pump
K+ changes altered excitability of
muscles
Eliminated by kidneys
renal problems cause hyperkalemia
Insulin: causes K+ to move from ECF ICF
Acidosis, trauma to cells, and exercise
cause K+ to move from ICF ECF:

H yperkalem ia:K+ > 5.5 m Eq/L

Major Causes
Increased potassium intake
excess or rapid delivery of K+
penicillin containing K+
Massive blood transfusion with irradiated packed red cells
Buntain and Pabari (1999)

Shift of K+ from the ICF to ECF

Acidosis, uncontrolled DM
increased cell lysis (e.g. cytotoxic drugs)

Decreased renal excretion

Digitalis toxicity, renal failure, overuse of potassium sparing
diuretics (spiroaldactone)

 Mainfestations:
weak skeletal muscles/ paralysis
paraesthesia
irritability
abdominal cramping with diarrhea
irregular pulse EKG changes cardiac
standstill
EKG changes

peaked T-waves and a shortened QT interval occur

Depressed ST segment and widened QRS interval

Management
Eliminate K+
Diuretics
Dialysis (if >6.5)
Kayexalate
Increased fluids

IV insulin
Cardiac monitor

H ypokalem ia K+ < 3.5 m Eq/l

Major causes
< intake of potassium or > cellular uptake
of potassium
Insulin: promotes K+ uptake by muscle &
liver cells
When insulin is given: K+ goes into ICF <
serum K+ level
Uncontrolled diabetes mellitus:
> Glucose: osmotic diuretic > potassium
via urinary excretion
Diabetic Ketoacidosis: H+ ions in ECF
exchange across cell membranes K+ is
first elevated and then K+ stores are
excreted via urine

 Epinephrine: promotes uptake into cells

stress, acute illness, hypoglycemia

Excessive GI loss: diarrhea & ng suction

metabolic alkalosis
Diuretics: Lasix (watch K+ levels)
Excessive renal excretion elevated
aldosterone diuresis

 Signs & Symptoms

Muscle weakness: hypotonia
Cardiac dysrhytmias (T-wave inversion

or PVCs)
Atony of smooth muscle
intestinal distention
constipation
paralytic ileus
urinary retention
Confusion or disorientation

Correction ofLost Electrolyte

Cations
(Expected-Observed) x 0.6 (assumed
volume of distribution)x Body Weight
Anions
(Expected-Observed) x 0.3 (assumed
Volume of distribution)x Body Weight

THANK YOU FOR

LISTENING

References
- Mini Lecture: IV Fluids, William Graham,
PGY2
January 2014; Department of
Medicine UC Irvine Medical Center.
- National Institute of Health:
http://www.nlm.nih.gov/medlineplus/ency
/article/000982.htm
Reduced osmolarity oral rehydration
salts (ORS) formulation - Report from a
meeting of experts jointly organized by
UNICEF and WHO. WHO/CAH/01.22;
http://www.medterms.com/script/main/ar
t.asp?articlekey=3870