Pediatric Fluids and Electrolytes

Roumilla Mendoza, M.D. Pediatric Gastroenterologist

Water
Total Body water 2 major compartments 1. Intracellular fluid (ICF) 2. Extracelular fluid (ECF) a. interstitial fluid b. plasma volume

Nelson, 17th ed

Compartments of Body Water

Intracellular 30-40%

Interstitial 15 % Extracellular 20-25%

Plasma 5 %

Factors Affecting Intravascular and Interstitial Space

1.

2.

Oncotic pressure -albumin - draws water to the intravascular space Hydrostatic pressure - pumping action of the heart -drives fluid out of intravascular space
Arterial end capillary Interstitial space Venous end

Plasma Cations Anions Cations

Intracellular Anions

Cl- (104) K+ (140) Na+ (140) HCO3- (24)

Phos- (107)

Prot- (40) Prot- (14) K+ (4) Ca+ (2.5) Mg+ (1.1) Other (6) Phos- (2) Mg+ (7) Na+ (13) HCO3- (10) Cl- (3)

Electrolyte Composition of Body Fluids

Serum mEq/L Sodium (Na+) Potassium (K+) Calcium (Ca++) Magnesium(Mg++) Total Chloride (Cl-) Bicarbonate (HCO3-) Protein(Pr) Organic Acids HPO4SO4Total 140 5 5 4 154 100 26 19 6 2 1 154 Interstitial Fluid mEq/L 138 8 8 6 160 119 26 7 6 1 1 160 Intracellular Fluid mEq/L 9 155 4 32 200 5 10 65 (-) 95 25 200

Osmolality
Plasma osmolality concentration of solute particles in plasma Na,blood glucose, urea nitrogen
Normal plasma osmolality = 285-295 mOsm/kg H2O 285-

intake = losses

Regulation of Osmolality
Increase plasma osmolality Volume depletion

hypothalamus ADH secretion Thirst

Water excretion decreases

Intake increases

Regulation of Osmolality
INCREASED OSMOLALITY

CONSERVATION OF WATER

Regulation of Volume
 

 

Na balance is the main regulator Kidney determines sodium balance - alters the percentage of filtered Na reabsorbed in the nephron Volume expansion
- Inhibition of Na reabsorption in the collecting duct

Volume depletion - renal retention of Na

Sodium
Main cation of ECF 40% of total body Na is in the bone Na+ K+ - ATPase pump maintains sodium concentration Absorbed throughout the GIT Kidney principal site of Na excretion

Hypertonic State
ECF (PV) Na+>150 mmol/L

blood vessel

cell H2O ICF

Hypotonic State
ECF (PV) H2O Na+ < 130 mmol/L

blood vessel

cell ICF

Isotonic State
ECF (PV) Na+ = 135 - 145 mmol/L H2O

blood vessel

ECF (IF) Na+

cell H2O ICF

= 135 - 145 mmol/L

Clinical Features of Sodium or Osmolality Disturbance

Isotonic Hypotonic Hypertonic

SKIN

Cold and dry Poor elasticity & turgor Dry

Cold & clammy Very poor elasticity & turgor Clammy or moist, presence of hypersalivation Comatose; occasionally with generalized convulsions Very low temperature BP in shock Thready pulse

Warm, velvety, doughy Normal to slightly poor elasticity Parched, patient complains of extreme thirst Lethargic or hyperirritable, seizures, increased muscle tone & DTR Febrile temperature Normal BP Normal to slightly increased PR

LIPS & TONGUE

CNS

Lethargic

VITAL SIGNS

Normal to low temperature Normal to low BP Rapid PR

Severe hyponatremia
Serum Na+ < 120 mEq/L Patients are often symptomatic eg. convulsions, shock, lethargy Treatment: NaCl: 2meq/ml Na+ needed = (desired Na+ conc actual Na+) x weight in kg x 0.6 e.g. actual Na+ = 115 meq desired Na+ = 125 meq weight = 10 kg Na+ needed = (125 -115) 10 x 0.6 = 60 meq or 30 ml of Nacl

Hypernatremia


Deficit, maintemance and replacement therapy is given over a period of 48 hours Fluid of choice should contain a Na+ concentration of 25 mEq/L

Potassium
 

  

Most is contained in muscles Plasma concentration is not always reflective of the total body content Na+ K+ - ATPase pump maintains K concentration Mostly absorbed in the small intestine Aldosterone is the principal hormone regulator in secretion

Potassium Replacement


Maintenance Requirement -20 -30 mEq of KCl per liter of IVF once patient has voided Hypokalemia ( ileus, muscle weakness, ECG changes) - 40 -50 mEq of KCL per liter of IVF once patient has voided - maintain a constant conc. of K+ for 3-4 days 3-

Hyperkalemia
  

Serum K+ level > 6.5 mEq Present in severe acidosis, renal insufficiency Treatment
1. NaHCO3 2. Glucose and insulin 3. Salbutamol IV or by nebulizer 4. Calcium gluconate 5. Kayexalate 6. hemodialysis or peritoneal dialysis

Calcium
 

99% is in the bone Important:

blood coagulation,cellular communication, exo/endocytois muscle contraction, neuromuscular transmission

Adequate intake to permit skeletal growth and mineralization Tight regulation of serum calcium concentration to permit normal physiologic function

Calcium Treatment


Hypocalcemia - 1-2 ml/kg of 10% Calcium gluconate Hypercalcemia - hydration

Magnesium
  

5050-60% is in the bone Necessary cofactor for a lot of coenzymes Treatment Hypomagnesemia 2525-50mg/kg of magnesium sulfate

Acid Base Balance

Normal pH ( 7.35 7.45)
Acid donates a hydrogen ion Base accepts a hydrogen ion

HA

H+ + A+

Acid Base Balance



Buffer systems - buffer defined as a substance that reduces the change in free hydrogen ion concentration of of a solution on the addition of an acid or base a. bicarbonate buffer system b. non- bicarbonate buffer system non-

Acid Base Balance

A. Bicarbonate buffer system
CO2 + H2O H+ + HCO3-

B. Non bicarbonate buffers - proteins histidine

- bone sodium bicarbonate calcium carbonate

Acid Base Balance



Pulmonary mechanism - can modify pH by changing PCO2 e.g. RR excretion of CO2 PCO2 pH Renal Mechanism - reabsorption of nearly all the filtered bicarbonate - excretion of hydrogen ion & addition of new bicarbonate to the blood

[H+] = 24 + Pco2/HCO3
Increase in Pco2 Decrease in HCO3 Decrease in Pco2 Increase in HCO3 Increases H+ =

pH

Decreases H+ = pH

Metabolic Acidosis
Clinical Manifestations - deep sighing breathing (Kaussmals) - pinkish cheeks/lips - hepatomegaly Treatment: mEq required=desired HCO3 actual HCO3 x k x weight in kg k = 0.5 0.6

Metabolic Acidosis


Empirical treatment 2 mEq/kg slow infusion not to exceed 3 doses Precaution 1. needle should be securely in the vein 2. given slowly 3. excessive administration should be avoided to prevent post acidotic tetany and hypernatremia

Fluid Loss
Degree of % Weight Loss dehydratio Infant n Children Mild 5% 3% Clinical features

Sunken eyes; depressed anterior fontanelle; dry skin,lips,tongue:mild oliguria Early shock;loss of skin elasticity & turgor;pale mottled skin;collapsed neck veins;marked oliguria;unstable vital signs Late shock;patient is dying or moribund

Moderate

10%

6%

Severe

15%

9%

Composition of Different Intravenous Fluids

Solution Na K Cl HCO3 Lactate Acetate 28 Ca Mg Lactated Ringers 130 4 109 1.5 -

Isotonic saline (NSS) 0.3 NaCl 0.45 NaCl Ionosol MB (IMB) Normosl M (NM) Normosol R (NR)

154 51 77 25 40 140

20 13 5

154 51 77 22 40 98

23

1.5 1.5 1.5

16 27

Rehydration Phase
Degree of dehydration MILD
Volume of fluid Manner of administration Fluid to administer Isotonic Hypotonic 0.3% NaCl in D5W 0.45% NaCl in D5W

infant 5% wt loss
50 ml/kg 1st 6 hours

children 3% wt loss
30 ml/kg

Hypertonic Deficit, maintenance and replacement combined and given in 48 hours as 0.15% NaCl in D5W

Rehydration Phase
Degree of dehydration Moderate
Volume of fluid Manner of administration Fluid to administer Isotonic Hypotonic Hypertonic D5LR D5LR D5 0.3% NaCl D5 0.45% NaCl

infant 10% wt loss

100 ml/kg 1st hour,1/4 of total

children 6% wt loss
60 ml/kg Next 5-6 hours:3/4 or 5remainder of deficit

( mix 1 part of 0.3% NaCl to 1 part plain D5W to make 0.15% NaCl in D5W

Rehydration Phase
Degree of dehydration SEVERE
Volume of fluid Manner of administration Fluid to administer Isotonic Hypotonic Hypertonic D5LR D5LR As above D50.3% NaCl D50.45% NaCl

infant 15% wt loss

children 9% wt loss
90 ml/kg

150 ml/kg

1st hour:1/3 of total Next 5-6 hours: 52/3 or remainder

Summary of Management During Rehydration Phase

1. 2. 3. 4.

Fluid loss Osmolality or sodium ion disturbance Other electrolyte abnormality AcidAcid-base imbalance

Maintenance Therapy
Body Weight (kg) Up to 10 100 mL/kg mL/Day

1111-20

1,000 mL + 50 mL/kg for each kg >10

Above 20

1,500 mL + 20 mL/kg for each kg > 20

Oral Rehydration Therapy



 

Simple method in the treatment of acute diarrhea thru the oral route Treats dehydration safely and effectively in over 90% of cases Reduces hospital admission by 50% to 60% Can be easily administer by mothers and caretakers

Physiologic Basis
Normal Small Intestine
INTAKE: isotonic salt isotonic salt + glucose

Moderate absorption (sodium + water)

Enhanced absorption (sodium + water)

Physiologic Basis
Acute Watery Diarrhea
INTAKE: nothing isotonic salt isotonic salt + glucose

RESULT: diarrhea diarrhea worsens dehydration develops

diarrhea hydration maintained or corrected

Clinical Types of Diarrhea

 

Acute watery diarrhea- last several hours or days: diarrheamain danger is dehydration Acute bloody diarrhea- dysentery, main dangers diarrheaare damage of the intestinal mucosa, sepsis and malnutrition Persistent diarrhea- lasts 14 days or longer, main diarrheadanger is malnutrition and serious non intestinal infection Diarrhea with severe malnutrition(marasmus or malnutrition(marasmus kwashiorkor)kwashiorkor)- main dangers are severe systemic infection, heartfailure & vitamin deficiency

Assessment of the Child with Diarrhea



History
- duration, number of watery stools/day - number of episodes of vomiting - presence of blood - presence of other symptoms/illness - feeding practices - drugs/other remedies taken

Physical Examination

Assessment of Diarrhea Patients for Dehydration

A LOOK AT: CONDITION* EYES THIRST* Well, alert Normal Drinks normally, not thirsty Goes back quickly

B Restless,irritable* Sunken Thirsty, drinks eagerly*

C Lethargic or unconscious* Sunken Drinks poorly, or not able to drink* Goes back very slowly*

FEEL: SKIN PINCH*

Goes back slowly*

DECIDE

The patient has NO DEHYDRATION

If the patient has 2 or more signs there is SOME DEHYDRATION

If the patient has 2 or more signs there is SEVERE DEHYDRATION Use Treatment plan C

TREAT

Use Treatment Plan A

Use Treatment Plan B

Estimate the Fluid Deficit

Assessment No dehydration Fluid deficit as % of body weight <5% Fluid deficit in ml/kg body weight <50 ml/kg

Some dehydration

5-10%

50-100ml/kg 50-

Severe dehydration

>10%

>100ml/kg

Treatment Plan A
   

Rule 1: Give the child more fluids than usual to prevent dehydration Rule 2: Give supplemental zinc for 10-14 days 10Rule 3:Continue to feed the child to prevent dehydration Rule 4: Take the child to health worker if there are signs of dehydration or other problems

Guidelines for Treating Children & Adults with Some Dehydration

Age Less than 4 months 4-11 months 12-23 12months 2-4 years 5-14 years 15 years or older

weight

Less than 5 kg 200-400 200-

5-7.9 kg

8-10.9 kg

11-15.9 kg 11-

16-29.9 kg 16-

30 kg or more 2200-4000 2200-

In ml

400-600 400-

600-800 600-

800-1200 800-

1200-2200 1200-

amount of ORS required can be calculated by multiplying the patients weight in kg by 75 If patient wants more ORS than computed, give more Continue breastfeeding If not breastfed and < 6 months old and using the old WHo ORS, give 100-200 ml of water 100-

The

ORT Failure
 

Continuing rapid stool loss Insufficient intake of ORS solution due to fatigue or lethargy Frequent severe vomiting ORS solution NGT Ringers Lactate Solution IV

WHAT TO DO?
 

Limitations of ORT
 

Abdominal distension with paralytic ileus Glucose malabsorption

Treatment Plan C
Age First give 30 mL/kg in: 1 houra Then give 70 mL/kg in: 5 hours

Infants (under 12 months Older

30 minutesa

2 hours

a. Repeat once if radial pulse is still very weak or not detectable

IV therapy not available

WHAT TO DO


ORS can be given thru NGT by trained healthworkers at a rate of 20 mL/kg for 6 hours If NG treatment not possible but the child can drink, ORS can be given by mouth at a rate of 20 mL/kg for 6 hours Reassessment should be done at least hourly

Persistent Diarrhea
 

 

Appropriate fluids to prevent or treat dehydration Nutritious diet that does not cause diarrhea to worsen Supplementary vitamins and minerals Antimicrobials to treat diagnosed infection

Diarrhea and Severe Malnutrition



 

Signs that remain useful -eagerness to rink -cool & moist extremities -weak or absent radial pulse - reduced or absent urine flow Special ORS (RESOMAL) is given over 12 hours Supplemental electrolytes

Antimicrobial
Cause Cholera Antibiotic(s) of choice Tetracycline 12.5 mg/kg 4x a day for 3 days CoCo-trimoxazole Ciprofloxacin 15mg/kg 2x a day for 3 days Cotrimoxazole at 5mg/kg 2x a day for 5 days Alternative Erythromycin 12.5 mg/kg 4x a day for 3 days Ceftriaxone 5050-100 mg/kg OD IM for 2 to 5 days Nalidix acid 15 mg/kg 4x a day for 5 days

Shigella dysentery

Antimicrobial
Cause Amoebiasis Antibiotic(s) of choice Metronidazole 10 mg/kg 3x a day for 5 days (10 days for severe disease)

Giardiasis

Metronidazole 10 mg/kg 3x a day for 5 days

Comparison of Oral Solutions

Solution Glucose Na (mmol/L) (mmol/L) 111 90 75 60 45 90 K (mmol/L) 20 20 20 20 20 80 Cl Base Osm (mmol/L) (mmol/L) 80 65 50 30 10 10 30 30 25 310 245

WHO (old)

WHO (new) 75 Glucolyte Pedialyte Hydrite 106.56 140 110

Comparison of Previous & Current Classifications of Dehydration

PREVIOUS NO MILD MODERATE SEVERE CURRENT NO SOME SEVERE

10

11

12