FLUIDS AND

ELECTROLYTES IN
PEDIATRICS

Christian John F. Fernandez, RN, MD, DPBEM, FPCEM

 F and E
• DEHYDRATION

• most common cause of uid and electrolyte

abnormalities in children

• results from a negative uid balance due to

decreased intake, increased output (renal,
GI, or insensible losses from the skin or
respiratory tract), or disease states such as
burns, sepsis, or diabetes
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 Dehydration
• infants and children are particularly • Infants also have a higher turnover rate for water
susceptible to dehydration
• TBW % body weight decreases from 70%
in a term infant
• dependent on caretakers to provide
oral uids (cannot regulate their • 75% to 80% in premature infants
intake)
• 60% at 1 year of age, remaining at this
percentage until puberty
• increased uid requirements
• decreased ability to concentrate the urine,
predispose infants to dehydration
• basal metabolic rates are highest in
young children (peak at 12 months • young children are more prone to
of age and gradually decreasing hypermetabolic states, such as high fever, which
starting at 3 years of age) also increases the need for free water
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 Dehydration
• change in weight - weight loss is the gold
standard for assessment of volume status

• spectrum of physical ndings ranging from a

normal exam if dehydration is mild, to hypovolemic
shock if dehydration is severe

• Tachycardia is an early sign of dehydration as the

body compensates for a decreased circulatory
volume
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 Water De cit Volume

• Water De cit = Pre - Illness weight (kg) - Illness Weight (Kgs)

• % dehydration = (pre -illness wt - illness wt / pre-illness wt) x 100%

• If wt loss is not known, clinical observation may be used

• Each 1% dehydration corresponds to 10ml/kg uid de cit

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 Laboratory Testing

• routine laboratory testing for assessing dehydration alone is generally not

required

• several studies have found a lack of correlation between laboratory values

and degree of dehydration based on percent weight lost

• perform a bedside glucose test in any child presenting with altered

level of consciousness, and rapidly correct hypoglycemia
 Overall Guidelines in F&E Mangement
• Appropriate uid management involves the calculation and administration
of water volume and electrolyte concentration of:

• Maintenance requirements

• De cit repletion

• Ongoing losses

• Clinical context is important (treat the underlying etiology rather than

responding to scenarios or laboratory values) and should be the basis for
the decision to start or hold maintenance uid
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 Maintenance Solute
• Urine represents the primary source of electrolyte loss, with variability based
on renal ability to dilute and concentrate.

• Although 3 mEq of Na per 100 mL of water should be su cient to maintain

+

basic sodium needs, there is overwhelming evidence that administration of

hypotonic uids to hospitalized children can lead to hyponatremia

• clinical practice, for isonatremic dehydration, one can estimate a sodium

repletion requirement of 8–10 mEq/100 mL uid de cit (in addition to 3 mEq/
100 mL of maintenance uid)

• maintenance potassium requirements (20 mEq/L of uid) should be given, as

long as the child is not in renal failure unless if patient is in hypokalemia
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Maintenance Treatment
Maintenance Treatment
 Calculate for the MR

• 6 kgs

• A 9 months old with fever, poor • 6 x 100 = 600

feeding with a weight of 6kgs.
• 600/24 =

• 25 cc/hr
 Calculate for the MR

1. 2 yrs old - 14kgs

2. 7 year old - 28kgs
3. 11 year old - 35kgs
 Calculate for the MR

• 2 yrs old - 14kgs

• 10 X 100 = 1000
• 4 X 50 = 200
• 1000 + 200 = 1200/24
• = 50 cc/hr
 Calculate for the MR
• 7 year old - 28kgs
• 10 x 100 = 1000
• 10 x 50 = 500
• 8 x 20 = 160
• 1000 + 500 + 160 = 1660/ 24
• 69 cc/hr
 Calculate for the MR

• 11 year old - 35kgs

• 10 x 100 = 1000
• 10 x 50 = 500
• 15 x 20 = 300
• 1000 + 500 + 300 = 75 cc/hr
Fluids to Use as MR
Age Fluids

0 day old - 7 days D5IMB or Dextrosity

1 week - 2 yrs old D5IMB

2 yrs above D5.3Nacl/ D5NSS

Special Conditions Fluids

Cancer Patients D5NM

Diabetic/Hydration PNSS/PLR

Dengue D5LR
 Dextrosity in Newborns
• Total Fluid Rate:

• Preterm = 100ml/kg • Divide the TFR over 2 (12hrs)

• Term = 80ml/kg • To Compute:

• Other way to compute: • Cal Gluc = wt x 2

• <1500 = 100ml/kg • D50W = 0.055 (TFR/2)

• 1500 - 2500 = 90ml/kg • D5W = ([TFR/2] - D50w - Calgluc)

• >2500 = 80ml/kg
 How to Compute
• Preterm Infant at 1.7kgs

• 1.7kgs x 100 = 170 divided by 2 = 85

• Cal Gluc = 1.7kgs x 2 = 3.4

• D50W = 0.055 x 85 = 4.657

• D5W = 85 - 3.4 - 4.657 = 76.9

• In a soluset, pls start above computation to run for 12 hrs x 2 cycles

 Important Notes
• Everyday, add 10ml to the TFR

• If a NB has a weight of 1.4kgs = 1.4 x 100 = 140ml

H T
I G
W E E
• Day 1 of Life = 1.4 x 110ml = 154ml S A T
A Y O N
LW N E
• Day 4 of Life = 1.4 x 140ml = 196ml A E
T H
• Day 8 = D5IMB

• Change D5W to D10W in TERM Infants, no D50w

 FOR A TERM INFANT

• 3 DAYS OLD AT 3.2 KGS

• 3.2kgs x 80ml = 256ml divide by 2 = 128ml

• Cal Gluc = 3.2kgs x 2 = 6.4

• D10W = 128 - 6.4 = 121.6

• In a soluset, pls start above computation to run for 12 hrs x 2 cycles

 Solve for the ff Dextrosity

1. Preterm Neonate at 1.5kgs

2. Term Neonate at 2.8kgs

3. 3 Day old Term Infant at 2.1kgs

4. 1.2kgs del at lying in, brought to ED for admission

5. 2.9kgs baby boy found in a trash bin

 Answer

1. Preterm Neonate at 1.5kgs

2. Term Neonate at 2.8kgs
• 1.5kgs x 100 = 150 / 2 = 75
• 2.8kgs x 80 = 224 / 2 = 112
• Cal Gluc = 1.5kgs x 2 = 3
• Cal Gluc = 2.8 kgs x 2 = 5.6
• D50W = 0.055 x 75 = 4.125
• D10W = 112 - 5.6 = 106.4
• D5W = 75 - 7.125 = 67.875
 Answer
4. 1.2kgs del at lying in, brought to
ED for admission
3. 3 Day old Term Infant at 2.1kgs
• 1.2kgs x 100 = 120/ 2 = 60
• 2.1kgs x 110 = 231 / 2 = 115.5
• Cal Gluc = 1.2 kgs x 2 = 2.4
• Cal Gluc = 2.1kgs x 2 = 4.2
• D50W = 0.055 x 60 = 3.3
• D10W = 115.5 - 4.2 = 111.3
• D5W = 60 - 2.4 - 3.3 = 54.3
 Answer

5. 2.9kgs baby boy found in a trash

bin

• 2.9kgs x 80 = 232 / 2 = 116

• Cal Gluc = 2.9kgs x 2 = 5.8

• D10W = 116 - 5.8 = 110.2

Correction of Dehydration
Hemorrhagic or Hypovolemic Shock
Hemorrhagic or Hypovolemic Shock
Correction of Dehydration
Dehydration
Weight Fluids to Use
Status

Less than 10kgs x More than 10kgs x

Mild D5.3Nacl
50ml 30ml

Less than 10kgs x More than 10kgs x 1/4 - PNSS for 1 hr

Moderate
100ml 60ml 3/4 - D5LR for 7 hrs

Less than 10kgs x More than 10kgs x 1/3 - PNSS/LR x 1hr

Severe
150ml 90ml 2/3 - D5LR x 7hrs
 Example
• 5.2kgs, moderately dehydrated

• 5.2 x 100 = 520 ml

• A 2 months old presented with LBM
approximately 10 eps and vomiting of • 520 divide by 4 = 130
6 episodes. He is moderately
dehydrated and weights 5.2kgs. • 520 - 130 = 390
Calculate for the uid requirement:
• 130 ml x 1hr

• 390 x 7hrs
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 Example
• 50 kgs - severely dehydrated

• Give 10ml per kilo til with BP or with signs of

volume overload

• A 14 years old presented with LBM • May start inotropes

for 3 days, He has cold clammy skin,
lethargic, sunken eyeballs, palp 40BP • Or you may use 50kgs x 90 = 4500
and weights 50kgs. Calculate for the
uid requirement: • 4500/3 - 1500 (bolus)

• 3000/7 = 428ml/hr (use this if pt still has no

BP or signs of uid overload, but make sure
to monitor pt and if with u/o, revert to mod or
mild rate)
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 Calculate for the FR

1. 9kgs, mildly dehydrated

2. 15kgs, faint pulse at 129, cracked lips, last UO 8hrs ago

3. 32kgs, deep set eyes, dry lips, tenting skin, PR 102

 Answer

1. 9kgs, mildly dehydrated

• 9kgs x 50ml = 450ml

• 450ml divide by 8hrs =

• 56cc/hr
 Answer

2. 15kgs, faint pulse at 129, cracked lips, last UO 8hrs ago

• 15kgs x 90ml = 1350cc

• 1350 divide by 3 = 450cc

• Give 450cc as bolus now then 900 cc for 7 hrs (128cc/hr)

• OR - 150cc bolus til with stable VS

 Answer

3. 32kgs, deep set eyes, dry lips, tenting skin, PR 102

• 32kgs x 60 = 480ml

• 205ml/hr for 7 hrs

• Always take note if with signs of improvement you can convert to

mild or maintenance rate
 On Going Losses
• represent continued losses of uid and solute after initial presentation
(persistent vomiting and/or diarrhea, high fever with diuresis, or nasogastric
suction)

• If losses can be measured directly, they should be replaced 1:1 concurrently

• If losses cannot be measured,
• estimate of 10 mL/kg body weight for each watery stool
• 2 mL/kg body weight for each episode of emesis
•
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Dengue Fluid Management
 Fluid Management in Dengue

• Fluid management for admitted

patients without signs of shock

• Use isotonic solutions (D5LR, D5NSS

or D50.9NaCl)

• Use the Holiday Segar or Ludan

Method
 Dengue with MD or WS
• If patient shows signs of mild dehydration but is NOT in shock, the volume needed for mild
dehydration is added to the maintenance uids to determine the total uid requirement (TFR)

• TFR = Maintenance IVF + Fluid for Mild Dehydration or

• TFR = 3cc/kg

• computed as follows:

• Infant = 50 ml/kg

• Other Child or Adult = 30 mL/kg

• One-half of the computed TFR is given in 8 hours and the remaining one-half is given in the
next 16 hours
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 Example

• 18kgs, Dengue with Warning Signs

• 18 kgs maintenance rate = 1400ml

• 18 kgs at mild dehydration = 540ml

• 1940ml divide by 24hrs = 81cc/hr

• TFR of 3 = 3 x 18kgs = 54cc/hr

 Answer

• 10kgs, 6months old, low PC at 88

• 10kgs maintenance rate = 1000ml

• 10 x 50ml = 500ml

• 1500ml divide by 24 = 62cc/hr

• TFR 3 = 10 x 3 = 30cc/hr
 Reassessment

• Periodic assessment is needed so that uid may be adjusted accordingly

• Clinical parameters should be monitored closely and correlated with the

hematocrit

• Ensure adequate rehydration, avoiding under and over hydration

• IVF rate may be decreased anytime as necessary based on clinical

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Monitoring by Health Care Providers:
• Patients with warning signs should be monitored until the “at-risk” period is over
• Vital signs and peripheral perfusion (1-4 hourly until the patient is out of critical phase)
• Urine output (4-6 hourly)
• Hematocrit (before and after uid replacement, then 6-12 hourly)
• Blood glucose
• Other organ functions (such as renal pro le, liverpro le, coagulation pro le, as
indicated)
•
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Dengue with Compensated Shock
• Start intravenous uid resuscitation with isotonic crystalloid solutions at 10 - 15 mL/kg/hr over 1
hour

• reassess the patients condition (vital signs, capillary re ll time, hematocrit, urine output) and
decide depending on the situation:

• If the patients condition improves, intravenous uids should be gradually reduced to

• 5-7 mL/kg/hr for 1-2 hours, then

• 3-5 mL/kg/hr for 2-4 hours, then

• 2-3 mL/kg/hr and then

• reduce further depending on hemodynamic status, which can be maintained for up to 24 to

48 hours
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Dengue with Compensated Shock
• If If vital signs are still unstable (shock persists), check the hematocrit after the rst bolus:

• If hematocrit increases or is still high (>50%), repeat a second bolus of crystalloid solution
at 10- 20 mL/kg/hr for 1 hour

• After this second bolus, if there is improvement, then reduce the rate to 7-10 mL/kg/hr for
1-2 hours, and then continue to reduce as above

• If hematocrit decreases compared to the initial reference hematocrit (<40% in children),

this indicates bleeding and the need to cross-match and transfuse blood as soon as
possible

• Further boluses of crystalloid or colloidal solutions may need to be given during the next
24 to 48 hours

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 Answer

• 17kgs, 2 years old, HR of 143, BP 90/70

• The patient is in?

Dengue with Hypotensive Shock
• Initiate intravenous uid resuscitation with crystalloid or colloid solution (if
available) at 20 mL/kg as a bolus given over 15 minutes to bring the patient out of
shock as quickly as possible.

• If the patient’s condition improves, give a crystalloid/ colloid infusion of 10 mL/kg/

hr for 1 hour, then continue with crystalloid infusion and gradually reduce

• To 5-7 mL/kg/hr for 1-2 hours, then

• To 3-5 mL/kg/hr for 2-4 hours and then
• To 2-3 mL/kg/hr or less, which can be maintained for up to 24 to 48 hrs
• Fluid should not exceed 3L per day to avoid uid overload
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Dengue with Hypotensive Shock
• If vital signs are still unstable (shock persists), check hematocrit after the rst bolus:

• If hematocrit increases compared to the previous value or remains very high (>50%),

• change intravenous uids to colloid solutions at 10-20 mL/kg as a second bolus

over 1⁄2 to 1 hour.

• after this dose, reduce the rate to 7-10 mL/kg/hr for 1-2 hours

• then change back to crystalloid solution and reduce rate of infusion as mentioned
above when the patient’s condition improves

• Further boluses of uid may need to be given during the next 24 hours. The rate and
volume of each bolus infusion should be titrated to the clinical response. Patients with
severe dengue should be admitted to the high dependency or intensive care areas.
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 Answer

• 29kgs, palp 40BP, faint pulses, clear breath

• How will you manage this patient?

Electrolyte Imbalance
 Hyponatremia
• most common electrolyte disturbance in critically ill children

• de ned as S. sodium less than 135 mEq/L

• serum sodium above 130 mEq/L is usually asymptomatic and no treatment is

necessar

• serum sodium falls rapidly to 125 mEq/L or less cerebral edema can occur and
CNS symptoms can occur

• child is to be treated with hypertonic saline, 3% NaCl 10-12 ml/kg over a period
of 2-4 hours (1 ml NaCl= 0.5 mEq Na)

• once the acute symptoms are controlled further correction is done gradually over
a period of 48 hours
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Sodium Requirement Formula

• 0.6 × body weight × (135 – measured serum sodium)

• 135 is the expected serum Na

• should be given over 48 hours

• serum sodium is to be increased at a rate 0.5 mEq/L per

hour or not more than 12 mEq/day
 Hypernatremia
• Serum sodium level above 150 mEq/L, rare compared to hyponatremia, often due to increased free water loss
or true gain in sodium

• occurs in:
• infants with ADD especially when they are o ered high solute containing uids
• extremely premature babies who have large insensible water losses through immature skin
• exclusively breast fed infants when there is lactation failure or in hot weather can develop hypernatremia
• central or nephrogenic diabetes insipidus can result in excessive water loss
• accidental or intentional salt poisoning, sea water drowning, administration of hypertonic saline or
sodium bicarbonate are other causes.

• Marked thirst and irritability inappropriate for other signs of dehydration are the characteristic features in
infancy
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 Treatment
• more common problem is hypovolemic
• No uid bolus unless the child is in
hypernatremia or hypernatremic dehydration
which is due to free water de cit
shock

• correction should be done by slow rehydration • free water de cit can be calculated as:
• uid de cit should be corrected in 48 hours or • Free water de cit = 0.6 × Wt × (S.
longer sodium – expected sodium) – 1
(this de cit is pure water)
• volume of uid to be given is

= 2 × maintenance uid + calculated • total free water de cit can be calculated

de cit to be given equally spread over 48 and the rest of the uid can be given as
hours isotonic saline
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 Treatment
• rate of fall of sodium should not be not more than 0.5 mEq/ L/hr or not more than 12
mEq/L/day

• sudden fall in S. sodium is to be avoided as this can result in several complications

(cell from shrinkage, cerebral edema, seizures, respiratory and pupillary irregularities
and even death, extrapontine myelinolysis

• Hyperglycemia encountered in hypernatremic dehydration as the high serum sodium

has an inhibitory e ect on insulin secretion

• Insulin should not be given as this will worsen cerebral edema

• Glucose in IV uids can be reduced to 2.5% or patient is allowed free water orally by
nasogastric tube as hourly instalment to prevent worsening of hyperglycemia
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 Hypokalemia
• de ned as serum potassium of < 3.5 mEq/L which can
occur in this conditions with total body potassium is low: • Clinical history along with analysis of urine potassium, acid base
balance and urine chloride gives the right diagnosis:

• PEM • Urine K < 20 mEq/L

• GI losses in diarrhea or vomiting • Low Bicarbonate—Diarrhea High Bicarbonate—Vomiting
• Ketonuria • Urine K > 20 mEq/L

• RTA • Low Bicarbonate—RTA

• Bartter’s syndrome • Urine K > 20 mEq/L, Urine Cl < 10 mEq/L

• Steroid therapy • Vomiting

• Hypokalemia without decrease in body potassium can • Urine K > 20 mEq/L, Urine Cl > 10 mEq/L
occur due to transcellular shift of potassium as in
• Diuretics, Bartter’s syndrome, Mg depletion, Extreme K
(administration of glucose, insulin, catecholamines, depletion
bicarbonate)
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 Treatment
• Hypokalemia need to be corrected slowly, orally if feasible

• if given IV it should be diluted and given with uids, upto 40 mEq/L

• If up to 80 mEq/L can be given if required under continuous ECG monitoring in ICU set up

• One ml KCl yields 2 mEq of potassium

• Rapid correction may be necessitated in severe hypokalemia

• cardiac arrhythmias, bradycardia, slow respiration and severe muscular weakness

• 0.5 to 1 mEq/kg can be given suitably diluted over 1 hour with continuous ECG monitoring

• should never be given as a bolus, max of 3mEqs/kg in 6hrs

• persistent hypokalemia should arouse suspicion of hypomagnesemia

• co-existant hypocalcemia and acidosis correction should be deferred since bicarbonate can still lower serum potassium
and administration of calcium can precipitate cardiotoxicity
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 Hyperkalemia
• De ned as serum potassium more than 5 mEq/L • Spurious hyperkalemia occur during excessive pressure of
tissues during the collection of blood
• Causes - often renal as kidney is the main route
• Mild hyperkalemia
of excretion of potassium
• K level is < 6.5 mEq/L No ECG changes
• Renal failure
• Moderate
• Drugs like ACE inhibitors
• K levels 6.5 mEq/L ECG changes -peaking of T
waves.
• Aldosterone antagonists
• Severe
• Adrenal insu ciency
• K levels >8 mEq/L or regardless of plasma K
• Transcellular shifts of potassium from ICF → levels ECG shows
ECF occurs in acidosis, β blockers
• Widened QRS complexes, attenig of p waves
or ventricular arrhythmias.
• Crush injuries, burns
•
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 Treatment
1. Sodium bicarbonate 2 mEq/kg IV diluted and
as a rapid push in 3 to 5 minutes
• Measures aims at:
2. Calcium gluconate 10% 0.5 to 1 ml/kg IV as a
rapid push over 3 to 5 minutes
• Shift of potassium into cells
3. Glucose 0.5 to 1 gm/kg IV over 30 minutes
• Antagonism of e ects of accompanied by regular insulin 0.1 to 0.2 u/kg
potassium
4. Na/K cation exchanger orally or as a retention
enema over 30 to 45 minues.
• Removal of potassium from
body. 5. Finally, if these measures fail or because of
accompanying renal failure, peritonial or
hemodialysis must be instituted.
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 Hypocalcemia
• De ned as total serum calcium • In children the causes are:
• Vitamin D de ciency
• less than 8.5 mg/dl in children
• Hypoalbuminemia
• less than 8 mg/dl in term
neonates • Alkalosis

• less than 7 mg/dl in pre term • Hypoparathyroidism

babies
• Renal failure
• Cause of hypocalcemia varry with • Malabsorption syndrome
age
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 Treatment
• Asymptomatic hypocalcemia is treated with oral Ca. 100- 200 mg/kg/day of elemental Ca as calcium
gluconate or carbonate

• Vitamin D supplements may be required in patients with renal disease and vitamin D de ciency states.
• In critically ill patients IV calcium is given as 10% calcium gluconate in a dose of 1-2ml/kg IV over 3-5
minute up to a total of 10 ml with cardiac monitoring

• Calcium gluconate contains 9.8 mg/ml or 0.45 mEq/ml of elemental calcium

• Calcium chloride 10% contains 27mg/ml and so is more irritating to the veins
• The bolus can be followed by 100-200 mg/kg of IV calcium gluconate infusions over 24 hours in
children

• If magnesium is low, 50% magnesium sulfate may be given as 0.1 - 0.2 ml/kg IM every 12-24 hours
as needed.

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 Hypercalcemia
• De ned as S. calcium levels >12mg/dl
• rare as compared to hypocalcemia
• Causes varry with age and in infants and children the causes
• Vitamin D excess
• Primary hyperparathyroidism
• Idiopathic infantile hypercalcemia
• William’s syndrome
• Severe autosomal recessive hyperphosphatasia
• Thiazide diuretics
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 Treatment
• Primary line of treatment is to augment urinary losses of calcium by saline
diuresis coupled with IV furosemide

• 1.5- 2 times the maintenance uid requirement is given with close monitoring
of S. electrolytes and urine output

• If serum calcium is greater than 14 mg/dl calcitonin 2-4 units/kg every 6-12
hours may be used

• Biphosphonates such as pamidronates at 0.5 to 1 mg/kg/dose over 4-5

hours can be tried but rarely used in children

• In severe hypercalcemia dialysis is life-saving

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 Hypomagnesemia
• De ned as serum Mg < 1.8 mEq/L
• Causes
• Diarrhea
• nasogastric suction IBD
• ↑ Renal losses with drugs like Thiazides
• Loop diuretics, Aminoglycosides, Amphoterecin B
• Poorly controlled diabetes, recovery of diabetic keto- acidosis
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 Treatment
• if mild and asymptomatic oral replacement with 10-20 mg/ kg/day of elemental
magnesium in 3-4 divided doses is enough

• In symptomatic hypomagnesemia IV magnesium can be given 1 mEq/kg over 2-6 hours

on day 1

• followed by 0.5 mEq/kg over 2-4 hours for next 3 days

• 50% Mg SO contains 4 mEq per ml (48 mg)

4

• total replacement recquired would be about 4 mEq/kg

• careful monitoring of electrolytes and blood pressure is required during IV magnesium

infusion due to the chance of developing hypotension, hypocalcemia and
hypermagnesemia
 Hypermagnesemia

• is de ned as serum magnesium levels above 2.5 mEq/L

• patients in renal failure with excessive intake of Mg, trauma, shock, burns,
initial dehyrated phase of DKA
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 Treatment
• IV calcium gluconate 1 ml/kg diluted is given slowly with cardiac
monitoring to antagonize the e ects of Mg at the cardiac membrane and
neuromuscular level

• If urine output is good, saline diuresis can be given

• non Mg containing enemas or cathartics may be given to enhance GI

clearance

• In hypermagnesemia with S. Mg >8 mEq/L dialysis is indicated and also in

any patient with cardiovascular or neuromuscular e ects of
hypernagnesemia, irrespective of the serum level
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Acid Base Disturbance
 Values Obtained
• pH—represents a measure of the overall acid-base balance.

• PCO —represents arterial CO levels and thus gives a measure of the

2 2

ventilatory status.

• PO —represents the oxygen tension in the arterial blood and gives the
2

oxygenation status.

• HCO —Base excess or de cit indicate the metabolic component of acid-

3

base status.
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 Steps in Analyzing the Values
1. What is the overall acid-base status given by pH- acidosis or alkalosis?

2. What is the ventilatory status given by the PCO2 and oxygenation status
given by PO2?

3. What is the metabolic status given by HCO3?

4. What is the problem?.

Acute? Compensated? Uncompensated? Partially Compensated?
Simple? Mixed?
Chronic?
Practical Approach to Rapid Analysis of ABG

1. Look at pH < 7.35 Acidosis > 7.45 Alkalosis

Normal pH does not rule out an ABG disorder

2. Look at bicarbonate. Is it normal?

If bicarbonate is responsible for the pH change, the pH will change in
the direction of the change in bicarbonate.

3.Look at PCO2. Is it normal?

If CO2 is responsible for the change in pH then the pH will change in the
opposite direction of the change in PCO2. Increase in PCO2 will
decrease pH and vice versa.
 Correction
• calculating the total base de cit

• based on the fact that HCO is located in the extracellular compartment

3

which consists of 30% of body weight

• total base de cit is calculated by

• Base de cit estimate is using the weight multiplied by 2

• 10 kg Child x 2 = 20

• Give 20meqs of sodium bicarb at 1:1 dilution

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 Correction
• Only half the calculated dose is to be
given in 2-3 hours
• If with ABG Result
• Due to the detrimental e ects
• Base Excess x wt x 0.6 encountered with bicarbonate therapy
(fast correction) (tetany, cardiac arrhythmias, intra-
ventricular hemorrhage in newborn) base
• Base Excess x wt x 0.3 de cit is not corrected until the serum
(slow correction) bicarbonate value is < 10 mEq /L or
the pH is <7.2 unless there is
cardiopulmonary instability
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 Answer

• FAST CORRECTION • SLOW CORRECTION

• BE - 14 • BE - 4

• Wt - 19kgs • Wt = 12kgs

• 14 x 19 x 0.6 = 159.2 /2 = 79.8 • 4 x 12 x 0.3 = 14.4/2

• MAX OF 50 meqs • = 7.2meqs

 General Rule of Treatment
• Respiratory Acidosis
• maintenance of ventilation and hemodynamic status is the mainstay of treatment
• correction of the speci c underlying disorder also is essential
• alkali therapy is not indicated unless the patient has severe hyperkalemia and
ventricular brillation

• chronic respiratory acidosis per se does not require speci c therapy but
hypoxemia must always be treated

• chronic respiratory acidosis is over compensated then metabolic alkalosis may

occur and in such situation patient may be treated with potassium chloride
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 General Rule of Treatment
• Respiratory Alkalosis

• Most common cause is functional hyperventilation. Other causes are Gram neg
sepsis, salicylate intoxication, asphyxiants and cerebral diseases with involvement
of respiratory centre producing hyperventilation.

• Treatment is to correct the underlying disorder. In hyperventilation rebreathing into a

bag will usually terminate the attack

• Metabolic Acidosis

• Look for anion gap. Wide anion gap means addition of an acid load. Bicarbonate
therpy is given when pH is < 7.2 after ensuring good perfusion and ventilation.
 General Rule of Treatment
• Metabolic Alkalosis
• Classi ed according to urinary chloride.
• Low urinary chloride (<10 mEq/L) “Chloride responsive” Hypovolemic
• Diuretic therapy, Nasogastric suction, Vomiting, Secretory diarrhea
• High urinary chloride (> 20 mEq/L) normo or hypervolemic, Bartter’s syndrome,
Cushing’s syndrome, Hyperaldosteronism, Potassium depletion, Alkali
administration

• Treat the underlying cause rst and correct by normal saline if indicated
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Questions?