PEDIATRIC FLUIDS

Katinka Kersten, MD

ECF and ICF

Body has two fluid compartments
Extracellular fluid (ECF) space makes up 1/3 of our body fluids Intracellular fluid (ICF) space makes up 2/3 of our body fluids

Extracellular space refers to fluids outside our cells which may be interstitial fluid or plasma Total body water = 0.6 X weight (kg) for children and adults and 0.78 X weight (kg) for neonates and infants

Approach to Fluid Calculations

1. Maintenance: Determined by a system: a. Caloric expenditure method b. Holliday-Segar method c. Surface area method Determined by acute weight change or clinical estimate Determined by measuring

2. Deficit: 3. Ongoing losses:

Maintenance Fluids

Caloric Expenditure Method

Based on understanding that water and electrolyte requirements parallel caloric expenditure but not body weight Is effective for all ages, shapes, and clinical states, many age based tables exist for estimating caloric needs Per 100 calories metabolized you need 100120 ml H2O, 2-4 mEq Na+, and 2-3 mEq K+

Holliday-Segar Method
Quick, simple formula that estimates caloric expenditure from weight alone Assumes that for each 100 calories metabolized, 100 ml H2O will be required (50 ml/100 calories for insensible loss, 67 ml/100 calories for urine and 17 ml/100 calories gained from metabolism) Not suitable for neonates < 14 days old

Holliday-Segar cont.
WEIGHT (kg)
0 - 10 11 20 >20

FLUIDS
100 ml/kg/day 1000 ml + 50 ml/kg for each kg above 10 1500 ml + 20 ml/kg for each kg above 20

Electrolyte needs per 100 ml:

Na+ 3 mEq Cl- 2 mEq K+ 2 mEq

Body Surface Area Method

For non-dehydrated patients Water 1500 ml/M2/24 hr Sodium 30-50 mEq/M2/24 hr Potassium 20-40 mEq/M2/24 hr Mild dehydration Water 2000 ml/ M2/24 hr Moderate dehydration Water 2500 ml/ M2/24 hr

Examples
A 6 kg child needs 600 ml/day, which equals 25 ml/hr
A 35 kg child needs 1800 ml/day,which equals 75 ml/hr A 14 kg child needs 1200 ml fluids with: Na K Cl 36 mEq (3 mEq/100 cal) 24 mEq (2 mEq/100 cal) 48 mEq (4 mEq/100 cal)

Modifications
Increase Fever (12% for each oC above 37 oC ) High ambient temperature Diabetes mellitus Diabetes insipidus Vigorous exercise Decrease Renal failure Heart failure Inappropriate secretion of ADH High-humidity respiratory therapy

Acute Renal Failure

Meticulous management of fluids and electrolytes is required, including twice daily weights, strict I/Os and close laboratory monitoring Oligo-anuric patients should receive fluid intake equal to their total output; output must include insensible losses Insensible losses should be replaced with D5W (or D10W)

Neonates
Insensible losses in neonates vary with gestational age and birth weight and may be dramatically increased by phototherapy or radiant warmers Newborns cannot concentrate urine as well and GFR is lower so they are more prone to fluid overload

Deficit Therapy

Clinical Observations
Examination Skin turgor Skin-touch Buccal mucosa/lips Eyes Crying/tears Fontanelle CNS Pulse Urine output 3-5% (mild) Normal Normal Moist Normal Present Flat Consolable Regular Normal 10% (moderate) Tenting Dry Dry Deep set Reduced Soft Irritable Slight increase Decreased >10% (severe) None Clammy Parched Sunken None Sunken Lethargic Increased Anuric

Tenting

ECF and ICF Composition

ICF (mEq/L) Sodium 20 Potassium 150 Chloride --Bicarbonate 10 Phosphate 110-115 Protein 75 ECF (mEq/L) 135-145 3-5 98-110 20-25 5 10

Electrolytes in Body Fluids (mEq/L)

Na 20-80 100-140 10-90 10-30 50-130 K 15 15 40 10 15 Cl 125 155 40 25 75 HCO3 0 40 40 0 0

Gastric juice Small-intestinal juice Diarrhea Sweat normal Sweat CF

ECF and ICF Percentage of Loss

% fluid of deficit from ECF 80 60 % fluid of deficit from ICF 20 40

Duration of illness <3 days >3days

Laboratory Tests that can Help

Urine specific gravity Urine electrolytes Fractional excretion of Na+ (UNa/PNa)/(UCr/PCr) Serum electrolytes Serum osmolality
2(Na) + BUN/2.8 + glucose/18

Renal function

Isonatremic Dehydration
Patient is dehydrated and Na+ is 135-145 mEq/L Determine fluid deficit as percentage of weight based on clinical findings Determine which parts of deficit come from ICF versus ECF compartments based on duration of illness ECF Na+ loss = Fluid deficit (L) X % from ECF X 145 ICF K+ loss = Fluid deficit (L) X % from ICF X 150

Hyponatremic Dehydration
Na+ is < 135 mEq/L Follow same steps as for isonatremic dehydration Additional Na+ requirement = (CD CP) X fD x wt
-CD is concentration desired -CP is concentration present -fD is distrubution factor as fraction of body weight (L/kg); 0.6-0.7 for Na+

Hyponatremic Dehydration cont.

Frequently seen in children with vomiting and diarrhea who have received tap water as an oral replacement Shock is an early symptom Physical exam findings usually exaggerate amount of dehydration Correcting Na+ to quickly in adults can lead to central pontine myelinosis; this has not been described in children

Hypernatremic Dehydration
Before you start any fluid and electrolyte calculations you need to determine free water (FW) amount
(Na+)actual (Na+)desired x 100 ml/L x 0.6L/kg of body weight = ml/kg FW + (Na ) actual

Based on above formula for Na+ < 170 mEq/L approximately 4 ml of FW needed to bring Na+ down by 1 mEq/L/kg; for Na+ > 170 mEq/L approximately 3 ml of FW needed to bring Na+ down by 1 mEq/L/kg Subtract FW from total fluid deficit and replace remainder in same way as done for isonatremic dehydration

Hypernatremic Dehydration cont.

Mortality can be high Often iatrogenic The circulating volume is preserved at the expense of the intracellular volume and circulatory disturbance is delayed The patient looks better than you would expect based on fluid loss Always assume total fluid deficit of at least 10% You only want to correct half of the fee water deficit in first 24 hours if Na+ < 175 mEq/L For Na+ > 175 mEq/L you do not want to correct faster than 1 mEq/L/hr because of risk of cerebral edema

Electrolytes in Popular Drinks

Na (mEq/L) K (mEq/L) Apple juice 0.4 26 Coke 4.3 0.1 Gatorade 21 2.5 Milk 22 36 OJ 0.2 49 Pedialyte 45 20 WHO ORS 90 20

Composition of Parenteral Fluids

Fluid cal/L Na mEq/l D5W 170 D10W 340 NS 154 1/2 NS 77 D5 1/4 NS 170 34 LR 130 Alb. 25% 1000 100-160 K CL HCO3

154 77 34 109 28 <120

Clinical Dehydration Scenarios

Isonatremic Dehydration
A 2 year old has a 4-day history of gastroenteritis, poor fluid intake and infrequent urination. On exam you find dryness of the mucous membranes, sunken eyes with mild tenting of the skin. The serum sodium is 137 mEq/L. The weight is 10 kg. You determine the child is suffering from about 10% dehydration. What are the fluid and electrolyte requirements?

Isonatremic Dehydration
H2O Na K Cl (ml) (mEq) (mEq) (mEq) 1000 30 20 40
60

Maintenance Total deficit = 1000 ml Extracellular fluid deficit 600 87 (60% of total) Intracellular fluid deficit 400 (40% of total) Total 2000 117

60
80

100

Hyponatremic Dehydration
You see a 3 year old who has had diarrhea and been vomiting for 3 days. She has been drinking tap water most of this time. Examination shows sunken eyes and marked tenting of the skin but the child is not in shock. The serum Na+ is 120 mEq/L. The weight 14 kg. You estimate the deficit as 7%. What are the fluid and electrolyte requirements for this patient?

Hyponatremic Dehydration
Maintenance Deficit (7% of 14 kg) Extracellular fluid (60%) Intracellular fluid (40%) Additional sodium {(135-120) x 0.6 x 14} Additional chloride {(135-120) x 0.4 x 14} Total H2O Na K Cl (ml) (mEq)(mEq)(mEq) 1200 36 24 48 600 87 400 126 60 84 60 84 192

2200 249

Hypernatremic Dehydration
You see a 6 month old suffering for 4 days from severe diarrhea. The mucous membranes are dry, skin feels doughy and the child is somnolent and lethargic. The serum Na+ is 165 mEq/L. The child weighs 5 kg and you assume the fluid deficit is at least 10%.
What are the fluid and electrolyte requirements?

Hypernatremic Dehydration
Maintenance Total deficit = 500 ml Free water deficit {(165-145)x1/2x4x5} Remainder of deficit (500-200) = 300 ml Extracellular (60%) Intracellular (40%) Total H2O Na K Cl (ml) (mEq)(mEq)(mEq) 500 15 10 20

200

180 120

26 -

18 29

18 38

1000 42

Phase Approach
PHASE 1
Emergency restoration of circulation if patient is hypovolemic 10-20 ml/kg of isotonic fluids only

PHASE 2
Replacement of of the fluid loss (deficit and maintenance) in first 8 hours

PHASE 3
Replacement of remaining of the fluid loss (maintenance and remaining deficit) in next 16 hours Replacement of potassium after voids

Nursing Orders
Write the type of basic fluid
D51/2 NS most commonly used on pediatric wards (premixed bags are present) Can create any fluid you desire but may take longer to get if not premixed available

Add other electrolytes as desired to the basic fluid

Most commonly KCL added at 20 mEq/L but may need more to replace deficit Often only added after first void in dehydrated patients

Write how fast you want it to run in ml/hr For example for 15 kg non-dehydrated child write D51/2NS + 20 mEq/L of KCL to run at 50 ml/hr

Patient Rounds
Report total 24 hr intake Report what part of total intake was oral v.s. intravenous v.s. G-tube Subsequently report intake as ml/kg/day for children with weight < 10 kg Intake for children with weight > 10 kg should be reported as % of maintenance For example a 25 kg afebrile child had a total intake of 2000 ml for the past 24 hr, 1600 ml was from iv fluids and 400 ml was po, this represents 125 % of maintenance need for this child

Patient Rounds cont.

Report total 24 hr output Report where this output came from (urine, vomit, diarrhea, chest tube, stoma etc) For the urinary output report this in ml/kg/hr as well