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1) 24
2)
3)
(Volume)
24 maintenance fluid, deficit fluid
concurrent loss
Maintenance fluid
insensible water loss 45 mL/100 Kcal sensible water loss 55 - 105
mL/100 Kcal 1
30 mL/100 Kcal total maintenance fluid 100 mL/100 Kcal
parenteral nutrition urea
50 mL/100 Kcal 80 mL/100 Kcal/24 hr 4
mL/100 Kcal/hr maintenance fluid 150 mL/100 Kcal/24 hr
maintenance fluid Holliday Segar caloric requirement
Weight (Kg)
Kcal/kg/day
< 10
100
10 - 20
1000 + 50 Kcal/kg 10
> 20
1500 + 20 Kcal/kg 20
438
1 Maintenance fluid
(mL/100 Kcal)
Insensible water loss
- lung (ventilation)
- skin (evaporation)
Sensible water loss
- sweat
- stool
- urine
Total maintenance fluid
15
30
20
5
30 - 80
100 -150
Deficit fluid
(degree of dehydration) mild, moderate severe dehydration
skin turgor, mucous membrane, anterior fontanelle, eye balls, capillary
refill, vital signs 2
72 (acute dehydration) 72 (chronic
dehydration) calories calories
1 2
2 (degree of dehydration)
mild
3-5
30 - 50
moderate
5-7
50 - 70
normal
<2 sec
normal
not depress
good
normal
2-3 sec
slightly sunken
slightly depressed
fair
439
Severe
7
70 100
,
, pulse pressure
> 3 sec
marked sunken
markedly depressed
poor
, oliguria
(Form of fluid)
(maintenance)
(deficit) concurrent loss electrolyte concentration
fluid
fluid electrolytes maintenance deficit
form fluid fluid
maintenance deficit dehydration (type of dehydration) isotonic,
hypotonic hypertonic dehydration dehydration
deficit
3 isotonic dehydration (serum sodium = 130-150 mEq/L)
maintenance defieit 5%D/NSS/3 hypotonic (serum sodium < 130 mEq/L)
hypertonic dehydration (serum sodium > 150 mEq/L) 5%D/NSS/2 D/NSS/5
concurrent loss
Type of dehydration
isotonic
hypotonic
hypertonic
Maintenance
Water
Na+
(mL)
(mEq)
100
2-3
100
2-3
100
2-3
Deficit
Water Na+
(mL) (mEq)
100
8 - 10
100 10 - 12
100
2-4
440
Maintenance + Deficit
Water
Na+
(mL)
(mEq)
200
10 13
200
12 15
200
4-8
Form fluid
5%D in
NSS/3
NSS/2
NSS/5
Diarrhoea
necrotizing enterocolitis
maintenance + deficit
concurrent loss maintenance fluid Holliday & Segar deficit
441
Degree of dehydration
mild
moderate
severe
Cholera
E.coli
Rotavirus
others
(mEq/L)
Na+
K+
ClHCO-3
88
30
86
32
53
37
24
18
37
38
22
6
56
25
55
18
Surgical patients
Pre - operative care
elective surgery 3 - 4 IV fluid maintenance fluid
form 5% D/NSS/5
gut obstruction fluid maintenance deficit
concurrent loss fluid third space transudate
electrolytes isotonic solution NSS 75 25
plasma fluid NG tube drainage bile HCO-3
30 mEq/L gastric content bile pyloric stenosis
442
5%D/NSS/2
Post - operative care
24 stress surgical trauma corticosteroid ADH
water sodium retention fluid 80% maintenance 5%D/NSS/5
3 ( thrombocytosis )
24 72 tissue
breakdown
fluid maintenance
- gastric content bile 5%D/NSS/2 + KCl 20 - 40 mEq/L
- biliary system ileostomy 7.5% NaHCO3 3 - 5 mL 5%D/NSS/2 95 mL + KCl 20 - 40
mEq/L Ringers lactate solution
- CSF drainage ventriculostomy normal saline
Liver disease
chronic liver disease cirrhosis
1. hyponatremia increased ADH, diuretics, diarrhea
2. hypokalemia decreased dietary intake, diuretics, diarrhoea, vomiting, increased aldosterone
3. metabolic alkalosis diuretics, hypokalemia
conjugated bilirubin 20 - 25 mg/dl
impaired cellular oxidative phosphorylation
sensitized renal parenchyma to ischemic change
impaired renal tubular function
natriuresis and kaleuria
hyponatremia & hypokalemia
Acute hepatitis
hypoglycemia
maintenance + deficit 10% 15% dextrose in 1/3 NSS KCl
2 - 3 mEq/100 Kcal
443
444
80% maintenance 5%D/NSS/3 5%D/NSS/2 KCl 30 40 mEq/L ( K+ 5 - 6 mEq/100 Kcal/day) NaCl tablet (5, 10 mEq/tab)
120 - 130 mEq/L
Respiratory diseases
1. dehydration
2. hyponatremia ADH ultrasonic nebulizer water
of oxidation
3. acid-base disturbance
- respiratory alkalosis hyperventilation
- respiratory acidosis respiratory failure
- metabolic acidois poor intake dehydration hypoxia respiratory
failure lactic acid
Pneumonia
maintenance + deficit 5%D/NSS/3 5%D/NSS/2 hyponatremia
SIADH 80% maintenance maintenance
Bronchiolitis
30 - 50%
maintenance 5%D/NSS/5 2 - 3 mEq/100 Kcal
Asthma
hyperventilation diuresis theophylline
endogenous production of water, increased steroid (endogenous + exogenous) increased ADH
maintenance + deficit 5%D/NSS/5
maintenance 30 - 50%
NaHCO3 status asthmaticus
acidosis persistent metabolic acidosis
NaHCO3 ventilation
Chronic pulmonary disease
NaHCO3 PaCO2
hypercapnia paradoxical lowering pH CSF HCO-3 CSF CO2
PaCO2
ventilate respiratory acidosis NaHCO3
446
Burns
1. influx efflux
2. capillary permeability
albumin interstitial tissue
-
1. hyponatremia stress ADH pool
2. metabolic acidosis 30
3. respiratory alkalosis hyperventilation
4. intravacular hypovolemia
15
2
1. isotonic solution Ringer lactate isotonic
7.5%NaHCO3 10 . 5%D/NSS/3 100 . 150 mEq/L
2. hypertonic 0.5 mEq/kg/
Baxter 200 - 300 mEq/L cell dehydration
hypernatremia secondary hyperaldosterone
(volume) : 4 ././
(rate)
: 1/2 8 1/2 16
24 plasma leak intravascular space
restore fluid volume 24 plasma 0.3 - 0.5 ././
extensive burn
Acute renal failure
Pre - renal failure
2 0.5
././. well hydrate
furosemide 1 mL/kg IV low dose dopamine (2 - 3 g/kg/min) renal
447
blood flow
True renal failure
Oliguric phase
= insensible loss + urine output
insensible loss = 300 - 400 mL/m2 20 - 30 mL/100 Kcal
( water of oxidation = 15 - 25 mL/100 Kcal)
form
15 - 20 % D/NSS/5
0.5 - 1
Polyuric phase 50 - 70 mEq/L 5% D/NSS/2
NaCl tablet
volume
= insensible loss + urine output
renal failure hyperkalemia metabolic acidosis
Submersion
Fresh water
Hypotonic fluid influx into alveoli
lung injury
hypervolemia
hypoxia
metabolic acidosis
hypochloremia
hyponatremia
hemodilution
hemolysis
hemoglobinuria
hyperkalemia
448
Sea water
Hypertonic fluid influx into alveoli
lung injury
hypoxia
early phase
hemoconcentration
hypovolemia
hypoproteinemia
late phase
metabolic acidosis
hypernatremia
hyperchloremia
hypermagnesemia
449
PROFOUND SHOCK
5%D/NSS 20-40 mL/kg
in 30-60 min
- IV fluid 5 - 10 mL/kg/hr
colloid solution
hemaccel, dextran 40
10 mL/kg
30 - 60
5% albumin NSS
(25% albumin 50 mL + NSS
200 mL) plasma, FFP
10 mL/kg 30-60
- shock IV fluid
5%D/NSS/2
- 12 deficit
5 - 6%
- 1-2 mL/kg/hr
monitor
CVP
CVP
CVP (cmH2O)
mL/kg/hr
MONITORING
450
- vital signs 1 - 2
pulse presure 20 - 30 torr
- Hct 4 - 6
- 2
- intake / output mL urine specific gravity
- CXR heart size pleural effusion
<5
20
5 - 12
10
> 12
5
5% D/NSS
5% albumin
Dopamine
1. . , 2523.
2. Finberg L, Kravath RE, Hellerstein S, eds. Water and electrolytes in pediatrics, Physiology,
pathophysiology and treatment. 2nd ed, Philadelphia: WB Saunder, 1993.
3. Arieff AI, Defronao RA. Fluid, electrolyte, acid-base disorders. 2nd ed. Churchill Livingstone, 1995.
4. Somers MJ.G, Harmon WE. Clinical electrolyte and fluid management. In: Barratt TM, Avner ED,
Harmon WE, eds. Pediatric Nephrology. 4th ed, Baltimore: Williams & Wilkins, 1999:215-32.
5. Adelman RD, Solhaug MJ. Pathophysiology of body fluids and fluid therapy. In: Nelson textbook of
pediatrics. 16th ed. Philadelphia: WB Saunder, 2000.
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