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Principle of fluid and electrolyte therapy

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

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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)

Weight loss (%)


Water loss (mL / kg)
Pulse rate
Blood pressure
Capillary refill
Eyeballs
Anterior fontanell
Skin turgor
Urine output

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

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Severe
7
70 100
,
, pulse pressure
> 3 sec
marked sunken
markedly depressed
poor
, oliguria

Concurrent loss maintenance fluid


abnormal fluid electrolyte losses
skin
lungs
renal
GI
CSF

low humidity, sweat (fever), burn


hyperventilation, chylothorax
polyuria from diabetes mellitus, diabetes insipidus
diarrhea, vomiting, drainage from stomach, small intestine
ventricular drainage

(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

3 maintenance deficit fluid sodium 1

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

(Rate 0f intrvenous fluid)


mild dehydration
24 moderate severe
circulatory volume 10 - 20 ././. 2
profound shock 20 - 40 ./. 15 - 30 push
crytalloid isotonic solution 5%D/NSS, Ringer lactate solution, Ringer acetate solution
colloid solution hemaccel, dextran, plasma whole blood
10 ././. vital signs

24 10 2000 .
20 ././. (200 ./.) 2
22 2000 - 400 = 1600 . 1600 / 22 70 ./.
profound shock IV fluid
(severe dehydration)

deficit fluid deficit fluid


8 16 initial hydration
10 maintenance 1000 .
1000 . 2 20 ././. (200 ./.)
deficit fluid 8 500 - 400 = 100 . maintenance fluid 8
1000 / 3 = 333 . 8 initial hydration 2
333 + 100 = 433 . 433 / 6 = 70 ./.
666 + 500 = 1166 . 16
1166 / 16 = 70 ./. initial
hydration 2

Diarrhoea


necrotizing enterocolitis
maintenance + deficit
concurrent loss maintenance fluid Holliday & Segar deficit
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Degree of dehydration
mild
moderate
severe

Deficit fluid (mL/kg)


30 - 50
50 - 70
70 - 100

concurrent loss 20 - 50 mL/kg/day


oral electrolyte solution
50 mEq/L 4
Form I.V. fluid
5%D/NSS 5%D/NSS/2 form fluid
maintenance deficit
3 isotonic dehydration 5%D/NSS/3 hypotonic hypertonic dehydration
5%D/NSS/2 5%D/NSS/5
4 electrolytes acute diarrhoea

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
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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
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Acute hepatic failure



hyponatremia, hyperammonemia metabolic acidosis hypoglycemia coagulation factor
(prolong prothrombin time PT 20%)
hyponatremia SIADH
80 % maintenance 10% D/NSS/2
hypertonic NaCl 130 mEq/L
10 mEq/L acute hyponatremia 5 mEq/L chronic
hyponatremia central pontine
myelinolysis (CPM) deficit + maintenance
coaggulation defect FFP 10 - 20 ./.
Post - operative neurosurgery

Pituitary diabetes insipidus

- (urine volume 4 mL/100 Kcal/hr)


- urine specific gravity osmolarity
- hypernatremia
maintenance + deficit + concurrent loss concurrent loss
4 mL/100 Kcal/hr Form I.V. fluid 2
maintenance deficit 5% D/NSS/5 concurrent loss
8 - 10 mEq/L 2.5%D/NSS/10
maintenance 2 - 3 mEq/100 Kcal/day
4 - 6 mEq/100 Kcal/day
I.V. fluid 3 5 pitressin DDAVP fluid
retention brain edema
2.5%D/NSS/10 maintenance
hemolysis
osmolarity 180 mosm/L pitressin
DDAVP insensible loss + deficit + urine output
5%D/NSS/5

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Syndrome of inappropriate ADH secretion (SIADH)


Criteria SIADH
- hyponatremia and hypoosmolarity
- loss in urine (natriureris, UNa > 20 mEq/L)
- increased urine osmolarity
- no signs of dehydration
- normal renal, adrenal and thyroid function

80 % maintenance
insensible loss + urine output water excess 5% D/NSS/2 hypertonic
NaCl (3%NaCl Na+ 0.5 mEq/mL) 130 mEq/L 10
mEq/L IV drip 4 - 6 diuresis restrict fluid

= (130 - Actual Na+) X TBW ( mEq)


TBW = total body water % body weight
new born
= 80% BW
infant
= 70% BW
> 1 year
= 60% BW
Brain edema
restrict fluid 80% maintenance 5%D/NSS/2
diabetes insipedus (DI)
brain edema osmotherapy mannitol
hypernatremic dehydration shock free water
diuresis monitor vital signs, urine output
Congestive heart failure

hyponatremia, hypokalemic metabolic alkalosis hyponatremia
dilutional hyponatremia
120 - 130 mEq/L
120 mEq/L 5 mEq/L IV drip 4 - 6
1 mEq/100
Kcal/day 80% maintenance 5%D/NSS/5
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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

fluid influx into capillary

lung injury

hypervolemia

hypoxia
metabolic acidosis

hypochloremia
hyponatremia

hemodilution

hemolysis
hemoglobinuria
hyperkalemia

448

80% maintenance 5%D/NSS/2 NaHCO3 1 - 2 mEq/kg


metabolic acidosis CO2
hemoglobinuria
1 mL/kg/hr 7.5% NaHCO3

Sea water
Hypertonic fluid influx into alveoli

water and protein efflux from


capillary into alveoli

lung injury
hypoxia

early phase

hemoconcentration
hypovolemia
hypoproteinemia

late phase

metabolic acidosis

shift of fluid and


electrolytes into circulation

hypernatremia
hyperchloremia
hypermagnesemia

hypovolemia initial hydration Ringers


lactate 5%D/NSS/2 100 mL + NaHCO3 8 mL ( 150 mEq/L)
10 - 20 mL/kg/hr 2 plasma 10 mL/kg 1 2 maintenance fluid 5%D/NSS/5
Dengue Hemorrhagic Fever
stage
Stage 1 prodromal stage
(hyperventilation)
( )

449

Stage 2 shock stage


shock bleeding ( 4 - 6 ) capillary permeability
leakage fluid, electrolytes albumin
shock guideline

Stage 3 convalescent stage


fluid & electrolytes fluid overload
IV fluid congestive heart failure furosemide

Guideline for fluid therapy in Dengue hemorrhagic shock


IMPENDING SHOCK
5%D/NSS 10-20 mL/kg/hr
IV drip 1 - 2 hours

PROFOUND SHOCK
5%D/NSS 20-40 mL/kg
in 30-60 min

- IV fluid 5 - 10 mL/kg/hr

maintenance 5 -10% deficit


- IV fluid
maintain vital signs urine output
1 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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