Fluids, Electrolytes, and Dehydration

Mark Davenport and S. H. S. Syed

2.1

Appreciation of basic physiology is the key to safe preoperative resusciation enabling appropriate surgery. Administration of appropriate postoperative fluid regimens ensures optimal outcome.

2.1.1 Normal Fluid Physiology

Most of us are made up predominantly of water.

~60% of body weight (BW) i.e. total body water ~42L in 70kg man.
This is divisible into two compartments: (a) Intracellular (~40% BW) high K+, high [proteins]. Regulated by active Na+/K+ pump at cell membrane. (b) Extracellular (~20% BW) high Na+, high Cl

Plasma Intravascular osmotic pressure maintained by albumin, and regulated by cap Lymph Connective tissue, bone water, CSF, etc . Interstitial (~5%)
illary membrane (i.e., Starlings Law oncotic pressure and pore size).

N.B. transcellular compartment includes the mythical third-space (<2%). (NB circulating blood volume (65mL/kg) is made up of not only plasma but red cell mass as well.)

M. Davenport (*) Paediatric Surgery Department, Kings College Hospital, London, UK C. K. Sinha and M. Davenport (eds.), Handbook of Pediatric Surgery, DOI: 10.1007/978-1-84882-132-3_2.1, Springer-Verlag London Limited 2010 9

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M. Davenport and S. H. S. Syed

2.1.2 Age-Related Changes

Total body water (80% in neonate vs. 60% in adult) ECF ICF (almost parity in newborn vs. 3:1 in adult) Surface area/body mass ratio
2.1.3 Normal Fluid and Electrolyte Requirements
In general, normal neonatal fluid prescription depends on (a) body weight and (b) day of life (Tables2.1.1 and 2.1.2). Basic prescription is 100mL/Kg/day (up to 10kg). (Beyond neonatal period.)
Table2.1.1Estimated fluid requirements in childhood Day of life Premature infant 1st 2nd 3rd >3rd Term infant 1st 2nd 3rd >3rd Child >4weeks of age, 10kg Child 1020kg Child >20kg ml/kg/day 60150 70150 90180 Up to 200 6080 80100 100140 Up to 160 100 1L+50mL/kg/day for each kg over 10 1.5L+20mL/kg/day for each kg over 20

Table2.1.2Sample fluid requirements (by body weight) Body weight 3 5 10 20 45 70 Calories required (kcal/day) 300 500 1,000 1,500 2,000 2,500 Maintenance (mL/day) 300 500 1,000 1,500 2,000 2,500 Maintenance (mL/h) 12 20 40 60 80 100

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2.1.4 Insensible Fluid Loss

This is an obligate fluid loss, largely from radiation and evaporation related to body surface area and the work of breathing. ~300mL/m2/day Body surface area (m2) = weight(kg) height(m) 3,600

2.1.5 Postoperative Fluid Regimens

The composition (if not the volume) of postoperative maintenance fluid prescription has recently come under scrutiny (at least in the UK), and is changing from one using predominantly low or no saline solutions (e.g., 5% dextrose, 4% dextrose/0.18% saline, described wrongly as hypotonic) to using high saline solutions (i.e., 0.9% saline, described as isotonic), on the basis that the former regimens lead to hyponatremia, whereas use of the latter seldom leads to hypernatremia (although it gives far more than normal daily requirement of Na Cl Table2.1.3). Further, because of the metabolic response to surgery (see Chap. 2.2), there is inappropriate secretion of ADH, and many units will prescribe only two-thirds of the calculated maintenance volume in the first 2448h. Finally, consider ongoing losses from drains, NG tubes, stomas, and fistulas (Table2.1.4). In principle, replace Like with Like. In most cases, this is a ml. for ml. replacement with an isotonic (0.9%) saline solution (20mmol of K+/L).
Table2.1.3Sample electrolyte requirements (by body weight) Na (mmol/kg) Neonate (preterm) Neonate (term) 10kg 1020kg 20Adult 46 3 12 12 K (mmol/kg) 23 2 12 1

Table2.1.4Electrolyte content of gastrointestinal secretions Secretion Saliva Gastric Bile Pancreas Small intestine
a

Na+ (mmol/L) 44 20120a 140 140 110120

K+ (mmol/L) 20 10 5 5 510
+

Cl (mmol/L) 40 100 100 70 90130

HCO3 (mmol/L) 40 70110 2040

Depends on pH and therefore reciprocal with H

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Table2.1.5 illustrates composition of commonly available intravenous fluids.

2.1.6 Dehydration
 Dehydration may be thought of as contraction in predominantly the ECF compartment because of the relative loss of fluids and sodium. Is referred to in terms of % body weight loss

One principal cause of dehydration is excess intestinal losses due to diarrheal illness, and it is a cause of death in >1.5 million children/year. It is important that a pediatric surgeon has a basic working knowledge of diarrheal illness, as it is so common both in the community (and therefore on the ward).

Infective Causes

Surgical Causes

Viruses Rotavirus Calcivirus (incl Norovirus) Astrovirus Adenovirus Bacteria Campylobacter spp Salmonella spp E. coli Clostridium difficle Shigella spp Protozoa Giardia lamblia Crypotosporidium Entamoeba histolytica

Intestinal obstruction Appendicitis Intussusception Fistula losses (also stomas)

Table2.1.5Intravenous and oral rehydration solutions Glucose (mmol/L) 300 300 240 110 140 90 111 45 60 50 90 <160 154 154 136 80 35 60 40 154 154 154 125 <2 20 20 20 20 145 145 5 <0.4 30 30 Common in UK 30 30 77 77 Not available in UK Gelatin (35g) Gelatin (40g) Starch (60g) Starch (100g) 154 154 5g/L=170kcal/L 131 111 5 29 130 110 4 25 Lactate Ca 2+ Lactate, Ca 2+ Na (mmol/L) Cl K HCO3 Notes

Osmolarity (mOsm/L)

Intravenous solutions (crystalloid)

Lactated Ringers1

273

Hartmanns2

278

0.9% NaCl normal saline

308

Dextrose (5%)

252

2.1 Fluids, Electrolytes, and Dehydration

D5+0.45% NaCl

454

D4+0.18% NaCl

284

Intravenous solutions (Colloids)

Haemaccel

293

Gelofusine

308

Hetastarch

310

Pentastarch

326

Albumin (4.5%)

300

Oral rehydration solutions

WHOORS

330

Pedialyte

270

Dioralyte

Electrolade

(N.B. CHO=3.4kcal/g, compared with fat 9kcal/g)

Sydney Ringer (18361910) British physiologist and physician at University College, London. 13

Alexis Hartmann (18981964) American pediatrician, modified original Ringer solution by the addition of lactate to treat acidosis in children.

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2.1.7 Management
In general, the treatment aims to restore normal fluid and electrolyte balance safely without precipitating complications (e.g., hypernatremic convulsions). The key is to recognize the degree of dehydration (expressed in terms of % body weight loss i.e., 5% of a 20-kg child implies a deficit of 1,000mLs. of fluid) (Table2.1.6) and then the type as defined by the plasma sodium level (Table2.1.7). Aim for rehydration within 1224 h, unless hypernatremia is documented (Na >150mmol/L), where the period should be lengthened to ~3648h. In general, oral rehydration solutions (Tables2.1.5 and 2.1.6) should be used whenever possible (may be defined as presence of a functioning GI tract). Intravenous resuscitation may well be required for more severe episodes of dehydration, particularly where there is a shock-like state and fall in CBV.

Table2.1.6WHO classification of dehydration No dehydration Adult Child Mental status Thirst CVS Respiratory Extremities Mucous membranes Skin fold Urine output <3% 5% Alert Normal Normal pulse/BP Normal Normal Moist Immediate recoil Normal Encourage normal diet and fluids Mild moderate 39% 10% Restless, listless Thirsty Tachycardia, CRT >2s Rate Cool Dry Delayed (>2s) Diminished ORS 3080mL/h Consider via NG tube if failing. REASSESS CRT capillary refill time ORS oral rehydration solution (see Table2.1.5) Severe >9% 15% Lethargic, comatose Unable to drink Tachy/brady, CRT >>2s Inc rate and volume Cold, mottled Dry >2s Absent IV initially e.g., 20mL/kg NaCl (0.9%)

Management of nonsurgical dehydration

2.1 Fluids, Electrolytes, and Dehydration Table2.1.7Types of dehydration Isotonic Hypotonic Hypertonic

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130150mmol/L <130mmol/L >150mmol/L

2.1.8 Specific Electrolyte Problems

2.1.8.1 Potassium
(Normal 3.55.5mmol/L variability in neonates) Hyperkalemia 5.5 mmol/L NB-beware factitious result due to hemolysis

Surgical Causes Dehydration, renal failure, transfusion, tumor lysis syndrome, rhabdomyolysis. Signs ECG: tall tented T waves, PR interval QRS complex duration Treatment Calcium resonium (oral or rectal) cation exchange resin Calcium gluconate (100 mg/kg, IV if >7 mmol/L) myocardial membrane
stabilization Dextrose/Insulin IV Salbutamol (IV or inhaled)

2.1.8.2 Hypokalemia

Surgical Causes Fistula, dehydration. Aldosterone-secreting tumors. Signs ECG: (less obvious changes) flat T waves, U waves, AV conduction defects. Treatment

(a) Slow K+replacement (do not exceed KCl 0.51 mmol/kg/h IV, unless on ECG monitor)

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2.1.8.3 Calcium
(Normal total 2.02.5mmol/L8.510.2mg/dL) (Normal ionized 1.01.25mmol/L45mg/dL) Most is stored and relatively fixed in bone. Serum calcium is made up of different components (bound to albumin (~40%) and complexed with bicarbonate (<10%) and free ions (~50%)). Ionized calcium is the active part and is <1% of total. Calcium balance is regulated by parathormone and acid/base balance.

2.1.8.4 Hypocalcemia (always check magnesium levels additionally)

Usually neonates

Surgical causes Chronic renal failure (e.g., PUV), postthyroidectomy, pancreatitis, malabsorption,
i.e., muscle irritability. Signs tetany, 3 Chvostek twitching of facial muscles by tapping facial (VII) nerve. 4 Trousseau inflation of BP cuff causes carpal spasm (main daccoucheur hand of the obstetrician/deliverer) Di George syndrome, and CHARGE syndrome.

Treatment Calcium (10%) gluconate (IV) Calcium supplements (oral) Vitamin D metabolites
Hypercalcemia  Usually children

Surgical causes MEN (types I, II), Chronic renal failure, parathyroid tumors, hyperthyroidism, Signs
rhabdomyosarcoma, neuroblastoma, metastatic disease.

Stones, Bones, Psychic groans, Abdominal moans, i.e., renal calculi, osteoporosis,
bone cysts, psychiatric manifestations, weakness, confusions, pancreatitis, peptic ulcers.

Treatment

Saline rehydration (with furosemide diuresis) Calcitonin Bisphosphonates, etc.

3 4

Frantisek Chvostek (18351884), Austrian physician. Armand Trousseau (18011867) French physician.

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2.1.9 AcidBase Imbalance

2.1.9.1 Concepts
Definition Acid H+ donor Cation is a +ve ion Base H+ acceptor Anion is a ve ion

pH=log10 [H+]

Neutral pH at 37C=6.8 Normal blood pH=7.4 (H =40nmol/L) (range 7.27.6) Normal intracellular pH=7.0 (H =100nmol/L)
+ +

Anion gap difference between summated anions and cations there is always more of the latter owing to unmeasured anions (e.g., [protein]). An elevated anion gap is usually due to an increase in [lactate], [butyrate] and others. Normal is up to 30mmol/L (but depends on what is being measured),

Key Equations
Henderson5 equation [H+]+[HCO3] [H2CO3] [CO2] + [H2O] [HCO 3] [CO2]

HendersonHasslebalch6 equation pH=pK+log

2.1.10 Base Excess (or Deficit)

Definition the quantity of base (acid) required to return the plasma invitro to a normal pH under standard conditions. Normal body equilibration is maintained by a series of buffer systems. (a) Chemical bicarbonate, phosphate, protein (b) Respiratory elimination of CO2 (c) Renal elimination or retention of bicarbonate

5 6

Lawrence J. Hendersen (18781942) American biochemist. Karl A. Hasslebalch (18741962) Danish chemist.

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2.1.11 Abnormal AcidBase States

Metabolic Acidosis [H+] [HCO3] [BE]
Multiplicity of causes, but can be subdivided on the basis of change in anion gap. Thus, the subdivisions are:

Normal anion gap Loss of base Renal loss of bicarbonate in renal tubular acidosis. Fistula loss of bicarbonate (pancreatic) Increased anion gap Tissue hypoxia anerobic metabolism [lactate ] + [H ] Ketoacidosis diabetic
+

2.1.11.1 Treatment
(a) Correct the underlying problem (b) Sodium bicarbonate (4.2% IV) infused over 30min. (c) Ensure ventilation adequate to excrete excess CO2 N.B. give half calculated dose repeat blood gas

Metabolic Alkalosis [H+] [HCO3] [BE]

This is much less common in pediatric practice. Causes include

Loss of acid Vomiting of HCl e.g., pyloric stenosis Loss of acid stools chronic diarrhea Loss of chloride Chronic use of diuretics Renal perfusion impairment with changes in renin/aldosterone axis. Dehydration, cirrhosis Hypokalemia causes hydrogen ion exchange in kidney Contraction alkalosis as the body fluids are alkali, dehydration causes a fall in total
body water and concentration of electrolytes, hence pH.

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2.1.11.2Treatment
(a) Treat the underlying cause (b) Often simple correction of fluid and saline deficit will allow restoration of homeostasis. Base deficit (mmol/L)body weight (kg)0.3=mmol/L of HCO3 required for full  correction

Further Readings
1. Holliday MA, Ray PE, Friedman AL (2007) Fluid therapy for children: facts, fashions and questions. Arch Dis Child 92:54650 2. Word Health Organisation (2005) The treatment of diarrhoea: a manual for physicians and other senior health workers. Geneva, Switzerland, 4th revision

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