Fluids and

Electrolytes

Department of Family & Community

Medicine
Cebu Velez General Hospital

tango,md'08

Why is a child more prone to

dehydration?
Higher metabolic rate
Larger skin surface area
Prone to greater fluid loss
Immaturity of the infants kidneys

tango,md'08

3 sources of normal water loss (components of

maintenance water):
urine 60%
insensible losses 35% (skin & lungs)
*evaporative losses of skin DO NOT
include sweat
stool 5%

tango,md'08

Total Body Water

term infant - 75% of birthweight
1st yr of life to puberty - 60% of body weight
boys remains - 60% of body weight
girls decreases - 50% of body weight

tango,md'08

Electrolytes
Sodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d

tango,md'08

Rehydration Phase

tango,md'08

GIT potentially a source of considerable water loss

diarrhea high HCO3 in stool metabolic
acidosis
emesis or losses from NGT metabolic alkalosis
Average composition of diarrhea:
Na: 55 mEq/L
K: 25 mEq/L
HCO3: 15 mEq/L

tango,md'08

Average composition of gastric fluid:

Na: 60 mEq/L
K: 10 mEq/L
Cl: 90 mEq/L
Calculation of Deficit water & electrolytes:
water deficit percent dehydration x wt
(Degree

of dehydration x wt) in 6/8 hours

Maintenance in 18/16 hours

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Fluid and Electrolyte

Therapy

tango,md'08

Parenteral Solutions
IV

Glucose

Na

Cl

Ca

HCO3

154

154

130

109

28

PLR

130

109

28

NM

40

40

13

IMB

25

22

20

23

D 5W

50 mg/L

D10W

100 mg/L

0.9 NSS/
PNSS
D5LR

50 mg/L

D5 0.9NaCl

50 mg/L

154

154

D5 0.3NaCl

50 mg/L

51

51

tango,md'08

IVF of Choice
LBM
PLR
Vomiting PNSS, D5 NSS
Maintenance
< 2 years old
> 2 years old

D5 IMB
D5 NM

Bronchial asthma
Fever & Sweating
Drowning

D5 0.3% NaCl
D5 0.3% NaCl

(freshwater)
D5 W
AscitesD5W, D10W

tango,md'08

IVF of Choice
CHF
Hypertension
CHF (NPO)
Heat Stroke
Burns
Bleeding
UTI
Dengue Fever
DM
tango,md'08

D5 NSS
D5W, D5 LR
D5 NSS
D5 NSS
PLR
D5 LR
D5 NSS
PNSS, PLR
PNSS, PLR

ORS Solutions
Reduced Osmolarity
ORS solutions
Standard ORS
solution (meq/L)

(mEq or mmol/L

Glucose

111

75

Sodium

90

75

Chloride

80

65

Potassium

20

20

Citrate

10

10

Osmolarity

311

245

tango,md'08

Dehydration Status
Minimal or None
(<3% loss of BW)

Mild to Moderate
(3-9% loss of BW)

Severe
(>9% loss of BW)

Mental status Well, alert

Normal, fatigued or
restless, irritable

Apathetic,
lethargic,
unconscious

Symptom

Thirst

normal

Thirsty, eager to
drink

Drinks poorly,
unable to drink

Heart Rate

Normal

Normal to
increased

Tachycardia,
bradycardia

Pulses

Normal

Normal to
increased

Weak, thready,
impalpable

Breathing

Normal

Normal or fast

Deep

Eyes

normal

Slightly sunken

Deeply sunken

tango,md'08

Dehydration
Symptom

Minimal or None
(<3% loss of BW)

Mild to Moderate
(3-9% loss of BW)

Severe
(>9% loss of BW)

Tears

present

decreased

Absent

Mouth,
tongue

moist

dry

Parched

Skinfold

Instant recoil

Recoil in < 2 sec

Recoil >2 sec

Cap. Refill

Normal

Prolonged

Prolonged,
minimal

Extremities

warm

cool

Cold, mottled,
cyanotic

Urine ouput

Normal to
decreased

Decreased

minimal

tango,md'08

Calculating Rehydration fluid

1.
2.
3.
4.

CDD - WHO
Ludans Method
Malcolm-Holiday
Nelsons 18th Edition

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

TREATMENT OF DIARRHEAS
OBJECTIVES
: to prevent dehydration if there are no
signs
: to treat dehydration if it is present
: to prevent nutritional damage
: to reduce the duration and severity of
diarrhea, and the occurrence of
future
episodes by giving
supplemental zinc

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

HOME TREATMENT
4 RULES:
1. FLUIDS
2. GIVE SUPPLEMENTAL ZINC
3. FEED
4. ReFERRAL

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

HOME TREATMENT- PLAN A
1.

FLUIDS
WHAT? home fluids, breastmilk, rice
water, soups, unsweetened
juices, coconut water, water,
ORS

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

HOME TREATMENT- PLAN A
1. FLUIDS
2. ZINC
-10mg/ml drops or 20mg/ 5ml syrup
< 6 MONTHS:10 MG/DAY x 2 WEEKS
6 MONTHS: 20 MG/DAY x 2WEEKS

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

HOME TREATMENT-PLAN A
1. FLUIDS
2. ZINC
3. FEED
0-6 months= breastfeeding, usual milk if not
breastfed, try relactation
6 mos -59 mos= follow feeding
recommendations for age

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

HOME TREATMENT-PLAN A
4. ReFERRAL
starts to pass many watery stools
has repeated vomiting
becomes very thirsty
is eating or drinking poorly
develops a fever
has blood in the stool
child does not get better in three days

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

TREATMENT-PLAN B
GOAL: to correct deficit fluid loss using ORS
DETERMINE AMOUNT of ORS TO GIVE IN 4 HOURS
= using a table or 75 ml/k
= < 6 months old, formula fed: 100-200ml of
water in addition to ORS
= SHOW the mother the amount to give in 4
hrs.
MONITOR hydration status
REASSESS after 4 hours
= select the appropriate Treatment Plan
= feed the child

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

TREATMENT-PLAN B
Indication for ORS by nasogastric tube or IV
therapy:
Continuing rapid stool loss
(more than 15-20 ml/k/hour)
Insufficient intake of ORS solution owing
to fatigue or lethargy
Frequent, severe vomiting

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

TREATMENT-PLAN B
Indication for IV Therapy :
Abdominal distention with paralytic ileus
usual causes: loperamide, hypokalemia
Glucose malabsorption

tango,md'08

ACUTE DIARRHEAS (CDD-WHO)

TREATMENT-PLAN C

Age

First give
30 ml/kg in

Infants under 12
mos.

1 hour

Children (12 mos

up)

30 min

tango,md'08

Then give
70ml/k in
5 hours

2 1/2 hours

LUDANS METHOD
Age

MILD

MODERATE

SEVERE

100cc/kg/6hrs
< 2 YEARS OLD 50cc/kg/6hrs 1/4: 1st hr
3/4: next 5 hrs

150cc/kg/6hr
s
1/3: 1st hr
2/3: next 5
hrs

60cc/kg/6hrs
30cc/kg/6hrs 1/4: 1st hr
> 2 YEARS OLD
3/4: next 5 hrs

90cc/kg/6hrs
1/3: 1st hr
2/3: next 5
hrs

tango,md'08

Malcolm-Holiday
Age

MILD

MODERATE

SEVERE

100cc/kg/8hrs
< 2 YEARS OLD 50cc/kg/8hrs 1/4: 1st hr
3/4: next 7 hrs

150cc/kg/8hr
s
1/3: 1st hr
2/3: next 7
hrs

60cc/kg/8hrs
> 2 YEARS OLD 30cc/kg/8hrs 1/4: 1st hr
3/4: next 7 hrs

90cc/kg/8hrs
1/3: 1st hr
2/3: next 7
hrs

tango,md'08

Oral Rehydration
(Nelsons 18th Edition)
Minimal or No Dehydration
Replacement of losses:
<10kg BW: 60-120 ORS for each stool or
vomit
>10kg BW: 120-240 ml ORS

Continue BF, or resume to age

appropriate diet
tango,md'08

 Mild to Moderate Dehydration

ORS: 50-100ml/kg BW over 3-4
hours
Do replacement of losses
Continue BF or resume to age
appropriate diet

tango,md'08

 Severe Dehydration
LR or NSS in 20ml/kg until perfusion
and mental status improve
100ml/kg ORS over 4 hours or 5%
glucose NSS IV at twice the MF
rate
tango,md'08

Fluid Management of Dehydration

(Nelsons 18th Edition)

Restore Intravascular volume

NSS: 20 ml/kg over 20 minutes
Repeat as needed
Rapid volume repletion
20 ml/kg (NSS or LR) over 2 hours
Calculate 24-hr fluid needs: MF + deficit
volume
Deficit volume=patients wt x %
dehydration
tango,md'08

Maintainance Phase

tango,md'08

Maintenance Therapy
Goals of Maintenance Fluids:
Prevent dehydration
Prevent electrolyte disorders
Prevent starvation ketoacidosis
Prevent protein degradation

tango,md'08

Maintenance fluids
- generally composed of:
water
glucose provides 20% of normal
caloric needs
Na
K
- do not provide adequate calories,
protein, fat, minerals or vitamins

tango,md'08

Calculating daily maintenace fluid

1. Holiday-Segar
2. Basal Caloric Expenditure
3. Surface Area

tango,md'08

Holiday Segar
Body
Weight

Fluid per Day

010 kg

100 mL/kg

1120 kg

1,000 mL + 50 mL/kg for each kg > 10 kg

> 20 kg

1,500 mL + 20 mL/kg for each kg > 20kg

tango,md'08

Basal Caloric Expenditure (BCE)

MF = (BCE x Wt x 1.5) / 24
NB: 45-50 cal/kg
3-10kg: 60-80
10-15kg: 45-65
15-25kg: 40-45
25-34kg: 35-40

tango,md'08

Surface Area (SA)

MF = SA x 1500*
SA = (wt x 4 + 7) / (90 + wt)
* 1500 = patients with meningitis
800 = patients with cardiac problem (CHF)

tango,md'08

Maintenance electrolytes:
Na: 2-3 mEq/K/24H (3x wt.)
K: 1-2 mEq/K/24H
(2 x wt)

Na Deficit:
(desired - actual) x wt x 0.6

tango,md'08

K Deficits:
*Pedia
(desired - actual) x wt x 0.6
*Adult
(desired - actual) x 350
3

tango,md'08

Fever
from 37.5

12% per degree celsius rise

10-15% increase per degree celsius

rise
above 38
Tachypnea 15 to 25%
Phototherapy 20%

tango,md'08

Neonates
term infants 60 mL/kg on day 1
premature infants 70 mL/kg on day 1
Increase by 10 cc/k/day until 150 cc/k/day is
reached

tango,md'08

Special Considerations
Phototherapy
Tachypnea
Fever
Hypermetabolic
Sweating
KVO : ugtt = 3.5
gtt = 10
tango,md'08

MF + 20%
MF + 15- 25%
MF + 12% q 1C
> 37.5 C
MF + 25 - 50%
MF + 10-25%

Exercise
5 y.o. patient came in due to LBM x5
episodes 50cc/episode, irritable,
thirsty with sunken eyeballs. vs:
38.5C, 120bpm, 60cpm,
90/60mmHg, wt18kg.
What treatment plan should be
used?

tango,md'08

Exercise
After 4 hours in the DTU unit, patient
now lethargic, drinks poorly, with
sunken eyeballs; vs: 38.5C,
120bpm, 60cpm, 90/60mmHg,
wt18kg.
What treatment plan should be
used?
What IV fluid should be started?
How?
Compute for the maintenance rate.
tango,md'08

Exercise
Labs show serum K of 3.0; compute
for the deficit.

tango,md'08

Thank YOU

Rate in gtts/min

Cc/hour

Hours to
consume 1L

# of 1L
bottles/day

10

40

25

~1

20

80

12.5

~2

30

120

8.33

~3

40

160

6.25

~4

50

200

~5

60

240

4.1

~6

tango,md'08