Fluids and

Electrolytes
Rafael Alphonso Pintacasi
Class 2016

Total body
water (65%)

Intracellular
fluid (2/3)
Extracellular
fluid (1/3)

Interstitial
space (75%)
Plasma (25%)

Newborn

1-3years

Adult

TBW

75%-80%

65%

55%-60%

ECF

45%

25%

25%

ICF

35%

40%

40%

Fluid Therapy
employed

to maintain or restore the

normal volume & composition of body
fluids

Goal:

to normalize the intracellular &

extracellular chemical environments
that optimize cell & organ function

Principles of fluid and electrolyte

therapy
Dimensions of
fluid therapy

Maintenance Phase

Normal Maintenance
(Normal daily
requirement of water)

Active Replacement
therapy ( active
replacement of
continuing losses)

Rehydration Phase

Deficit therapy

3 Categories of Fluid Therapy

1. Rehydration/ Deficit therapy
designed to replace abnormal losses of
fluids & electrolytes
3. Replacement therapy based on
measured or estimated continuing
abnormal losses
3. Maintenance therapy designed to
replace usual losses of fluid & electrolytes

I. Rehydration Phase
designed

to replace abnormal losses of

fluids & electrolytes which are
reflected in the body composition by
an acute loss in body weight.

Best guide for assessing fluid loss is

to Determine the acute change in
body weight or the WEIGHT LOSS

FLUID
LOSS

Weight
LOSS

In most instances, computation of weight

loss is difficult due to no record of infant
or childs previous weight.
However, estimation to the degree of
dehydration can be assessed based on
fairly evident clinical criteria.

Clinical Manifestations of Fluid Loss

Degree of
Dehydration

% Weight Loss

Clinical Features

Mild
dehydration

<5% in an infant;
<3% in an older child
adult

Sunken EB; depressed fontanel;

moist mucous membranes, alert,
normal skin turgor

Moderate
dehydration

10% in an infant;
6% in an older
child/adult

Lethargic, Rapid pulse, rapid or

orthostatic SBP, Dry mucous
membranes, absent tears, decreased
urine output, CRT >2secs, slow skin
turgor

Severe
dehydration

15% in an infant;
9% in an older
child/adult

Obtunded, rapid and/or weak pulses,

very low SBP, cracked/very dry mucous
membranes, absent tears, little or no
urine output, CRT >2secs, very poor
skin turgor

Results from previous abnormal

losses of fluid and electrolytes such as
diarrhea, vomiting and other dehydrating
conditions

In

acute conditions, it is assumed to be

exclusively loss of water and
minerals without loss of tissue solids

 In

chronic conditions, consideration of

tissue losses should be made
at the immediate correction
of the abnormal losses of fluid and
electrolytes which are reflected in the
body composition by an acute loss in
body weight (dehydration)

Aimed

Should be accomplished within 6

hours after initiation of therapy,
either by oral rehydration or IV
therapy, to restore the normal fluid
and electrolyte balance

The following should be corrected:

1.Fluid loss
2.Osmolality or sodium ion
disturbances
3.Other electrolyte disturbances like
potassium, magnesium, calcium, etc.
4.Acid base balance

Correction of Dehydration

Estimate Fluid Deficit

(Mild, Moderate, Severe = % weight

loss)

Find Type of Dehydration

(Isotonic, Hypotonic, Hypertonic)

Give daily Maintenance

Classifying based on
Na+:
Hyponatremic
Serum Na+ < 130 mEq/L
Implies excess Na+ loss
Isonatremic (isotonic)
Serum Na+ 130-150 mEq/L
Hypernatremic
Serum Na+ > 150 mEq/L
Implies free water (FW) loss

Clinical Manifestations of Sodium or Osmolality Disturbances

Isotonic

Hypotonic

Hypertonic

SKIN

Dry

Moist and clammy

doughy

LIPS AND
TONGUE

dry

Clammy or moist;
presence of
hypersalivation and
shedding of tears if
serum sodium is 110
mEq/L or less

Parched; patient
complaining of thirst

CNS

lethargic

Comatose; occasionally
with generalized
convulsions

Lethargic when
undisturbed; hyperirritable
when aroused; focal or
generalized seizures; inc.
muscle tone and tendon
reflexes; meningismus

VITAL
SIGNS

N to low temperature;
normal to low B.P.,
rapid P.R.

Very low temperature,

B.P. in shock thready
pulse

Febrile temperature,
normal B.P., N to slightly
increased P.R.

Isotonic

Hypotonic

Hypertonic

Mild
Infants

5% of
wt. loss

50
mL/kg

1st 6
hours

0.3% NaCl
in D5W (50
mmol/L
NaCl)

Children

3% of
wt. loss

30
mL/kg

0.45% NaCl Deficit,

in D5W (75 maintenance
and
mmol/L
replacement
NaCl)
therapy are
combined and
given in 48
hours as 0.15%
NaCl in D5W.

Isotonic

Hypotonic

Hypertonic

Moderate
Infants

10% of
wt.
loss

100
1st hour:
mL/kg of
total

Ringers
lactate or
acetate in
D5W

Ringers
lactate or
acetate in
D5W

Childre
n

6% of
wt.
loss

60
Next 5-6
mL/kg hours:
or
remaind
er of
deficit

After the
Follow with
initial
0.45% NaCl
hydrating
solution
follow with
IV fluid as
above:
0.3% NaCl
in D5W

(mix 1
part of
0.3%
NaCl to 1
part
plain
D5W to
make
0.15 NaCl
in D5W

Isotonic

Hypotonic

Severe
Infants

15% of
wt. loss

150
mL/kg

Children

9% of
wt. loss

90
mL/kg

1st hour:
1/3 of total

Ringers
lactate or
acetate in
D5W

Ringers lactate or
acetate in D5W

Next 5-6
hours: 2/3
or
remainder
of deficit

0.3% NaCl in 0.45% NaCl in D5W

D5W

Potassium replacement: after the patient has voided, add 20-30 mEq/L of KCl to
IV fluid for maintenance potassium requirement.
-in hypernatremia and in the presence of hypokalemia, administer 40-50 mEq/L
of KCl
-for hypokalemia, maintain a constant concentration of potassium for 3-4 days

Monitoring Therapy

VITALS
Pulse
Blood pressure

INTAKE AND OUTPUT

Fluid balance
Urine output and specific gravity

PHYSICAL EXAMINATION
Weight
Clinical signs of depletion or overload

ELECTROLYTES

II. Maintenance Therapy

-designed to replace usual losses of
fluid & electrolytes
-based on measured or estimated
continuing abnormal losses
Fluid is continually lost from the
body in the form of Insensible water
losses (skin and lungs) and urinary
Loss.

Replaces urine, water and sweat loss

and therefore avoid the development
of dehydration and deficiencies of
sodium and potassium
Maintenance Fluid Requirement
amount of Fluid required to keep the
body fluid in BALANCE .

 Goals:
Prevent dehydration
Prevent electrolyte disorders
Prevent ketoacidosis
Prevent protein degradation

Holliday and Segar Method

Body
Weight

Fluid per day

0-10 kg

100 mL/kg

11-20 kg

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

>20 kg

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

*maximum fluid per day is normally 2, 400 mL

Example:
25kg

8 year-old weighing

100

(for 1st 10 kg) x 10 kg = 1000

ml/day
50 (for 2nd 10 kg) x 10 kg = 500
ml/day
20 (per remaining kg) x 5 kg = 100
ml/day
Total:1600 ml/day

Conditions that alter maintenance fluid

Conditions

Adjustment Needed

Extra Needed
Fever

12% for each 0C>37.50C or

7 mL/kg for each 0.50C > 37.50C

Room Temperature

30% per 0C rise

Hypermetabolism
-major surgery

20-30%

-burns

2% increase per 1% area burnt

Diarrheal /vomiting

Volume per volume

Less required
Hypothermia

12% for each 0C < 37.50C

High humidity

30%

Oliguria/ Edema

Case-to-case/ 30%

Sedated/ Paralyzed

40%

IVF

Dextrose

Na+

Cl-

K+

Lactate

(mEq/L)

(mEq/L)

(mEq/L)

(mEq/L)

LRS

130

109

NSS

154

154

50

25

25

D5 0.3% NaCl 50

51

51

D5 0.45%
NaCl

77

77

D5 0.9% NaCl 50

154

154

D5 IMB

50

25

D5 LRS

50

D5 NM
D5NR

D5 0.15%
NaCl

Others (mEq/L)

28

Ca2+: 3

22

20

23

Mg2+: 3; PO4-: 3

130

109

28

Ca2+: 3

50

40

40

13

Mg2+: 3; acetate: 26

50

140

98

Mg2+:3; acetate: 27
Gluconate: 23

50

Example
A

mother brought her 2 year old child

because of diarrhea. He weighed
10kgs. And showed the following signs
and symptoms: sunken eyeballs, dry
skin, dry lips and tongue, PR:
110bpm, no tears, urine output of
25cc/hr

Deficit calculation
Estimated fluid loss:6%
Fluid to Administer:
(60 mL) (10 kg)
600mL in 6 hours
First hour:
600 mL/4 = 150 mL/hour
40 gtts/min
Next 5-6 hours:
600mL- 150 mL = 450mL
450mL/5 hours = 90 mL/hour
23 gtts/min

Maintenance Calculation
10 kg = 1000 mL/kg
1000ml / 18 hours
55 cc/hr
15 gtts/min

Potassium Deficiency

Clinically manifests as muscular weakness and respiratory acidosis.

Potassium corrections should be given orally whenever possible.

Intravenous correction is reserved for conditions where oral route is not

feasible

Salt substitutes

50 65 mEq per level teaspoon

May be the ideal form of oral therapy
A rise in 1 1.5mEq in serum after 40 60mEq is given
Cardiac monitoring for infusion rates >0.5mEq/kg/hour

The End!!!