FLUIDS AND ELECTROLYTES

Two major sources of water in the body:

1. Liquids or water in food ( 2100 ml/day)
2. Synthesized in the body via oxidation of carbohydrates ( 200 ml/day)
Sources of Water Loss:
1. Insensible Water Loss evaporation from respiratory tract and diffusion through skin
( 700 ml/day)
- ~ 1/3 of total maintenance water ( 40% in infants and closer to
25% in adolescents and adults)
2. Sensible Water Loss
a. Urine most important contributor to water loss ( 60%)
b. Stool minor source of water loss ( 5%)
c. Sweat 100 ml/day
Body Fluid Compartments:
Interstitial Fluid (15%)
ECF ( 20-25%)
Plasma (5%)
Total Body Fluid
( 60%)
Transcellular Fluid ( 1-2 L)
ICF ( 30-40%)

The fetus has very high TBW,

decreases gradually to ~ 75% of
birth weight for a term infant.
Premature infants have higher
TBW than term. During 1st year of
life, TBW decreases to ~ 60% of
body weight and remains until
puberty.

Electrolyte Composition of Body Fluid:

Electrolyte
CATION

Serum

Interstitial fluid

Intracellular fluid

Sodium (Na+)
Potassium (K+)
Calcium (Ca++)
Magnesium (Mg++)

140 mEq/L
5
5

138 mEq/L
8
8
6

9 mEq/L
155
4
32

Total
ANION

154 mEq/L

160 mEq/L

200 mEq/L

Chloride (Cl-)
Bicarbonate (HCO3-)
Protein (Pr)
Organic Acids
HPO4SO4-

100 mEq/L
26
19
6
2
1

119 mEq/L
26
7
6
1
1

5 mEq/L
10
65
95
25

Total

154 mEq/L

160 mEq/L

200mEq/L

Dynamic Equilibrium of Fluids and Electrolytes:

-

The isotonicity of ECF is governed mainly by sodium ion.

1mEq of sodium exerts 1 milliosmole of osmotic pressure
Note that sodium is combined with an anion (Cl) thus to get the serum osmolality multiply
the serum sodium concentration by 2, thus 145 mEq/L x 2 = 290 milliosmole/L.
Normal serum osmolality: 280-300 mOsm/L
~10 mOsm/L come from glucose and urea nitrogen ( 5 mOsm/L each)

Principles of Fluid and Electrolyte Therapy

Dimensions:
1. Rehydration Phase - deficit therapy; aimed at immediate correction of abnormal losses of
fluid and electrolytes; accomplished within 6 hours after initiation of therapy ( oral
rehydration or IV therapy)
2. Maintenance Phase normal maintenance and active replacement therapy; stabilized
internal milieu after being restored by rehydration phase; normal daily requirement and
ongoing abnormal losses
I.

Rehydration Phase
The following should be corrected:

a. Fluid Loss
b. Osmolality or sodium ion disturbance
c. Other electrolyte disturbances
d. Acid-base imbalance
Assess degree, then type of dehydration
Clinical Manifestations of Fluid Loss
Degree of Dehydration
% Weight Loss
Clinical Features
Mild dehydration
<5% in an infant; <3% Sunken EB; depressed fontanel; dry skin, lips and
in an older child adult tongue; mild oliguria
Moderate dehydration
10% in an infant; 6% Early shock: loss of skin elasticity and turgor,
in an older child/adult pale, mottled skin; collapsed neck veins; marked
enopthalmus; marked oliguria; unstable VS
Severe dehydration
15% in an infant; 9% in Late shock: Px is dying or moribund; no urine
an older child/adult
output; very sunken EB and fontanel; no tears;
parched mucous membranes; delayed elasticity
(poor skin turgor); very delayed capillary refill
(>3 sec); cold and mottled; limp, depressed
consciousness
Clinical Manifestations of Sodium or Osmolality Disturbances
Isotonic

Hypotonic

Hypertonic

SKIN

Cold and dry; poor

elasticity and turgor

Cold and clammy very

poor elasticity and
turgor

Warm, velvety, and

doughy; normal to slightly
poor

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

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

0.45% NaCl
in D5W (75
mmol/L
NaCl)

Deficit,
maintenance and
replacement
therapy are
combined and
given in 48 hours
as 0.15% NaCl
in D5W.

Mild
Infants

5% of
wt. loss

50
mL/kg

Children

3% of
wt. loss

30
mL/kg

1st 6
hours

Isotonic

Hypotonic

Hypertonic

Moderate
Infants

10%
of wt.
loss

100
mL/kg

1st hour:
of total

Ringers
lactate or
acetate in
D5W

Ringers
lactate or
acetate in D5W

Children

6%
of wt.
loss

60
mL/kg

Next 5-6
hours: or
remainder
of deficit

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

Follow with
0.45% NaCl

(mix 1 part of 0.3%

NaCl to 1 part plain
D5W to make 0.15
NaCl in D5W

Isotonic

Hypotonic

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
D5W

0.45% NaCl
in D5W

Severe
Infants

15% of wt.
loss

150 mL/kg

Children

9% of wt.
loss

90 mL/kg

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

Isotonic: serum Na ( 135-145 mEq/L) and serum osmolality ( 280 300 mOsm/L)
Parenteral fluid: contains ~50 mEq/L Na ion ( 0.3% NaCl in D5W)
Hypotonic: serum Na and serum osmolality are low ( serum Na < 130 mEq/L and serum
osmolality , 260 mOsm/L)
Parenteral fluid: contains 75 mEq/L or .45% NaCl in D5W or D2.5W
Hypertonic: elevated serum Na ( > 150 mEq/L) and serum osmolality ( > 300 mOsm/L)
Parenteral fluid: contains 25 mEq/L Na or 0.15% in D5W
Hydration Therapy ( Ludans Method)
MILD

MODERATE

SEVERE

< 15 kg, < 2y/o

50cc/kg

100

150

>15kg, > 2y/o

30

60

90

D5 0.3% in 6-8 hours

1 hr: PLRS

1st hr: 1/3 PLRS

Next 5-7 hrs:

D5LRS

Next 5-7 hrs: 2/3 D5

0.3%

Monitor:
Vital Signs: Pulse, BP
Input and Output: Fluid Balance, Urine Output
PE: Weight, Clinical Signs of Depletion or Overload
Electrolytes
II.

Maintenance Therapy
Goals:
a. Prevent Dehydration
b. Prevent electrolyte disorders
c. Prevent ketoacidosis
d. Prevent protein degradation

Holliday and Segar Method

Weight Method for Calculating Daily Maintenance Fluid Volume

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

Hourly Maintenance Rate

Body Weight

Fluid per hour

0-10 kg

4 mL/kg/hr

11-20 kg

40 mL/hr +[2mL/kg/hr x (wt-10 kg) ]

>20 kg

60 mL/hr +[1mL/kg/hr x (wt-20 kg) ]

*maximum fluid is normally 100 mL/hr

FLUID

[Na+]

[Cl-]

Normal saline (0.9% NaCl)

154

154

normal saline (0.45% NaCl)

0.2 normal saline (0.2% NaCl)

77
34

77
34

Ringer lactate

130

109

Basal Calorie Expenditure

[K+]

[Ca2+]

[Lactate-]

28

2-10 KG ---------60-80
10-15 KG---------45-65
15-25 KG---------40-45
25-35 KG---------35-40
35-60 KG---------30-35
>60 KG---------25-30
MF= BCE X WT X 15
24
= ugtts/min (: 4 = gtts/min)

Example: 5 kg infant
MF= BCE x wt (kg) x 1.5mL/cal
= 60 cal/24 hrs x 5 kg x 1.5 mL/cal
= 300 cal/24hrs x 1.5 Ll/cal
= 450 mL/24hrs

SHORT-CUT METHOD FOR MAINTENANCE FLUID (IV ROUTE)

Weight group

Maintenance fluid (ml/kg/day)

Sodium concentration of maintenance

fluid

Newborn

75 ml/kg

20-30 mEq/L

3-10 kg

100 ml/kg

10-20 kg

75 ml/kg

20-30 kg

50-60 ml/kg

40-50 mEq/L

Replacement fluid for Diarrhea

AVERAGE COMPOSITION OF DIARRHEA
Sodium: 55 mEq/L
Potassium: 25 mEq/L
Bicarbonate: 15 mEq/L
APPROACH TO REPLACEMENT OF ONGOING LOSSES
Solution: D5 1/4 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl
Replace stool mL/mL every 1-6 hr
Replacement fluid for Emesis or Nasogastric Losses
AVERAGE COMPOSITION OF GASTRIC FLUID
Sodium: 60 mEq/L
Potassium: 10 mEq/L
Chloride: 90 mEq/L

APPROACH TO REPLACEMENT OF ONGOING LOSSES

Solution:normal saline + 10 mEq/L KCl
Replace output mL/mL every 16 hr
ORAL REHYDRATION THERAPY
Glucose absorption (enterocytes) facilitates water and electrolyte absorption
8-1-1 (8 tsp sugar, 1 tsp salt, 1L water)
Composition of the WHO- recommended solution
INGREDIENTS
Sodium chloride
Solution bicarbonate
Potassium chloride
Glucose
COMPOSITION
Sodium
Potassium
Chloride
Bicarbonate
Glucose

Grams/ Liter of H2O

3.5
2.5
1.5
2
Mmol/L of Water
90
20
80
30
111

Limitation of ORT
1. Severe watery diarrhea
2. Hemodynamic shock
3. Losing greater than 10mL/kg/hr, who may be unable to drink enough fluid to replace the
continuing loss
4. Patient who cannot drink because of extreme fatigue, stupor, or coma
5. Patient with severe or sustained vomiting (>5x/hr)
6. Patient with glucose or sucrose intolerance
7. In patients with abdominal distensions
8. If ORS solution has been incorrectly prepared or is incorrectly administered
ELECTROLYTE IMBALANCE
1. SODIUM
A. Hypernatremia - > 145 mEq/L

Causes:
i.
Excessive sodium
ii.
Water deficit
iii.
Water and sodium deficit
Clinical Manifestation:
i. Dehydration
ii. Irritable
iii. Restless
iv. Weak
v. Lethargic
Treatment:
- Goal: to decrease serum sodium by <12 mEq/L every 24 hr, a rate of 0.5 mEq/L/hr
-1st priority: restoration of intravascular volume with isotonic fluid
- Water deficit = Body weight x 0.6 ( 1- 145/ [current sodium]) equivalent to 3-
ml of water per kg for each 1 mEq/L that the current sodium level exceeds 145
mEq/L
B. Hyponatremia serum sodium level < 135 mEq/L
Classification:
i.
Hypovolemic hyponatremia sodium loss from the body (sodium loss is
higher than water loss)
- Diarrhea due to gastroenteritis most common cause in
children
ii.
Hypervolemic hyponatremia excess of TBW and sodium although increase
in TBW is greater than increase in sodium
- In most of conditions causing this, there is a decrease in
effective blood volume (due to third space fluid loss),
vasodilation, or poor cardiac output.
iii.
Euvolemic hyponatremia hyponatremia with no evidence of volume
overload or volume depletion
- Patients have excess of TBw and slight decrease in total body
sodium
Clinical Manifestations:
i.
Anorexia
ii.
Nausea
iii.
Emesis
iv.
Malaise
v.
Lethargy
vi.
Confusion
vii.
Agitation
viii. Headache
ix.
Seizure
x.
Coma
xi.
Decrease reflexes
Treatment;
i.
Hypovolemic hyponatremia replace sodium and water deficit that is present
- Restore the intravascular volume with isotonic saline

ii.
iii.

Hypervolemic hyponatremia water and sodium restriction; diuretics may

also given to excrete both sodium and water; vasopressin antagonists are
effective for hypervolemic hyponatremia due to heart failure or cirrhosis
Isovolumic hyponatremia therapy is directed on eliminating excess water

2. Potassium
A. Hyperkalemia - > 6 mEq/L
Causes:
i.
Spurious Laboratory Value
ii.
Increased intake
iii.
Transcellular shift
iv.
Decreased excretion
Clinical manifestations:
i. Nausea
ii. Vomiting
iii. Diarrhea
iv. Heart block
v. Cardiac arrest
ECG Changes: peaked/ tented T waves,
at >7.0 mEq/L: prolonged PR, lowest ST, wide QRS
At> 8.0 mEq/L: P wave disappears, QRS merges with T
Treatment:
i. Stop all sources of potassium
ii. Reverse membrane effects: Ca gluconate 10% at 0.5-1.0 mL/kg IV over 2-10
mins
iii. Transfer K into cells (redistribute): 2 agonists; or Regular Insulin 10-20 U +
Glucose 25-50 g; or NaHCO3 50 mEq IV in 5 mins
iv. Enhance renal excretion of K: Kayexalate 15-50g PO diluted with 2-4 mL sorbitol
B. Hypokalemia - < 3.5 mEq/L
Causes:
i.
Spurious
ii.
Transcellular Shifts
iii.
Decreased Intake
iv.
Extrarenal Losses
v.
Renal Losses
Clinical Manifestations:
i.
Muscle weakness
ii.
Cramps
iii.
Paralysis
iv.
Respiratory paralysis
v.
Polyuria
vi.
Polydipsia
vii.
Hepatic encephalopathy
Treatment:

mmol K deficit = (desired actual) x 0.3 x wt (kg) OR wt (kg) x 50 x estimated %

deficit
K serum level
Estimated deficit
3 3.5 mEq/L
5% deficit (~ 200-400 mmol)
2 2.9 mEq/L
10% deficit
1 -1.9 mEq/L
20% deficit (~600 mmol and up)
i.
ii.

If asymptomatic: oral replacement 2-3 mEq/kg/d

IV replacement guidelines:
Rate: 0.2-0.3 mmol/kg/hr NOT to exceed 1 mmol/kg/hr
If via peripheral vein, not > 40 mmol/L
If via central vein, not >80 mmol/L; continuos ECG

3. Chloride
A. Hypochloremia - < 85 mEq/L
Seen in upper GI obstruction with vomiting
Treatment: Treat with KCL solution
May use NH4Cl or 0.1 N HCl (ideal for hypochloremia due to metabolic
Alkalosis )
B. Hyperchloremia - > 105 mEq/L
Seen in hypernatremia, uretero intestinal anastomosis, and obstructive uropathy
Associated with metabolic acidosis
Management:
i.
Correct associated abnormalities
ii.
Remove salt
iii.
Allow kidneys to compensate
4. Calcium
HYPOCALCEMIA
Clinical Features
Jitteriness
Tremors
Twitching
Frank convulsions
Chvostek sign
Trousseau sign
Serum Ca <7mg/dL
Ca gluconate 10% (8.9 mg/mL elemental Ca): 0.5-1.0mL/kg IV bolus over 20-30mins
with cardiac monitoring x3 doses
Maintenance: 500 mg/kg/24hr PO
5. Phosphorus
Hypophosphatemia
a. Oral maintenance doses:
i. 2-3 mmol/kg/day in divided doses
b. For severe deficiency or who cannot tolerate oral medications:
i. 0.08-0.16 mmol/kg over 6 hours
6. Magnesium

HYPOMAGNESEMIA
For symptomatic children
4-7 kg: 0.5mL of 50% MgSO4 (1mmol Mg)
> 7 kg: 1mL of 50% MgSO4 (2mmol Mg)