Treatment of dehydration can be approached by considering separately:

i. Fluid resuscitation
ii. Fluid maintenance

In fluid resuscitation,

Patients with signs of hypoperfusion should receive fluid resuscitation with

boluses of isotonic fluid (e.g. 0.9% saline or Ringer's lactate).
If dehydration is moderate, 20 ml/kg is given IV over 30 min.
If dehydration is severe, 3 boluses of 20 ml/kg will likely be required.
The end point of the fluid resuscitation phase is restoring peripheral perfusion and
BP and returning increased heart rate toward normal.

In fluid maintenance, two things need to be considered:

i. Volume of fluid to give to patient = daily fluid requirement + additional loss

ii. Electrolyte requirement according to BUSE

In a 70kg man

The daily fluid loss (in 24 hours): insensible = 200ml

urine = 1540ml
faeces = 200ml
sweating = 150ml
metabolism = 400ml

total = 2490ml ≈ 2500ml

Since 1 pint is 500ml, 2500ml = 5 pints

So, the daily fluid requirement in a 70kg man is 2500ml (5 pints).

Usually, for daily fluid requirement, a patient is given:

2 pints of normal saline

3 pints of dextrose 5%
} 1.5g KCl in alternating pints

For additional loss, it depends on the severity of dehydration.

E.g. In a patient who is 20% dehydrated,

20/100 x 2500 = 500ml

 = 1 pint

Therefore, he needs 5 pints (daily req.) + 1 pint (additional loss).

The daily requirement of the important electrolytes:

Na+ = 2mmol/kg/day
K+ = 1mmol/kg/day

2 x 70kg = 140mmol Na+/day

1 x 70kg = 70mmol K+/day

For daily sodium requirement (140mmol/day), it depends on the type of fluid:

0.9% NS contains 153mmol Na+ in 1L (2 pints!)

0.45% HS contains 153/2 ≈ 70mmol Na+ in 1L
0.18% paeds solution contains 153/3 ≈ 30mmol Na+

D5% contains water + 5g dextrose/100ml,

Its osmolarity is 252 mOsm/L. The osmolarity of the body is 283mOsm/L.
The fluid is isotonic when in the container. After administration, the
dextrose is quickly metabolized in the body, leaving only water - a
hypotonic fluid.
D5% functions to maintain osmolarity, not to give calories.

For daily potassium requirement (70mmol/day), it is given in ampoules.

1 ampoule = 1.5g K+ = 20mmol/L

When given alternately in 5 pints, 3 ampoules are used = 60mmol/L

Special consideration – rule of 40:

o Can’t give >40mmol/hour

o Can’t give >40mmol in 1 pint
o Can’t give if urine <40ml/hour (can’t give if patient has yet to pass urine)

o Remember the complications of hyperkalaemia!

So, to explain the usual daily req. regime, 2 pints of NS covers the daily Na + req. of
140mmol/day; the KCl in alternating pints covers the daily K+ req.; and to satisfy
the rest of fluid req. without influencing the electrolyte levels, 3 pints of D5 is
given.

If there is derangement of electrolytes (Na+, K+ and HCO3-) according to BUSE,

 Correction of deficit has to be given in addition to the daily req. of electrolytes.

For Na+, the formula is:

[Deficit x body weight x 0.6]/2 + daily req.

= [(135-a) x body weight x 0.6]/2 + 140mmol/day

For K+, the formula is:

[Deficit x body weight x 0.3]/2 + daily req.

= [(3.5-a) x body weight x 0.3]/2 + 70mmol/day

For HCO3-, the formula is:

[Deficit x body weight x 0.6]/2

HCO3- is given separately from the discussed fluid regime, whereby

0.84% NaHCO3 = 1mmol Na HCO3-/ml

Exercise

A 70kg man was admitted for diarrhoea and vomitting.

I/O chart = -1800ml

Na+ = 127mmol
K+ = 2.5mmol

First, determine how much fluid he needs.

Daily req. + additional loss = 2500 + 1800

= 4300mmol/day
≈ 9 pints

Second, calculate his electrolyte deficits.

Na+ = 127mmol → deficit = 135 – 127 = 8mmol

K+ = 2.5mmol → deficit = 3.5 – 2.5 = 1mmol

Na+ = [Deficit x body weight x 0.6]/2 + daily req.

= [8 x 70 x 0.6]/2 + 140mmol/day
= 168 + 140
= 308mmol Na+
 How many pints of NS to be given?

Remember, 0.9% NS contains 153mmol Na+ in 1L (2 pints!)

308/153 ≈ 2L → 4 pints of NS

K+ = [Deficit x body weight x 0.3]/2 + daily req.

= [1 x 70 x 0.3]/2 + 70mmol/day
= 10.5 + 70
= 80.5mmol K+

How many ampoules to be given?

Remember, 1 ampoule of 1.5g KCl = 20mmol K+

80.5/20 ≈ 4 ampoules

So, 9 pints over 24 hours = 4 pints NS

5 pints D5%
} 4 ampoules of
alternating pints
1.5g KCl in

:-)