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Maintenance fluids. The important thing for all of you to remember is that when you are
Maintenance Fluid Requirements (mL/kg/day) giving maintenance fluids to any child of any age, the first thing to ask yourself is, "Do I
expect the insensible water loss, urinary loss and stool loss to be normal?" If it is, then
Body Weight (kg) Fluid Requirement per 24 hours you can give normal maintenance amounts. But if there is either a reason to give more
or less depending upon these, you need to make modifications. If a child is up to 10 kg
of weight, we give 100 ml/kg to the normal child with normal renal function. That is a liter
Up to 10 kg 100 mL/kg for a child that weighs 10 kg. From 11 to 20, we give 1000 ml plus 50 ml/kg for each kg
between 10 and 20. For the child over 20 kg, we give 1500 ml for the first 20 then 20
11 to 20 kg 1000 mL + 50 mL for each kg over ml/kg for each kg over 20.
10 kg Maintenance electrolytes are not so much related to age but to weight and it is important
to remember that insensible water loss of electrolytes is relatively small. Only about 0.5
>20 Kg 1500 mL + 20 mL for each kg over mEq/kg of both sodium and potassium are lost. Most of the electrolytes which are lost
through the urine and on average it is about 3.0 mEq/kg of sodium and 2.0 mEq/kg of
20 Kg potassium. All of that should be given in maintenance fluids in the form of chloride.
Bicarbonate is not needed in maintenance fluids, but is needed in correcting a
metabolic acidosis.
There are of course three major types of dehydration. The ultimate character of the net
deficits will be determined by the quantity of fluid intake as well as the losses. Isotonic
dehydration is the type of dehydration that you will see most commonly. In this case,
Maintenance Electrolyte Requirements (mEq/kg/day) salts and water are lost and replaced proportionately. This is primarily caused by
diarrheal dehydration, involving losses from the GI tract. It is important to remember that
Na K Cl HCO3 the range that we would call isotonic dehydration is broader than normal serum sodium.
I've listed here what I would consider isotonic, being from 130-150 mEq/l. That means
Insensible 0.5 0.5 1 -- that the fluid intake and the diarrheal output were proportional. The fluids which we
commonly recommend for oral rehydration therapy in isotonic dehydration are designed
water losses to replace fluids as they are lost. In the United States rotavirus is the most common
cause of diarrhea; the concentration of sodium in diarrhea from rotavirus is about 15
mEq/l, actually similar in toxigenic E. coli diarrhea. Most diarrheas that we will see will
Urinary 3.0 2.0 5 -- have that, and therefore, the common electrolyte solutions like Pedialyte or Infalyte
losses have concentrations of sodium of 45 or 50 mEq/l, with appropriate amounts of chloride,
potassium, and citrate as a substitute for bicarbonate.
Stool losses -- -- -- -- Hypotonic dehydration. The balance between water and salts is disturbed either
because salt is lost in excess of water, or because very hypotonic fluids have been
Total 3.5 2.5 6 given as replacement. This is where, in oral rehydration, we should be very careful
about the so-called clear liquids, because the so-called clear liquids given, 7-Up or
Requrieme juices, are often very high in carbohydrate and very low in electrolyte. If we give fluids
that are clear liquids to the child who is having diarrhea, we may then produce
nts hypotonic dehydration. In addition to GI losses, we see hypotonic dehydration if we are
wasting sodium as result of adrenal cortical insufficiency, or as the result of renal
insufficiency, or if we are losing it from the skin in cystic fibrosis, or occasionally in an
infant who is given a very hypotonic solution.
Hypertonic dehydration is of course the opposite. The balance between water and salt
Estimation of Serum Osmolality is also disrupted because water is lost in excess or because sodium is given too much
in replacement. You see that sometimes if diarrheal dehydration is treated with soup
broth, which may be very high sodium containing. We see it, of course, in GI losses with
Serum osmolality (mosm/kg) = serum Na x 2 improper replacement, but we also see it in solute diuresis from glucose or urea. In
diabetics we may see hypernatremia. In a child who has transient renal failure and
+ serum K x 2 acute tubular necrosis, during the recovery phase from acute tubular necrosis, where
the urea is being rapidly washed out, water will be carried along with the solute of urea.
+ glucose (mg/dl With diabetes water will be carried along with the solute of glucose, and one may
develop hypernatremia. Diabetes insipidus, of course, is the classical circumstance in
18 which the kidney is unable to concentrate urine. It is extremely dilute and hypernatremia
is an important complication. Occasionally formula is improperly mixed. Now, most
+ BUN (mg/dl) people will be able to buy the premixed formula and we don't see this problem, but of
course it is much less expensive to use the formula powder. If one doesn’t add the
3 proper amount of fluid to it, the child can develop hypernatremia.
In assessing a child who has diarrheal dehydration or other forms of dehydration, the
most important criteria is loss of weight. Hopefully most of the patients who have been
Changes in serum osmolality effect ECF space since fluids in your practice you will have previous weight so you'll know what their weight has been.
equilibrate osmolality across a semi-permeable membrane. But even if the patient has not been in, if you can get a previous weight it is your most
reliable measure of weight loss. The clinical signs of dehydration are not terribly
1. hypotonicity leads to contraction of ECF. reliable. They give you a rough idea but they're not nearly as reliable as weight. If you
don’t have a weight, then clinical signs of dehydration can be helpful. Mild dehydration
2. hypertonicity leads to expansion of ECF. is about 5% dehydration in infancy, and about 3% dehydration in older children. If the
infant is less than 5% dehydrated, or a child is less than 3% dehydrated, you will not see
salt have been either lost or replaced proportionally. If you have a child who does have severe dehydration and is in shock, then it is very
important to be able to correct that intravenously. Although oral rehydration is
recommended for most mild and moderate dehydration, if the child is in shock you
cannot treat it orally because, of course, the intestine is also in shock and if you gave
Na+ = 130-150 mEq/1 any fluids orally, they would simply remain in the intestine and will not be absorbed.
You'd also have an ileus. Obviously, the best thing to do if possible is to use a
peripheral vein. If it is not available, central venous access is not difficult to do for an
experienced person, either in the subclavian or jugular veins, occasionally in the
a. Primarily caused by loss of fluids from the GI tract
femoral, one should achieve central venous access. But if that is not available, and
sometimes the child is in profound shock and we just can't get into a vein, it is important
that either you know how to provide intraosseous access. It is a marvelous way of
2. Hypotonic Dehydration. the balance between H20 and getting emergency fluids into the central circulation when no vessels are available.
salt is disturbed because either salt has been lost in Then you must assess why the child lost the fluids and give fluids that are appropriate
for loss. If there has been blood loss, we should give blood. If there has been crystalloid
excess of H20 or because fluids with little salt have been loss, we should give crystalloid and so forth. Whenever you are treating a child who is
in shock, the initial therapy should be with isotonic fluids. So even if you are dealing with
given to replace the fluid losses. hypertonic dehydration, the initial therapy for shock should be with isotonic fluids, and
the ones to give are normal saline, Ringer's lactate, Plasmanate, or, in the case of
blood loss, blood.
Na+ < 130 How much fluid do you give? If the child is in shock, you are probably going to need no
a. Causes: less than 20 ml/kg of either saline, Ringer's lactate, or Plasmanate. Generally, what I
like to do is give 10 ml/kg of an isotonic solution as a bolus, as rapidly as I can and then
(1) GI losses assess whether the shock has been reversed. If it has not been reversed, I will give the
second 10 ml/kg of isotonic solution. If the shock is severe, very often you will need to
(2) Adrenal cortical insufficiency give 40 ml/kg or sometimes more. Again, I like to do it in 10 ml/kg boluses, and
frequently I find it very worthwhile, if I have a child who is in shock and I am not sure
(3) Chronic renal failure why, to give half the solution as crystalloid and half the solution as powder.
(4) Cystic fibrosis If you have gotten the child out of shock and you are going on with your replacement
fluids, you calculated the fluids you want to give to the child. If treating intravenously, I
(5) Hypotonic intake in an infant generally will replace one-half of the deficit in isotonic or hypotonic dehydration in the
first 8-12 hours, a quarter of the deficit in the second 12 hours, and the final quarter of
(6) Factitious hyponatremia (Na in plasma while the deficit in the third 12 hours. In other words, completely correcting the deficit within
36 hours. With oral rehydration in a child who is slightly less severe, I often will correct
normal in plasma water),in hyperlipidemia, one-half in the first 6-8 hours and then the remainder over the subsequent 24 hours.
hyperglycemia
If you have hypotonic dehydration and the hypotonicity is severe, by severe I mean
generally a serum sodium that is less than 120, often less than 115, and associated with
CNS symptoms, severe lethargy or seizures, then 3% saline can be used to raise the
3. Hypertonic Dehydration. The balance between H20 serum sodium to a safe level. A safe level is the low 120s. It is rare for a child to seize
whose serum sodium is above 120. I didn't say never. You can have a child whose
and salt has been disrupted, either because of H20 has serum sodium started out at 135 who has rapidly diluted down, for example in water
intoxication, into the high 120s and see a seizure. But in most children with diarrheal
been lost in excess of salt or fluids with extra salt have dehydration and other causes of hypotonic dehydration, you will have a gradual
decrease in the sodium. You will not see seizures characteristically until it gets below
been given to replace the fluid losses. 120. Therefore, if you have a child who is seizing, is severely hypernatremic, I
recommend that you calculate the amount of 3% saline that you give to only raise the
sodium into the low 120s, and then calculate using more standard solutions, bringing
the child the rest of the way back up to lower edge of normal. It is extremely important
Na+ >150 that you not raise a sodium that is very low all the way to normal rapidly. In the adult,
there has been in a number of circumstances, descriptions of lysis of the pons, pontine
a. Causes of Hypertonic Dehydration myelinolysis brought about by rapid correction of serum sodium from severely
Severity Infants Older Children How should you assess the child? The child that is severely ill should be assessed at
least every 12 hours. You should repeat the electrolytes and creatinine, BUN and a
measure of their degree of acidosis. If the child has prerenal failure and their BUN is
Mild 50 ml/kg (5%) 30 ml/kg (3%) elevated to 30 or 40, it should fall very rapidly as you correct the dehydration. So one
should expect in 6-12 hours, the BUN, if elevated, should fall by 50%. If the BUN does
Moderate 100 ml/kg (10%) 60 ml/kg (6%) not fall, or if your initial BUN is greater than 50, that suggests that the degree of
dehydration, the inadequate perfusion, has led to some acute tubular necrosis in
Severe 150 ml/kg (15%) 90 ml/kg (9%) addition to the prerenal acidemia, and you are dealing with intrarenal as well as prerenal
failure. But in the majority of circumstances, with your moderate elevation of urea, it will
fall very rapidly. That is a good sign that you are only dealing with prerenal failure.
B. Determine the Type of Dehydration If the potassium is also elevated, as it may be with acidosis despite total body
potassium loss, it should fall as acidosis regresses. You should reassess a child
1. Pathophysiology of specific illness frequently. One of the things to remember about oral rehydration in the mild to moderate
child is that, although you may not be giving electrolytes, you may be treating the child
2. Specific physical signs at home, it is important that you assess that child on a regular basis. Do not feel that
because you are treating the child orally that the child is any less sick. Periodic
3. Measurement of initial plasma sodium reassessment to make sure the child is gaining weight and recovering from the
dehydration is essential.
1. Isotonic dehydration
1st 12 hours 1/2 deficit
2nd 12 hours 1/4 deficit
3rd 12 hours 1/4 deficit
Hyperkalemia. If the potassium is around 7, you will see peaked, intensive T-waves. If it
gets between 7 and 8, you see prolongation of the P-R interval. Very dangerous levels
C. Acidosis Associated with an Increased Anion Gap are at a potassium of 8 or slightly more wirh ST depression, the absence of P waves,
and gradual widening of the QRS. As we approach fatal levels of hyperkalemia, the
1. Increased endogenous anions: uremia (lactate, sulfate, QRS will widen more and more, eventually develop a sine wave and cardiac arrest and
asystole.
phosphate) ketones (diabetes)
Treatment of severe hyperkalemia. There are three elements to the treatment of
2. Increased exogenous acids: salicylate, ethanol, hyperkalemia. One is to reverse membrane effects. Calcium gluconate is the agent that
paraldehyde is recommended for treating for short-term therapy of severe hyperkalemia. The second
thing we can do is to transfer potassium into cells - to remove the hyperkalemia by
D. Acid-Base disorders induced by diuretics moving potassium out of the circulation and into cells. That can be done with sodium
bicarbonate and with glucose. The third thing is to remove potassium from the body,
1. Metabolic acidosis: carbonic anhydrase inhibitors which can be done with ion exchange resin, of which Kayexalate is an example, or by
dialysis.
(diamox), potassium retaining diuretics (spironolactone,
If we have a child who has hyperkalemia, we don't need to use all of those agents for
amiloride) every child. It is important that we think about the specific usage which may be most
appropriate. If the potassium is in the range of 5.5 to 7 in a previously normal child and
2. Metabolic alkalosis: loop diuretics (furosemide), thiazide we see peaked, intensive T-waves, that is, of course, hyperkalemia that requires
treatment, but it is not life-threatening hyperkalemia. My recommendation here is that
diuretics, mercurials you treat it with sodium bicarbonate. Dosage recommendation is between 1 and 3
mEq/kg. I generally will give the one right in between, I would use 2 mEq/kg, and that
can be used whether the child is acidotic or not. Two mEq/kg of sodium bicarbonate,
infused over about a 15 minute period would be effective in driving potassium into cells.
IV. Disorders of Potassium Balance It will begin to work in about 10 minutes. It will drive potassium into cells and potassium
will stay in cells for about two hours, and then the potassium will begin to leech back out
of cells, and probably by four hours it will be back out of the cells. So bicarbonate will
drive into the cells. If you have an acidosis you have corrected, it will drive into cells to
Electrocardiographic Changes Associated with Hypokalemia stay. Without an acidosis, it will drive it in still transiently. So after you have given
sodium bicarbonate I recommend that you give Kayexalate, 1 gm/kg given by high
and Hyperkalemia rectal enema. The Kayexalate takes about an hour to begin to work. It peaks at about
two hours. By the time the sodium bicarbonate is stopping working, the Kayexalate is
then peaking and removing potassium from the body. If you give 1 gm/kg of Kayexalate,
Serum Potassium EKG Changes you will generally, on average, lower the serum potassium by 1 mEq/l. So that that
therapy in this child would do quite well. You can repeat that in 6-12 hours and bring the
<3.0 Ventricular or atrial arrhythmias potassium down.
Low T wave, prominent U If you have major EKG changes, widening QRS certainly is a very important major one,
then I like to give calcium gluconate first. Calcium gluconate will act immediately, but the
wave, S-T segment depression effect will be gone in about 15 minutes. 10% calcium gluconate is recommended, 0.5
ml/kg and it should be given fairly rapidly over two to four minutes. It is very important
7.0 Peaked T waves that when you give intravenous calcium rapidly that you monitor the heart and that if
there is any sign of bradycardia that you stop the infusion immediately. There is an
7-8 Prolonged P-R interval immediate toxic effect of calcium. But given safely, what will happen is the EKG will
normalize or improve even though the potassium will not change. The calcium does is
stabilize the membrane transiently. You follow that right away with sodium bicarbonate 2
8-9 ST depression, absent P wave, mEq/kg in order to drive potassium into cells. You give the calcium gluconate to
stabilize the membrane, and you can then give the sodium bicarbonate to drive into the
widened QRS cells, in the meantime call in a critical care or in nephrology specialist to institute dialysis
in order to remove potassium from the body.
>9.0 Continued widening of QRS,
Kayexalate can then be given with severe hyperkalemia. Since use of Kayexalate only
sine wave pattern; arrhythmias reduces the potassium by 1 mEq/l it usually is not sufficient and you need to give the
child dialysis. Now glucose can be given at a 0.5 gm/kg ,and that can be given at the
same time. That will also drive potassium into cells. Notice I didn't put up there glucose
A. Hypokalemia and insulin. In the adults, you will see the use of glucose and insulin, but particularly in
dealing with infants, they have generally plenty of insulin around. If you infuse glucose
1. Causes of Hypokalemia alone, that will be sufficient. If the child begins to show moderate hyperglycemia, then of
(2) Major EKG changes The therapy in SIADH is to restrict fluids. The goal is to create a negative water
balance. Fluid restriction of 65-75% of maintenance requirements. The use of
(a) Calcium gluconate, 10% 0.5 ml/kg over 2-4 hypertonic saline can be given if you have severe hyponatremia, but as I mentioned to
you in hyponatremic dehydration, I would only use it if the hyponatremia is severe and
minutes, may be repeated then only to raise the sodium into the 120s. Otherwise, you should treat SIADH with fluid
restriction. What has been in the literature sometimes that I feel should not be used,
(b) Sodium bicarbonate, 1-3mEq/kg over 15-30 diuretics, ethanol and lithium have been suggested from time to time, and they are not
appropriate.
minutes
(c) Dialysis
(d) Glucose 0.5 gm/kg can be given over 30-60
minutes when there are EKG changes.
V. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
A. Clinical Manifestations of SIADH
1. Hyponatremia and serum hypoosmolality
2. Continuing sodium loss in the urine, despite hyponatremia
3. Inappropriately high urine osmolality
4. Absence of decreased blood volume
5. Normal renal function
6. Normal adrenal function
B. Treatment of SIADH
1. The goal of therapy is to create a negative water balance.
2. Fluid restriction to 65-75% of maintenance requirements.
3. Hypertonic saline only if symptomatic from hyponatremia.
VI. Diabetes Insipidus
A. Caused by lack of ADH secretion (pituitary diabetes
insipidus) or lack of response to ADH (nephrogenic diabetes
insipidus).
B. Causes of Pituitary Diabetes Insipidus
1. Congenital, hereditary defect
a. Autosomal dominant
b. Sex-linked recessive
2. Acquired
a. Idiopathic
b. Tumor. Craniopharyngioma, pinealoma, optic glioma,
References