FLUID

MANAGEMENT IN
PICU

Dr. S.SHABBIR
2nd year
postgraduate
 Learning Objectives
Contents of different fluid compartments in body
How to estimate maintenance fluid and electrolyte
needs
Composition of various fluids
Fluid management for patients with different
types dehydration
Fluid adjustment in special situations
Recognize the cause of electrolyte abnormalities
and understand how to replace in critically ill
children
 Total body water
Total body water as a percentage
of body weight varies with age
Infants and young children are at greater
risk than adults for disturbance in fluid
and electrolyte balance due to difference
in body position, higher metabolic rate,
and immaturity for physiologic regulation
systems
 Distribution of Body
Water
Intravascular(25%)

ECF
Interstitial(75%)
33%

Intracellular
ICF
66%
Body Fluid Compartments
Water loss by

Insensible water loss (35%):

evaporation from skin , loss from
respiratory tract
Sensible water loss(65%) : loss from
urine(60%) and stools(5%)
Fluid compartments
Electrolyte Composition
Difference in the distribution of cations:
Na-K+ ATPase pump: 3 Na out & 2 K+
in, this makes intracellular space
negative relative to extracellular space

Difference in the distribution of anions:

is determined by intracellular molecules
that do not cross membrane & the barrier
separating Intracellular space & Extra
cellular space
 osmolality
ICF & ECF are in osmotic equilibrium
because cell membrane is permeable to
water
Plasma osmolality = 285 to 295 mOsm/lit
 Osmolarity = solute/
(solute+solvent)
Osmolality = solute/solvent
(285~295mOsm/L)
Tonicity = effective osmolality
Plasma osmolality = 2 x (Na) +
(Glucose/18) + (Urea/2.8)
Plasma tonicity = 2 x (Na) +
(Glucose/18)
FLUID REQUIREMENT
 HOLIDAY AND SEGAR

Weight Requirement(24hr)
0-10 kg 100ml/kg
11-20 kg 1000 + 50ml/kg for
each Kg>10kg
>20 kg 1500 +20ml/kg for
each Kg>20kg
Example: 8 kg 800cc/24hr
child 33 cc/hr
 Weight VOLUME PER HOUR

0-10 kg 4ml/kg/hr
11-20 kg 40ml/hr +2ml/kg/hr
for each Kg>10kg
>20 kg 60ml/hr +1ml/kg/hr
for each Kg>20kg
Example: 8 kg 800cc/24hr
child 33 cc/hr
Normal electrolyte requirements
sodium 3 4 mEq/kg/day
potassium 2 3 mEq/kg/day
chloride 3 4 mEq/kg/day

calcium 50 200
mg/kg/day
magnesium 0.3 0.5 mEq/kg/day
 Composition of
Parenteral Fluids
FLUID Na+ K+ Cl- Ca Lact Osmo Kcal/
ate lality L
Normal 154 154 308
saline(0.9%
NaCl)
Half normal 77 77 154
saline
(0.45%
NaCl)
0.2 normal 34 34 68
saline (0.2%
NaCl)
3% NaCl 513 513 1026

Ringer 131 5 111 4 29 280

lactate
FLUID Na+ K+ Cl- Ca Lact Osmo Kcal/
ate lality L
5%dextrose 278 170

10%dextrose 556 340

5%dextrose 154 154 560 170

+ NS
5% Dextrose 77 77 332 85
+ NS
5% Dextrose 38 38 354 85
+ NS
Isolyte P 23 20 20 374 170
(1/5 NS +
5%D)
 Maintenance fluids
Goals
Prevent dehydration
Prevent electrolyte disorders
Prevent ketoacidosis
Prevent protein degradation
Selection of maintenance fluid
D5 + NS + 20mEq/L KCl
D5 0.2%NS + 20mEq/L KCl preferred in
<10Kg because of their high water needs
per kilogram
REPLACEMENT
OF DEFICIT
ECF and ICF Contributions to Loss

If losses occur over very short period most of

the loss is from ECF

If losses occur over long period of time losses

are about 50/50 ICF and ECF
 Fluid management plan
Maintenance fluid requirements
Correction of any fluid deficits
Quantification and replacement of
ongoing losses
 Fever
Each degree of fever above 38*C
increases basal metabolic rate
(BMR) 10%, leading to 10-15%
of increase in maintenance fluid
requirement
 Emesis or nasogastric losses
Metabolic Alkalosis
hypokalemia
Treatment:
normal saline +
10 mEq/L KCl

Replace output
ml/ml every 1-6 hr

Example: Pyloric Stenosis

 Dehydration
Types: Electrolytes

Water

Isotonic 80
Electrolyte = Water 70
Hypotonic 60
50
Electrolyte > Water
40
Hypertonic 30
Water > Electrolyte 20
10
0
Iso Hypo Hyper
 Degrees of Dehydration

Mild Moderate Severe

infant <5% 5-10% >10%
Older child <3% 3-6% >6%
Fluid Vol <50ml/kg 50- >100
ume loss 90ml/kg ml/kg

Skin Color Pale Gray Mottled

Skin normal Mild delay delayed

Elasticity
 Degrees of Dehydration
Mucous Dry Very Dry Parched
membranes
Urine Decreased Oliguria Marked
output Oliguria
BP Normal Normal or Lowered
lowered
Pulse Normal or Increased Rapid,
Increased thready
Cap Refil. <2 sec 2-3 sec >3 sec
Time.
consciousne alert irritable depressed
Loss of Skin
Elasticity due
to dehydration
 Isotonic dehydration
(Na 130-145 mEq/L)
Restore intravascular volume with an isotonic
solution,20 ml/kg like NS or RL over 20 min.
Repeat as needed.
Calculate 24 Hr fluid needs = maintenance +
deficit volume
Subtract isotonic fluid already administered
Administer remaining volume over 24 hr with D5
0.45%NS + 20mEq/L KCl
Replace ongoing losses
 Calculation of fluid deficit
Determine the percentage of dehydration
and multiply with the patients weight
eg., A child weighs 10 Kg and is 10%

dehydrated
Fluid deficit = (10 x 10) / 100
=1L
Hyponatremia Dehydration
(Na < 135 mEq/L)
+

Correction of intra vascular volume

depletion with isotonic fluid (NS or LR)
Calculate 24 Hr fluid needs =
maintenance + deficit volume
Correction of hyponatremia with 3% NS
 Hypernatremic
Dehydration
(Na >145 mEq/L)
+

The intravascular volume (extracellular

space) is preserved at the expense of
the intracellular volume
The patient looks better than you
would expect based on fluid loss
Always assume total fluid deficit of at
least 10%
 Management
First priority: Restore intra vascular volume
with normal saline 20 ml/kg over 20 min.
(repeat if needed). RL should not be used.
Correction
Total replacement fluid = maintenance
fluid + deficit volume
Calculate free water deficit and replace in
total fluid requirement
Replace ongoing losses
 Free water deficit
Free water deficit
= weight (kg) X 0.6 X (1-145/current Na+)
It gives 3-4 ml of free water per kg for each
1mEq of current Na+ above 145
So Free water deficit
= 4mlX body weight (current Na+ -145)
50% of free water deficit should be corrected in
24hours and entire should complete in
48hours
fluid :D5 0.45% NS with 20mEq/L KCl at rate :
1.25 1.5 times maintenance
Serum sodium should not decrease by > 12mEq/L
every 24 hours or > 0.5 mEq/L per hour
Time for correction (initial Na+
levels)
145-147 mEq/L: 24 h 158-170mEq/L: 48 hr
171-183 mEq/L: 72 hr
184-196 mEq/L: 84 hr
 Fluids in shock resuscitation
Isotonic crystalloids like NS/LR
20ml/kg over 10 to 15 minutes .
Upto 3 boluses
Colloids in refractory shock
 Fluids in cardiac failure
2/3rd to maintenance fluid
5%dextrose in 0.45% NS with added k+
Maintain an overall negative fluid
balance with diuretics.
 Fluids in renal failure
fluid requirement =
insensible water loss + urine output =400
ml/m2 of body surface area + urine output
Mosteller formula
= BSA(m2) weight(kg)xheight(cms)
3600
5%dextrose in 0.45% NS with no k+
unless hypokalemic
 Fluids in raised intracranial
pressure
Maintain high normal systolic BP so as to
maintain appropriate cerebral perfusion
pressure
Maintain euvolemia
Restrict free water
Avoid hypotonic fluids
Fluid: NS (hyperglycemia) or 5% D in NS
with potassium
Patients at risk of non-osmotic
ADH stimuli resulting in
dilutional hyponatremia
2/3rd maintenance volumes
Aim is serum Na+ > 137 mEq/L
Fluid: 5% D in NS or
5% D in NS with 20 mEq/L K+
MANAGEMENT OF
ELECTROLYTE
DISORDERS
 Hypernatremia
Serum sodium > 145mEq/L
Etiology
1.Euvolemic hypernatremia
excessive sodium ( increased total body
sodium with no water deficit )
a)Improperly diluted formulae
b)Iatrogenic: sodium bicarbonate, 3%Nacl
2. Hypovolemic hyponatremia
water and sodium deficit ,with water deficit > sodium deficit ( low total body
sodium )
Renal losses ( high urine Na+)
a)Osmotic diuresis mannitol,glucose(DKA)
b)Chronic kidney diseases,obsturctive uropathy
Extra renal losses (low urinary Na+)
a)Diarrhea
b)Emesis / nasogastric suction
c)Cutaneous losses excessive sweating
d)Osmotic cathartics
3. Relative hypernatremia
Free water deficit ( total body sodium is
normal )
Renal loss of free water( urine Na+ low)
a)Central and nephrogenic diabetes
insipidus
Extra renal loss of free water ( urine Na+
low)
I. Insensible loss premature infants,
radiant warmers, phototherapy.
II.Inadequate intake
 Clinical features
Dehydration seen in most children
doughy feel of pinched skin due to
intracellular dehydration
CNS dysfunction restless, irritability,
weak, lethargy, fever, hyperreflexia,
seizures and coma.
symptoms are seen at Na+ >160 mEq/L
 complications
Brain hemorrhage
ECF osmolality

Water shifts out of brain cells

Shrinkage of brain volume

Tearing of intracerebral veins and bridging vessels

Hemorrhages ( subdural, subarachnoid and
parenchyma)
 Cont..
Thrombotic complications due to
dehydration
Central pontine myelinolysis and extra
pontine myelinolysis.
 MANAGEMENT
Correct the underlying cause
Rapid correction of hypernatremia leads
to cerebral edema,manifests as seizures
to herniation leading to coma and death
Why?
Brain generates idiogenic osmoles which increases
intracellular osmolality to prevent water loss
rapid decrease in serum sodium

movement of water from plasma into brain cells

cerebral edema

seizures and herniation

coma and death

 Euvolemic Hypernatremic

Drinking water by enteral route or

5%dextrose IV.
AIM: slow correction with minimum
sodium input
 Hypervolemic hypernatremia
5% dextrose to reduce osmolality
Loop diuretics, 0.5 1 mg/kg to remove
excess sodium and water
Hypovolemic Hypernatremia
Correction
Total replacement fluid = maintenance
fluid + water deficit
Calculate free water deficit and replace
in total fluid requirement
Serum sodium should not decrease
by > 12mEq/L every 24 hours or
> 0.5 mEq/L per hour
 Hyponatremia
Serum sodium less than 135mEq/L
Severe hyponatremia :
Serum Na+ < 120mEq/L
Chronic hyponatremia:
hyponatremia > 48 hrs
 Pseudohyponatremia
Serum osmolality is normal
Eg., Hyperproteinemia, Hyperlipidemia
Displacement of water by protien, lipid leads
to false low serum sodium Lab error
factitious/translocational
hyponatremia Plasma osmolality is high
Redistribution of water from ICF to ECF by
non permeable solutes leads to dilutional
hyponatremia
Eg., hyperglycemia,iatrogenic (mannitol)
 True hyponatremia
Plasma osmolality is low
3 types
1.Hypovolemic hyponatremia
2.Euvolemic hyponatremia
3.Hypervolemic hyponatremia
 Hypovolemic hyponatremia
Renal losses:
Diuretics
Obstructive uropathy
Tubulointerstial disorders
Cerebral salt wasting
Adrenal insufficiency
Extra renal losses:
Gastrointestinal (emesis, diarrhoea)
Skin (sweating or burns)
Third space loss(burns, peritonitis)
 Euvolemic hyponatremia

SIADH
Glucocorticoids deficiency
Hypothyriodism
Water intoxication(iatrogenic,
psychogenic polydipsia)
 Hypervolemic hyponatremia
Congestive cardiac failure
Liver cirrhosis
Nephrotic syndrome
Renal failure
Capillary leak due to sepsis
 hyponatremia(decreased Serum Na+)

ECF osmolality

Shift of water from extra cellular to intra cellular

space

Cellular edema
 symptoms
CNS symptoms are predominant
due to increase in intra cranial pressure
Anorexia, nausea, emesis, lethargy,
Headache, confusion, agitation,
hyporeflexia
Seizuers, coma, cheyne stokes respiration
 Chronic Hyponatremia
Adaptation of brain cells to decreased
ECF osmolality by reducing intracellular
osmolality by extrusion of ions and small
organic molecules
Rapid correction leads to central pontine
mylenolysis.
Central pontine mylenolysis
Rapid correction by 3% NaCl

Increases in serum Na+

Water moves from brain cells in to ECF

Cellular shrinkage

Central pontine mylenolysis

 Clinical course
Biphasic
1.Initial encephalopathic phase
seizures, confusion, agitation
Recovers on normonatremia is restored
2. Second phase
dysarthria, dysphagia (cortcobulbar)
Flaccid quadriperesis (corticospinal) later becomes spastic
due to involvement of entire basis ponties
Pupillary and occulomotar abnormalities when lesions extending
upto tegmentum
 Management
Rate of sodium correction depends on
1.Presence of CNS symptoms
2.Chronicity of hyponatremia
3.Cause of hyponatremia
 Symptomatic hyponatremia
Acute management :
4-6 ml/kg of 3% NaCl
over 30 - 60 mins.
1ml/kg of 3% NaCl increases serum Na+
approximately by 1mEq/L
So rapid increase in serum Na+ by 4-5
mEq/L usually causes relief of symptoms
 Sodium correction
Amount of sodium needed to raise serum Na

mEq Na+ required

=(desired Na+ actual Na+)x 0.6 x
bodyweight(kg)
Increase in plasma Na+ at the rate of 0.5
mEq/L/hr and not exceed 12mEq/L in the first
24 hrs or 18 mEq/L in the 48 hrs
 Serum Na+ <135mEq/l
ASSESS FOR CIRCULATORY STATUS

DECREASED VOLUME NORMAL OR INCREASED

VOLUME
U.Na+ <20m U.Na+ >20m U.Na+ <20m Eq/L U.Na+ >20m
Eq/L Eq/L Eq/L
GI losses Diuretics, Congestive cardiac Renal failure
Osmotic diuresis failure
Salt wasting Nephrotic syndrome,
nephropathy Cirrhosis of liver

Third space Adrenal Water intoxication SIADH

loss insufficiency.
Cerebral salt
wasting

Correction of shock & replacement of Water restriction and specific therapy

fluids
 HYPERKALEMIA
Serum K+ levels > 5.5mEq/L
ETIOLOGY
Spurious hyperkalemia
Tissue ischemia during blood drawing
Thrombocytosis
Leucocytosis
Transcellular shifts
Acidosis
Insulinopenia
Hyperosmolality
Drugs like beta-blockers, Digitalis
Succinylcholine. Drugs
K+ sparing diuretics
ACE inhibitors/ ARB blockers
NSAIDS
Heparin
Increased K+ load
Hemolysis
Rhabdomyolysis
Tissue necrosis
Tumorlysis syndrome
Exercise
Hypercatabolic states like burns,surgery
Increased intake
Blood transfusions
Oral/ IV
Decreased excretion
Renal failure
Renal tubular :
pseudohypoaldosteronisim
Primary adrenal diseases: addisons
disease, CAH(21hydroxylase def, 3beta-
hydroxysteroid def,aldosterone synthase
def),
Hyporeninemic hypoaldosteronism:
sickle cell disease, urinary tract
obstruction
 Clinical features
Cardiac conduction disturbances
Muscle weakness, fasciculations ,
parasthesias, cramps
if serum K+ 6.0 -6.5 mEq/L , ECG
should be obtained to assess urgency
ECG changes
 Management
Goals of treatment
To stabilize the heart to prevent
lifethreatining arrhythmias
To remove potassium from the body
Steps
Antagonizing the membrane effects of K+
Driving extracellular K+ into the cells
Removal of excess K+ from the body
 Calcium gluconate (10%)
Presence of ECG changes or severe
hyperkalemia with serum K+ >7mEq/L
Antagonizing the membrane effects of K+
and gives myocardial protection
DOSE: 0.5 1 ml/Kg diluted in equal
volume of distilled water and give slowly
IV over 10 to 20 minutes under continuous
cardiac monitoring
Onset of action: 1-3 min
Duration of action: 30 min
Repeat if ECG changes persist
 Driving K+ into cells
1. Insulin-glucose infusion:
0.5 to 1 g/kg of glucose (2-4ml/kg of
25% dextrose solution) + 0.1 to 0.2
Unit/kg Regular insulin IV over 1 hr
Onset of action: 10-30 min
Duration of action: 2 hr
2. Nebulized beta2-agonists:
10 to 20 mg of salbutamal in 4ml NS (4 to
8 times of dose used in asthma)
Onset of action: 10-30 min
Duration of action: 2 hr 3.Sodium
bicarbonate(7.5%)
1 to 2mEq/kg IV of sodium bicarbonate
dilute in equal amount of 5% dextrose/
distilled water over 10 to 20 min
Onset of action: 10-30
min
Duration of action: 2 hr
 Removal of excess K+
1. Loop diuretics:
furosemide 1 to 2 mg/kg in
patients who are anuric
Onset of action: 30-60 min
Duration of action: until diuresis lasts
2. K+ exchange resins:
polystyrene sulfonate(kayexalate)
1gm/kg/dose orally or rectally dissolved
in 4ml of water with sorbitol/lactulose
Onset of action: 1hour
Dose may be repeated every 6 hours
3. Hemodialysis/rapid cycling peritonial
dialysis
hyperkalemia in acute renal failure
 HYPOKALEMIA
Serum K+ < 3.5mEq/L
ETIOLOGY
Transcellularshift
Alkalemia(metabolic>resiratory)
Hypokalemic periodic paralysis
Drugs (insulin, beta-2 agonists)
Decreased intake
Anorexia nervosa
 Increased excretion
Renal losses
Metabolic acidosis
1.Renal tubular acidosis
2.Diabetic ketoacidosis
3.Ureterosigmoidostomy
Metabolic alkalosis with low urinary
chloride
1.Chloride loosing diarrhoea
2.Cystic fibrosis
 Metabolic alkalosis with
high urinary chloride
Normal Blood pressure Hypertension
1.Bartter syndrome 1.Adrenal adenoma
2. Gittileman syndrome 2.Cushingsyndrome
3.Loop & thiazide 3.CAH (11,17 beta
diuretics hydroxylase deficiency)
4.Renin secreting
tumors
Others
Liddle syndrome,
 CLINICAL FEATURES
Skeletal muscle : cramps, weakness,
ascendingparalysis(serumK+<2.5mEq/L)
Respiratory paralysis
Rhabdomyolysis
paralytic ileus, urinary retention, gastric
dilatation
Polyuria, polydipsia
ST depression, prominent u-waves and
prolonged repolarisation
Approach to Hypokalemia
Management of Hypokalemia
IV potassium is indicated when
Presence of symptoms
Serum K+<3mEq/L
Enteral route not possible
the concentration of K+ in IV fluids should
not exceed 60mEq/L in peripheral vein and
80mEq/L in central vein
 Acute potassium correction
Serum K+<2.5mEq/L with ongoing
potassium depletion or life threatening
complications present
0.5 to 1 mEq/kg of KCl infused by
syringe pump over 1 hr with continuous
cardiac monitoring(dilute 2ml in 10ml
NS)
maximum dose: 40mEq/L
 Oral potassium
Safe and best
10% potassium chloride syrup contain
20mEq/L per 15ml
Dose : 1-2 mEq/kg/day in divided doses
 CALCIUM
Normal levels 8.8-10.8mg/dl
It is present in the body in three proportions
1.Ionized or unbound -50%
2. Protein bound -40%
3. Calcium complexed with phosphate,
sulphate and citrate -10%
80-90% of protein bound form is to
albumin with decrease of 1g/dl of albumin,
decrease of 0.8mg/dl of total serum
calcium occurs without altering ionized
calcium
Hypocalcemia is defined as

< 8.5mg/dl in children

< 8 mg/dl in neonates
<7mg/dl in preterm neonates
VitD deficiency malnutrition
,malabsorption,prolonged phenytoin
therapy
Increased losses idiopathic
hypercalciuria ,RTA,furosemide therapy
Metabolic hypoparathyroidism,
hypomagnesemia Metabolic alkalosis,
hypoproteinemia, sepsis
CNS-tremors , jitteriness, seizures, latent
tetany, apnoea
Neuromuscular numbness, tingling of
lips, hands and toes, carpopedal spasms,
muscle cramps, laryngeal stridor
CVS- hypotension, poor myocardial
contraction, bradycardia,prolonged QT
interval
Prolonged hypocalcemia manifests as
rickets and osteomalacia
Severe symptomatic Hypocalcemia
Immediate treatment with 1 to 2ml/kg body
weight of 10% Calcium gluconate diluted in
equal volume of distilled water and give
slowly IV over 10 to 20 minutes under
continuous cardiac monitoring
Continuous IV Calcium infusion:
infusion of 20-80mg/kg/day of calcium is
needed to maintain noromocalcemia
Asymptomatic hypocalcemia:
Oral calcium supplementation in a
dose of 25-100mg/kg/day in 4 divided
doses
Persistant hypocalcemia:
If hypocalcemia is severe or
persistant then hypomagnesemia is
suspected and treated with 25-50 mg/kg
of 50% MgSO4 IV over 15-30 minutes
with ECG monitoring or I.M. every 4-6th
hourly
 HYPERCALCEMIA
Causes:
1.Paratharmone excess parathyroid
adenoma, hyperplasia, paraneoplastic
syndromes
2.Vitamin D excess, hypervitaminosis A
3.Thyrotoxicosis, prolonged immobilization
, sarcoidosis, williams syndrome
 Clinical features
GI system nausea, vomiting, constipation,
abdominal cramps, paralytic ileus
Nervous system- irritability, confusion,
personality changes, hallucinations,
unsteady gait
Renal renal stones causing colic &
hematuria, nephrocalcinosis, polyuria,
polydypsia
Bone changes- fractures, deformities
 MANAGEMENT
Calcium intake restriction and increased
calcium excretion
Forced saline diuresis with furosemide
orcan rapidly lower serum calcium levels
Bisphosphonates like pamidronate and
etidronate have been used in the treatment
of hypercalcemia due to malignancy
immobilization and hyperparathyroidism
 SUMMARY
At birth TBW is high with ECF is more
than ICF which gradually decrease in
ECF and raise in ICF occurs and reaches
adult by one year of age.
Plasma osmolality = 2 x (Na) +
(Glucose/18) + (Urea/2.8)
Plasma tonicity = 2 x (Na) +
(Glucose/18)
HOLIDAY and SEGAR formula used for
calculating daily maintenance fluid
requirement.
 Ideal maintenance fluid is
D5 + NS + 20mEq/L KCl
D5 0.2%NS + 20mEq/L KCl (<10Kg)
In Dehydration total fluid replacement is
the sum of maintenance and deficit volume.
In renal failure fluid requirement is sum of
insensible loss and urine output .
Rapid correction of hyponatremia leads to
cerebral oedema. manifests seizures, and
herniation.
Brain hemorrhage is a severe complication
of acute hypernatremia.
Acute management of symptomatic
hyponatremia by 4-6ml/kg 3%NaCl over
30-60min.
Rapid correction of chronic hyponatremia
leads to osmotic demylenation syndromes.

10% calcium gluconate is used in severe

hyperkalemia with ECG changes.