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FLUIDS AND ELECTROLYTES
D E L P R A D O M. D.
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FLUID COMPOSITION Total Body Water: Intracellular Extracellular
60% Body Weight Intracellular 40% Body Weight Extracellular 20% Body Weight Interstitial: 15% Body Weight Intravascular: 5 % Body Weight
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INTRACELLULAR AND EXTRACELLULAR FLUID COMPOSITION
Intracellular (mEq/L) Extracellular (mEq/L) Na+ 20 K+ 150 3-5 Cl- - 98-110 HCO3- 10 20-25 PO4 3- 5 Protein 75
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Maintenance Requirements
Holiday-Segar Method Estimates caloric expenditure in fixed weight categories; it assumes that for each 100 calories metabolized, 100ml of water will be required.
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HOLIDAY-SEGAR METHOD Water Body Weight mL/kg/day ml/kg/hr First 10kg
100 24 hr/day 4 Second 10kg 50 2 Each additional kg. 20 1
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BODY SURFACE AREA METHOD
Mosteller’s Formula Surface area (m2): Square root (Height (cm) x Weight (kg)/ 3600)
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STANDARD VALUES FOR USE IN BODY SURFACE AREA METHOD
1500 mL/m2/24 hr Na+ 30-50 mEq/m2/24 hr K+ 20-40 mEq/m2/24 hr
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BSA TFR: Insensible water loss + urine output
IWL: ml/m2/day x BSA Urine: ml/m2/day x BSA
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CONDITIONS THAT ALTER MAINTENANCE FLUID
Fever: 12% for each C >37.5 C or 7ml/kg for each 0.5C > 37.5C Room temp: >31 C 30% per degree rise Hypermetabolism Major surgery Burns 20-30% 20% increase per 1% area burn
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CONDITIONS THAT ALTER MAINTENANCE FLUID
Less required Hypothermia High Humidity Oliguria/Edema Sedated/Paralyzed 12% for each C <37.5 30% Case to case/ 30% 40%
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DEFICIT THERAPY Fluid Deficit (L) % Dehydration
pre-illness weight (kg) - illness weight (kg) % Dehydration (pre-illness weight - illness weight)/pre-illness weight x 100%
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PERCENTAGE OF DEFICIT FROM EXTRACELLULAR AND INTRACELLULAR COMPARTMENTS
Duration of Illness Deficit from ECF (%) Deficit from ICF (%) <3 days 80 20 >3days 60 40
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CLINICAL OBSERVATION IN DEHYRATION
OLDER CHILD 3% (30mL/kg) 6% (60mL/kg) 9% (90mL/kg) INFANT Examination 5% (50mL/kg) 10% (100mL/kg) 15% (150mL/kg) Dehydration Mild Moderate Severe Skin Turgor Normal Tenting None Skin (Touch) Dry Clammy Buccal Mucosa Moist Parched/ Cracked
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CLINICAL OBSERVATION IN DEHYDRATION
Eyes Normal Deep Set Sunken Tears Present Reduced None Fontanelle Flat Soft CNS Consolable Irritable Lethargic/ Obtunded Pulse rate Slightly increased Increased Pulse quality weak Feeble/ Impalpable Capullary refil 2 sec > 3sec Urine Output Decreased Anuric
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LUDANS METHOD Mild Moderate Severe <15kg < 2y/o 50cc/kg 100 150
30 60 90 D5 0.3NaCl 6-8 hrs 1st hr 1/4 PLRS Next 5-7 hr 3/4 D5LRS 1st hr PLRS Next 5-7 hr 2/3 D5 0.3 NSS
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COMPOSITION OF FREQUENTLY USED PARENTERAL FLUIDS
LIQUID CHO g/100mL Protein Cal/L Na+ mEq/L K+ Cl- HCO3 Ca+2 mOsm/L D5W 5 - 170 252 NS (0.9% NaCl) 154 308 D5 0.3 51 LRS 0-10 0-340 147 4 155.5 D5 IMB 25 20 22 D5 NM 40 13 D5 NR 140 98
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ELECTROLYTE COMPOSITION OF VARIOUS BODY FLUIDS
Na+ (mEq/L) K+ (mEq/L) Cl- (mEq/L) Gastric 20-80 5-20 Pancreatic 5-15 90-120 Small Bowel 90-130 Bile 80-120 Ileostomy 45-135 3-15 20-115 Diarrhea 10-90 10-80 10-110 Burns 140 5 110 Sweat 10-30 3-10 10-35
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ANION GAP (Na + K) - (Cl + HCO3) N.V. : 8-16 mg/dL
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SODIUM DEFICIT mEq Na deficit :
(desired - actual) x TBW TBW = 0.6 x BW (kg) Initial goal : 120 mEq/L subsequent 130mEq/L in 24 hrs Correct up to 12 mEq/L/day
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Correct up to 10-15 mmol/L/day
HYPERNATREMIA (Plasma Na - 140) / 140 x TBW Correct up to mmol/L/day
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HYPOKALEMIA mmol K deficit :
(desired-actual) x 0.3 x wt.kg. Deficit : Wt. (kg) x 50 x Estimated % deficit
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