1. A FEW THOUGHTS ABOUT FLUIDS IN KIDS William Primack, MD UNC Kidney Center Chapel Hill NC USA August 21, 2006

2. HOMEOSTASIS The living organism does not really exist in the milieu exteriour (the atmosphere it breathes, salt or fresh water if that is its element) but in the liquid milieu interior formed by the circulating organic liquid which surrounds and bathes all the tissue elements, this is the lymph or plasma, the liquid part of the blood which in the higher animals is diffused through the tissues and forms the ensemble of the intercellular liquids which is the basis of all local nutrition and the common factor of all elementary exchanges. The stability of the milieu interior is the primary condition for the freedom and independence of existence, the mechanism which allows of this is that which ensures in the milieu interior the maintenance of all the conditions necessary to the life of the elements. Claude Bernard

4. Body spaces

5. Body spaces by age

6. Maintenance fluids Holliday M and Segar W –Pediatrics 1957;19:824 100 kcal~100ml Their data led to the 100:50:20 protocol for the AVERAGE hospital patient

7. Maintenance fluids Holliday M and Segar W –Pediatrics 1957;19:824 100 kcal~100ml Their data led to the 100:50:20 protocol for the AVERAGE hospital patient We never admit any kids like that!!!

8. MAINTENANCE FLUIDS What makes up 100 ml/kg Water (ml/100 kcal) Respiratory40-50 Sweat0-5 Urine50-75 Stool water5-10 ‘Hidden intake’ Water of oxidation (10-15) Totals100-125

9. MAINTENANCE FLUIDS Abnormal losses Water (ml/100 kcal) Abnormal losses Range (ml/kg) Respiratory 40-5025-200 Sweat 0-50-25 urine 50-750-300 Stool water 5-100-100 ‘Hidden intake’ Water of oxidation (10-15) Totals 100-125

10. Maintenance fluids Adjustments to 100:50:20 rule Increase maintenance fluids –By 12 % for each degree C of fever –Insensible losses from 45 to 50-60 ml/100cal for hyperventilation Decrease maintenance fluids –Insensible losses from 45 to 0-15 ml/100cal for high humidity (= ventilator)

11. Maintenance fluids Unless you know what you are replacing and why, using maintenance plus (e.g. 1 ½ x maintenance) is illogical

12. Maintenance fluids An alternative approach Based on body surface area Use estimated insensible losses and replace all other fluid losses based on volume and content Recalculate as often as needed q6h-q24h Probably more accurate for PICU type patients

13. BODY SURFACE AREA BSA (M2) of average proportioned Newborn=0.25 10 kg infant = 0.5 30 kg child = 1.0 70 kg adult = 1.73 If average proportioned 3-30 kg BSA=(wt + 4)/30

14. MAINTENANCE FLUIDS Daily water requirement Water (ml/100 kcal) Water looses per M2 BSA Respiratory 40-50400-600 Sweat 0-50-50 urine 50-75750 Stool water 5-1050-100 ‘Hidden intake’ Water of oxidation (10-15)(150) Totals 100-1251300-1500

15. Continuing losses NO MATTER WHICH SYSTEM YOU USE It is essential to regularly reassess child for continuing losses. Regularly reevaluate effectiveness of your fluid prescription and modify it p.r.n. May need to recheck labs more than q.d. Reweigh more than q.d. if appropriate

16. Contents of abnormal losses meq/liter FluidNaKClHCO3 gastric20-805-20100-1500 pancreatic120-1405-1540-8040-60 small bowel100-1405-1590-13025-40 bile120-1405-1580-12020-40 ileostomy45-1353-1520-11520-50 diarrhea10-9010-8010-1105-35

17. Comparison of Electrolyte Composition of Diarrhea Caused by Different Organisms Etiology Electrolytes (mMol/L) mOsmols Na+K+ClHCo 3 Cholera88308632300 Rotavirus3738226300 ETEC53372418300 Molla et al. J Pediatr 1981; 98: 835

18. MAINTENANCE FLUIDS Fluids based on BSA Water (ml/100 kcal) Water (ml/M2) Na MEQ/M2 K MEQ/M2 Insensible loss 45400-600 0 0 Sweat0-250-20020 urine50-757500-2005-100 Stool water5-1010030 ‘Hidden intake’ (10-15)(150)00 Totals100-1251300-150050-25055-155

19. Case 1 1 y.o., 10 kg, child develops vomiting for 12 hours and then diarrhea for 24 hours On exam decreased turgor, dry mouth, BP 90/60, wt= 9 kg. Labs Na=140, K=4, HCO3=17, BUN=30, creatinine=0.4. Receives 10-20 ml/kg bolus and makes some urine

20. Isotonic dehydration

21. Isotonic dehydration correction waterNaKHCO3 maint100025200 deficit

22. Isotonic dehydration correction waterNaKHCO3 maint100025200 deficit100075 20 total20001009520 ½ in first 8 hrs, remainder over 16 hours Reassess for and replace continuing losses

23. Case 2 1 y.o., 10 kg, child develops vomiting for 12 hours and then diarrhea for 24 hours Given ‘clear fluids’. On exam decreased turgor, dry mouth, BP 80/50, wt= 9 kg. Labs Na=125, K=4, HCO3=15, BUN=40, creatinine=0.4. Receives 10-20 ml/kg bolus and makes some urine

25. Hypotonic dehydration

26. Hypotonic dehydration correction waterNaKHCO3 maint100025200 deficit100075 +

27. Hypotonic dehydration correction (Desired Na – measured Na) X TBW (135 – 125) meq/l X.6 l/kg = 6 meq/kg Thus deficit= 60 meq Na

28. Hypotonic dehydration correction waterNaKHCO3 maint100025200 deficit100075 + 607530 total20001359530 ½ in first 8 hrs, remainder over 16 hours Reassess for and replace continuing losses

29. Case 3 1 y.o., 10 kg, child develops vomiting for 12 hours and then diarrhea for 48 hours Continues to drink cow’s milk On exam nl to ‘woody’ turgor, moist mouth, BP 90/50, wt= 9 kg. Labs Na=170, K=4, HCO3=18, BUN=25, creatinine=0.4. Receives 10-20 ml/kg bolus and makes some urine

30. Hypertonic dehydration

31. Hypertonic dehydration correction waterNaKHCO3 maint75025200 deficit1000 total Lower maintenance water requirement as high ADH will decrease UO

32. Hypertonic dehydration initial day correction waterNaKHCO3 maint75025200 deficit100075-65=102520 total17503545 Target is to drop Na by 10 meq/day. Lower maintenance requirement as high ADH will decrease UO Reassess for and replace continuing losses

33. Hypertonic dehydration correction Lower maintanence requirment as high ADH will decease UO Goal is to decrese Na by 10 meq/day (Desired Na – measured Na) X TBW (165 – 175) meq/l X.6 l/kg = 6 meq/kg Thus sodium surplus= 60 meq Na

35. Comparison of Effect of Glucose on Net Stool Rate with Galactose and Fructose in Perfusions Delivered Uniformly throughout Most of the Small Intestine via Multilumen Tube 12-HOUR PERIODS Pre-perfusion Perfusion with electrolytes and 61 mM galactose Perfusion with electrolytes and 56 mM fructose Perfusion with electrolytes and 58 mM glucose Perfusion with electrolytes only Post-perfusion 600 500 400 300 200 100 1 2 3 4 5 6 7 8 9 MEAN NET STOOL OUTPUT RATE (ml/hr) Adapted from Hirschhorn N et al. N Engl J Med 1968; 176

36. Na-glucose co-transport Intestinal brush border Duggan C JAMA 2004;291:2628

37. Outcome of Oral Treatment of 216 Patients with Rotavirus Initial TreatmentSuccessFailure* Oral (n = 197)188 (95)9 (5) Intravenous (n = 19)17 (89)2 (11) Total (n = 206)205 (95)11 (5) *Requiring unscheduled treatment intravenously. Percentages are given in parentheses. Taylor PR et al. Arch Dis Child 1980; 55(5):376-379

38. Spandorfer et al.Pediatrics 115 (2): 295. (2005 ) ORAL vs IV REHYDRATION IN MODERATE DEHYDRATION

39. ORS 30-50 ml/kg over 3-4 hours of ORS If vomiting give in sips (Pedialyte pops) May also add 5-10 ml/kg per diarrheal stool for ongoing losses Expect increased stool content After rehydration, CHO rich foods Continue nursing

40. ORS and other ‘clear liquids’ CHO g/l Na Meq/l K Meq/l Cl Meq/l base Meq/l mOsm/ kgH20 Pedialyte2.545203530250 WHO ORS 2.075206530280 Gatorade 5.9212.5170377 Apple juice 11.90.426-- 700 Coca cola 10.94.30.1--13.4656 OJ10.40.249--50654