Quick review on fluid management

1. FLUID
MANAGEMENT IN
SPECIAL
CIRCUMSTANCES
Presented by: Dr. Jyoti Jha
Department of Pediatrics

2. COMPOSITION OF BODY FLUIDS
Total body water:
TBW = Intracellular fluid +
Extracellular fluid
TBW as a percentage of body weight
varies with age.

3. FLUID COMPARTMENTS

4. Oncotic pressure is a form
of osmotic pressure exerted by
proteins either in the blood
plasma or interstitial fluid.
Hydrostatic pressure is a force
generated by the pressure of
fluid on the capillary walls either
by the blood plasma or
interstitial fluid.

5. 1. Hypoalbumiemia :
Low albumin=Decreased
oncotic pressure of
intravascular compartment =
edema
2. Heart failure:
Impaired pumping =
Expansion of intravascular
volume=
Increase venous hydrostatic
pressure=
Fluid moves from
intravascular to interstitial
space.

6. ELECTROLYTE COMPOSITION

7. TERMINOLOGY
Osmolarity is number of osmotically active particles per one litre
Osmolality is number of osmotically active particles per one Kg
Tonicity refers to osmolality of a solution relative to plasma
Normal 285- 295 mosm/kg

8. OSMOLALITY
The concentration of a solution expressed as the total number of
solute particles per kilogram
Plasma osmolality = 285-295 mOsm/kg
Formula:
Osmolality=2x( Na ) + glucose/18 + BUN / 2.8

10. TONICITY

11. COMMON IV FLUIDS
5 % Dextrose (D5)
10 % Dextrose (D10)
Normal Saline (NS)
Ringer Lactate (RL)
5% Dextrose Normal Saline (DNS)
5% Dextrose ½ Normal Saline (½
DNS)
Isolyte P
3% Saline (Hypertonic Saline)

12. Isotonic fluid Hypotonic fluid Hypertonic fluid
Omsolality = body fluid
osolality
Omsolality < body fluid
osolality
Osmolality > Body fluid
osmolality
Example : Normal saline
Ringer lactate
5% dextrose
Half Normal saline 3% Normal saline
DNS
10% Dextrose

13. Normal Saline ( 0.9% w/v)
Each 100 ml contains:
Sodium chloride 0.9 g
Each litre contains:
Sodium = 154 mmol
Chloride = 154 mmol
Osmolality = 308

14. Ringer Lactate
Each 100 ml contains
Lactic acid = 0.24 ml
Equivalent to
Sodium lactate = 0.32 g
Sodium chloride = 0.6 g
Potassium chloride = 0.04 g
Calcium chloride = 0.027 g
Each litre contains :
Sodium = 131 mosm
Potassium = 5 mosm
Calcium = 2 mosm
Bicarbonate = 29 mosm
Chloride = 111 mosm
Osmolality = 273 mosm

15. DNS
Each 100 ml =
Dextrose anhydrous = 5 g
Sodium chloride = 0.9 g
Electrolytes / litre
Sodium = 154 mosm
Chloride = 154 mosm

17. MAINTEANCE THERAPY
Maintenance intravenous fluids are used in a child who cannot be fed enterally
GOALS OF MAINTENANCE FLUIDS:
 Prevent dehydration
 Prevent electrolyte disturbance
 Prevent ketoacidosis
 Prevent protein degradation

18. CALCULATION
HOLIDAY SEGAR FORMU
LAFor one day:
Upto 10 kg BW: 100ml/kg
11-20 kg BW:
1000+ 50 ml /kg for each 1 kg >
10kg
> 20Kg BW: 1500+ 20 ml/kg for
each kg > 20 kg
Hourly:
Upto 10 kg BW: 4ml/kg/hr.
11-20 kg BW:
40 ml/hr+ 2 ml/kg/hr x (wt – 10
kg)
> 20Kg BW: 60ml/hr + 1
ml/kg/hr x (wt -20)

19. MAINTENANCE WATER
 Crucial component of maintenance fluid therapy.
 Maintenance water = Measurable loss of water 65% (Urine 60%, stools 5%) +
Insensible of water 35% (skin & lungs)

20. INSENSIBLE WATER LOSS
Source of water loss
Insensible loss - Lungs and
Skin= 35%
Sensible water loss
Urine – 60%
Stool – 5 %
CALCULATION
Insensible water loss 400 ml/M2
BSA
Or 1/3 maintenance
30ml/kg in infancy
20ml/kg in children
10ml/kg in adults

21. INTRAVENOUS SOLUTION
Normal saline (NS) and Ringer lactate (LR) are isotonic solutions
 The usual choices for maintenance fluid therapy in children are half-
normal saline (1/2 NS) and NS. These solutions are available with 5%
dextrose (D5) or without dextrose.
A normal plasma osmolality is 285-295 mOsm/kg.
 Infusing an intravenous solution peripherally with a much lower
osmolality can cause water to move into red blood cells, leading to
hemolysis.
Thus, 0.2NS (osmolality = 68) should not be administered
peripherally, but D5 0.2NS (osmolality = 346) or D5 1/2 NS + 20
mEq/L KCl (osmolality = 472) can be administered.

22. oHypotonic fluids increase the risk of hyponatremia
o0.2NS is no longer recommended as a standard maintenance fluid and
its use is restricted at many hospitals.

23. GLUCOSE IN MAINTENANCE FLUID
Maintenance fluids usually contain D5
It provides 17 calories/ 100 mL and nearly 20% of the daily caloric
needs
This level is enough to prevent ketone production and helps
minimize protein degradation
If prolonged , receives inadequate calories and will lose 0.5-1% of
weight each day.

24. SELECTION OF MAINTENANCE
FLUIDS
nonosmotic ADH production
D51/2NS + 20 mEq/L KCl is recommended in the child who is NPO.
Children with volume depletion, baseline hyponatremia, or at risk for
nonosmotic ADH production (lung infections such as bronchiolitis or
pneumonia; central nervous system infection)
should receive D5 NS + 20 mEq/L KCl.

25. Surgical patients
Typically receive isotonic fluids (NS, LR) during surgery and in the
recovery room for 6-8 hr postoperatively
the rate is typically approximately two-thirds of the calculated
maintenance rate,
with dextrose added if clinically indicated.
Subsequent maintenance fluids should be D5 NS or LR, with addition of
10-20 mEq/L of KCl based on the serum potassium and the clinical
setting.
Electrolytes should be measured at least daily in all children receiving
more than 50% of maintenance fluids intravenously unless the child is
receiving prolonged intravenous fluids (TPN).

26. MONITORING WHILE ADMINISTERING FLUIDS*
 electrolytes and glucose 4-6 hours after commencing,
and then according to results and the clinical situation
but at least daily.
 particular attention to the serum sodium on measures of
electrolytes.
 If <135mmol/L (or falling significantly on repeat
measures) If >145mmol/L (or rising significantly on
repeat measures)
 Children on iv fluids should have a fluid balance chart
documenting input, ongoing losses and urine output.
*Royale Children’s Hospital Melbourne Guidelines

27.  Child should be weighed prior to the commencement of
therapy, and daily afterwards.
 Children with ongoing dehydration/ongoing losses may
need 6 hourly weights to assess hydration status
 All children on IV fluids should have serum electrolytes
and glucose checked before commencing the infusion
(typically when the IV is placed) and again within 24 hours
if IV therapy is to continue.
*Royale Children’s Hospital Melbourne Guidelines

28. ADJUSTMENT IN MAINTENANCE
WATER AND ELECTROLYTES

29. CLINICAL CONDITION THAT MODIFY
NORMAL WATER AND
ELECTROLYTE
Factor Alteration
Fever (persistent) 10-15% increase for every 1C/1.8F
increase in temperature above
38C/100.4F
Hyperventilation 10-60 ml/kg (per 100 kcal)
Sweating 10-60 ml/kg
Humidified ventilation Reduce
GI and Renal loss Monitor and adjust

30. REPLACEMENT FLUID
 The gastrointestinal (GI) tract is potentially a source of considerable water
loss.
GI water losses are accompanied by electrolytes and thus may cause
disturbances in intravascular volume and electrolyte concentrations.
 GI losses are often associated with loss of potassium, leading to
hypokalemia.
 Because of the high bicarbonate concentration in stool, children with diarrhea
usually have a metabolic acidosis, which may be accentuated if volume
depletion causes hypoperfusion and a concurrent lactic acidosis.
Emesis or losses from an NG tube can cause a metabolic alkalosis

31. It is impossible to predict the losses for the next 24 hr; better to
replace excessive GI losses as they occur.
The child should receive an appropriate maintenance fluid that does
not consider the GI losses.
The losses should then be replaced after they occur, with use of a
solution with a similar electrolyte concentration as the GI fluid.
The losses are usually replaced every 1-6 hr, depending on the rate of
loss, with very rapid losses being replaced more frequently.

32. Diarrhea is a common cause of fluid loss in children. It can cause dehydration
and electrolyte disorders
Average composition of Diarrheal stools (except cholera)
Na 55 mEq/l
K 25 mEq/l
Bicarbonate 15 mEq/l
Approach to Replacement of Ongoing Losses
D5 1/2 NS + 30 mEq/l sodium bicarbonate + 20 mEq/l KCl
Replace stools ml/ml every 1 to 6 hrs

33. REPLACEMENT FLUIDS
Replacement fluid for Emesis or Nasogastric losses*
Average composition of Gastric Fluid
Na 60 mEq/l
K 10 mEq/l
Chloride 90 mEq/l
Approach to Replacement of Ongoing Losses
NS + 10 mEq/l KCl
Replace Output ml/ml every 1 to 6 hrs
*Nelsons Text book of pediatrics 19th edition

34. REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria /Anuria
Place patient on insensible fluids (25 to 40% of maintenance)
with D51/2NS
Replace Urine output ml/ml by D5 half NS+/- KCL
Polyuria
Replacement of insensible fluids (25 to 40% of maintenance)
with D5 ½ NS +/- KCL
Measure urine electrolytes
Replace Urine output ml/ml with solution based on measured
urine electrolytes *Nelsons Text book of pediatrics 19th edition

35. DEFICIT THERAPY
Dehydration, most often caused by gastroenteritis, is a common
problem in children

36. CALCULATION OF THE FLUID
DEFICIT
Determining the fluid deficit necessitates :
clinical determination of the percentage of dehydration and
multiplication of this percentage by the patient’s weight;
a child who weighs 10 kg and is 10% dehydrated has a fluid deficit of 1
L.

37. APPROACH TO SEVERE DEHYDRATION
The child with dehydration needs acute intervention to ensure that
there is adequate tissue perfusion
Resuscitation phase:
Requires rapid restoration of the circulating intravascular volume and
treatment of shock with an isotonic solution, such as normal saline
(NS) or Ringer lactate (LR).
The child is given a fluid bolus, usually 20 mL/kg of the isotonic
fluid, over approximately 20 min.
The child with severe dehydration may require multiple fluid boluses
and may need to receive the boluses as fast as possible.
In a child with a known or probable metabolic alkalosis (the child with
isolated vomiting), LR should not be used because the lactate would
worsen the alkalosis.

38. The initial resuscitation and rehydration phase is complete when the
child has an adequate intravascular volume. Typically, the child
shows clinical improvement, including a lower heart rate,
normalization of blood pressure, improved perfusion, better urine
output, and a more alert affect.

39. MONITORING AND ADJUSTING
THERAPY

40. IDEAL CONCENTRATION OF SODIU
M IN IVF?
Below 10 kg BW:
D5 ¼ NS + 20 mmol/L of KCl
Above 11 kg BW:
D5 1/2 NS + 20 mmol/L of KCl
Ref: Nelson text book of pediatrics. 18 th edition P.310

41. Clinical conditions and fluid management

42. HYPONATREMIC DEHYDRATION:
The pathogenesis of hyponatremic dehydration usually involves a
combination of sodium and water loss and water retention to
compensate for the volume depletion.
Goal : correction of intravascular volume depletion with isotonic fluid
(NS or LR).
Avoid correcting the serum sodium concentration by >12 mEq/L/24 hr
or >18 mEq/L/48 hr.
An overly rapid (>12 mEq/L over the first 24 hr) or overcorrection in
the serum sodium concentration (>135 mEq/L) is associated with an
increased risk of central pontine myelinolysis
 Patients with neurologic symptoms (seizures) need acute infusion of
hypertonic (3%) saline to increase the serum sodium concentration
rapidly.

44. HYPERNATREMIA
Sodium concentration >145 mEq/L, sometimes defined as >150
mEq/L.
should not be corrected rapidly.
Goal: is to decrease the serum sodium by <12 mEq/L every 24 hr, a
rate of 0.5 mEq/L/hr.
In hypernatremic dehydration, the first priority is restoration of
intravascular volume with isotonic fluid
 Normal saline is preferable to lactated Ringer solution because the
lower sodium concentration of the latter can cause the serum sodium
to decrease too rapidly, especially if multiple fluid boluses are given.

45. DETERMINANTS OF THE RATE OF
DECREASE OF SODIUM
CONCENTRATION
The sodium concentration of the deficit replacement fluid,
•the rate of fluid administration, and
•the presence of continued water losses.
Formula for calculating the water deficit:
Water deficit = Body weightx 0.6 (1-45) /current sodium
•This calculation is equivalent to 3-4 mL of water per kg for each 1 mEq
that the current sodium level exceeds 145 mEq.
•The utility of such formulas has never been proven in clinical practice.

46. HYPERNATREMIC DEHYDRATION

47. ACUTE WATERY DIARRHOEA
1. Assessment of dehydration
2. In case of severe signs of dehydration best iv fluid is Ringer lactate.
Age First give Then give
<12 months 30ml/kg in one hour 70 ml/kg in 5 hours
12 months – 5 years 30ml/kg in 30 min 70 ml/kg in 21/2
hours
Repeat again if the radial pulse is still very weak or not detectable

48. DIABETES KETOACIDOSIS

50. SHOCK

51. ACUTE RENAL FAILURE
Fluid challenge to differentiate pre-renal from intrinsic renal failure.
For intrinsic renal failure failure maintenance fluid is reduced to
insensible loss
Plus urine output
In oliguric renal failure no electrolyte should be added to the fluid.

52. CONGESTIVE CARDIAC FAILURE
They are in state of fluid overload
Daily maintenance should be reduced to two third value
Fluid of choice for 10 kg child = N/5 D5 with 2 ml KCL per 100
ml fluid
@ 70ml/kg

53. INTESTINAL OBSTRUCTION
NG aspirate should be replaced with N/2 or N/3 saline with added
potassium
NS or RL can be used

54. BURN
Fluid resuscitation should begin soon after the injury has occurred
Parkland formula:
4 mL lactated Ringer solution/kg/% BSA burned
Half of the fluid is given over the 1st 8 hr, calculated from the time of
onset of injury; the remaining fluid is given at an even rate over the
next 16 hr.
The rate of infusion is adjusted according to the patient’s response
to therapy.
Pulse and blood pressure should return to normal, and an adequate
urine output (>1 mL/kg/hr in children; 0.5-1.0 mL/ kg/hr in
adolescents) should be accomplished by varying the IV infusion rate.

55. Vital signs, acid–base balance, and mental status reflect the adequacy
of resuscitation.
Because of interstitial edema and sequestration of fluid in muscle
cells, patients may gain up to 20% over baseline (preburn) body
weight.
Patients with burns of 30% of BSA require a large venous access
(central venous line) to deliver the fluid required over the critical 1st
24 hr.
Patients with burns of >60% of BSA may require a central venous
catheter
In addition to fluid resuscitation, children should receive standard
maintenance fluids

56. FLUID MAINTENANCE DURING
SURGERY AND ANESTHESIA
Patients who are unconscious and immobile have lost venous pump
mechanisms and have peripheral venous pooling.
 Volume expansion is most commonly provided by isotonic salt-
containing solutions (normal saline, lactated Ringer solution).
 Autonomic responses may be increased as part of the surgical
stress response, with vasoconstriction and intravascular volume
contraction caused by diuresis, intravascular volume loss from
hemorrhage, evaporation (insensible loss, increased during surgery),
and third space (interstitial space) fluid losses resulting from the
inflammatory response.
Abnormalities in the distribution of renal blood flow and secretion of
antidiuretic hormone further complicate the regulation of
intravascular volume.

57. ELECTROLYTE CONCENTRATION OF ST
OCK SOLUTION
FOR EVERY ONE ML
IV Preparations - One ml Electrolyte content
3% saline
8.4% Sodium bicarbonate
Potassium chloride
10% Calcium gluconate
0.5mEq of sodium
1 mEq of Na and HCO3
2 mEq of potassium
9.3 mg of Elemental ca

58. THANK YOU