intravenous fluid and electrolytes are important topics in medical science. potassium is one of the vital electrolytes of the human body. this presentation has a discussion on several iv fluids and potassium balance and also how to manage the potassium imbalance.

1. Presenter:
Dr Maimuna Sayeed
Resident- Phase B
Paediatric Gastroenterology and Nutrition
BSMMU, Dhaka
Fluid
and
Electrolytes

2. Introduction
 Fluid and electrolyte balance is a dynamic process
that is crucial for life
 It plays an important role in homeostats
 Imbalance may result from many factors, and
it is associated with the illness

3. Body fluids/Water
• Provide transportation of nutrients to cells
• Carry waste products away from cells
• Provide the environment for electrolyte chemicals
reactions to occur
• Aids in regulation of body temperature
• Maintain blood volume
• Solvent for minerals, vitamins and glucose

4. Fluid compartment of the body
Total body fluid
60% of total body weight
Extracellular fluid
Total 20% of body weight
Intracellular fluid
Total 40% of total body weight
Interstitial fluid
15% of total body weight
Plasma
5% of total body weight
Transcellular fluid
Fluid in potential
spaces
Fluid in GIT and
respiratory tract
Intraocular
fluid
CSF
Pleural cavity
Pericardial cavity
Peritoneal cavity

6. Fluid therapy
• Intravenous fluid therapy:
oCrystalloid
oColloid

7. Definitions
• Solute: a particle, usually a salt
• Solvent: liquid, usually water
• Solution: solute and solvent mixed together

8. • Osmolarity: the concentration of a solution
expressed as the total number of solute particles
per litre.
• Osmolality: the concentration of a solution
expressed as the total number of solute particles
per kilogram
• Tonicity: is a measure of the effective osmotic
pressure gradient, as defined by the water potential
of two solutions separated by a semipermeable
membrane

9. what solutions’ tonicity can be:
• Hypotonic: low solute, high solvent
• Isotonic: equal solute and solvent ratio
• Hypertonic: high solute, low solvent

10. • Osmolality: 275-295mmol/kg
oLower osmolality is <275mmol/kg and means blood is
hypotonic
oHigher osmolality is >295mmol/kg and means blood is
hypertonic

11. Isotonic
• Iso: same/equal
• Tonic: concentration of a solution
• The cell has the same concentration on the inside
and outside which in normal conditions the cell’s
intracellular and extracellular are both isotonic.
• Isotonic solutions are used: to increase the
EXTRACELLULAR fluid volume due to
oblood loss
osurgery
odehydration

12. Isotonic fluids
1) 0.9% NaCl (Normal Saline)
2) 5% dextrose in water (D5W) (In the bag)
also used as a hypotonic solution after it is administered because
the body absorbs the dextrose BUT it is considered isotonic
3) 5% Dextrose in 0.225% saline (D5W1/4NS)
4) Lactated Ringer’s

13. Hypotonic
• Hypo: ”under/beneath”
• Tonic: concentration of a solution
• The cell has a low amount of solute extracellularly and
it wants to shift inside the cell to get everything back to
normal via osmosis. This will cause CELL SWELLING
which can cause the cell to burst or lyses.
• Hypotonic solutions are used when the cell is
dehydrated and fluids need to be put back
intracellularly.
o diabetic ketoacidosis (DKA)
o hyperosmolar hyperglycemia

14. Hypotonic solutions
1) D5W (in the body)
2) 0.25% NaCl
3) 0.45% NaCl (half normal saline)
4) 2.5% Dextrose

15. Hypertonic
• Hyper: excessive
• Tonic: concentration of a solution
• The cell has an excessive amount of solute
extracellularly and osmosis is causing water to rush out
of the cell intracellularly to the extracellular area which
will cause the CELL TO SHRINK.
• When hypertonic solutions are used (very cautiously;
most likely to be given in the ICU due to quickly arising
side effects of pulmonary edema/fluid over load).
• In addition, it is preferred to give hypertonic solutions
via a central line due to the hypertonic solution being
vesicant on the veins and the risk of infiltration.

16. Hypertonic solutions
1) 3% Saline
2) 5% Saline
3) 10% Dextrose in Water (D10W)
4) 5% Dextrose in 0.9% Saline
5) 5% Dextrose in 0.45% saline
6) 5% Dextrose in Lactated Ringer’s

18. Electrolyte composition &
osmolarity of common IV fluid
Intravenous fluid
(crystalloids)
Osmolarity
(mOsm/L)
Na+
(mmol/L)
Cl-
(mmol/L)
Components
Normal saline (0.9% NaCl) 306 154 154 NaCl
5% dextrose in aqua 278 - - Glucose
5% dextrose in NS 560 154 154 Glucose., NaCl
0.45% NaCl 153 77 77 NaCl
%5 dextrose in 0.45% NaCl 406 77 77 Glucose, NaCl
5% dextrose in 0.25% NaCl 320 34 34 Glucose, NaCl
3% NaCl 1026 513 513 NaCl
Ringer’s lactate 273 130 130 NaCl, K+, Ca++,
lactate

19. Hypertonic, Hypotonic, & Isotonic
Fluid Solution Quiz

20. • A patient is being admitted with dehydration due to
nausea and vomiting. Which fluid would you expect
the patient to be started on?
A. 5% Dextrose in 0.9% Saline
B. 0.33% saline
C. 0.225% saline
D. 0.9% Normal Saline
The answer is D: 0.9% Normal Saline

21. • _______ solutions cause cell dehydration and help
increase fluid in the extracellular space.
A. Hypotonic
B. Osmosis
C. Isotonic
D. Hypertonic
The answer is D: Hypertonic

22. • Which of the following is not a hypertonic fluid?
A. 3% Saline
B. D5W
C. 10% Dextrose in Water (D10W)
D. 5% Dextrose in Lactated Ringer’s
The answer is B: D5W

23. • The doctor orders an isotonic fluid for a patient.
Which of the following is not an isotonic fluid?
A. 0.9% Normal Saline
B. Lactated Ringer’s
C. 0.45% Saline
D. 5% Dextrose in 0.225% saline
The answer is C: 0.45% Saline

24. Common intravenous colloid
solution
1. Albumin solution
• 5% albumin in normal saline,
• 25% albumin in normal saline
2. Dextran solution
3. Hetastarch solution

25. Clinical use of colloid solution
• Act as plasma expander in hypovolemic state
• Infusion of colloid solution increases the colloidal
osmotic pressure of plasma, because infused
colloids remain restricted in intravascular space
since they are impermeable to capillary epithelium.
As a result fluid from extravascular space moves
into intravascular space to increase plasma volume
which helps to maintain normal cardiovascular
health in hypovolemia and during major surgery
causing hemorrhage

27. Electrolytes
• Electrolytes account forapproximately 95%
solute molecules in body water.
• Sodium Na+ predominantextracellular cation.
• Potassium K+ is thepredominant
intracellular cation.

29. Potassium
• Potassium is the second most abundant cation in
the body
• About 98% of potassium is intracellular and that is
particularly in the skeletal muscle.
• Because most potassium is intracellular, the plasma
concentration does not always reflect the total
body potassium content.
Hypokalemia andHyperkalemia in Infants
andChildren: Pathophysiologyand
Treatment,Kayleen Daly,

30. Nelson TEXTBOOK of PEDIATRICS EDITION 20

31. Distribution
Most abundant cation of ICF, help to maintain ICF
volume.
• 2% in the ECF
• 98% in the ICF

32. 3Na+
2K+
ATPase
K+
cell = 140-160 mEq/L
K+
e = 4-5 mEq/L
Trans-cellular K+ Distribution

33. • The Na+K+-ATPase maintains the high intracellular
potassium concentration by pumping sodium out of
the cell and potassium into the cell.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

34. Importance
• Potassium is necessary for the electrical responsiveness of
nerve and muscle cells and for the contractility of cardiac,
skeletal, and smooth muscle.
• The intracellular potassium concentration affects cellular
enzymes.
• Potassium is necessary for maintaining cell volume because
of its important contribution to intracellular osmolality.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

35. Normal serum potassium levels in
children
Age Range (mEq/L or mmol/L)
Premature infant 4 to 6.5
Newborn 3.7 to 5.9
Infant 4.1 to 5.3
Child > 1 year old 3.5 to 5
UpToDate

36. Intake
Potassium is plentiful in food. Dietary consumption
varies considerably, even though 1-2 mEq/kg is the
recommended intake.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

37. Foods high in potassium
• Fruits
Bananas, oranges (citrus), cantaloupe, watermelon, apricots,
raisins, prunes, pineapples, cherries, and tomatoes
• Vegetables
Green and leafy, potatoes, avocados, artichokes, lentils, beets,
white mushrooms, and onions
• Meats/Fish
All contain potassium (the lowest levels are in chicken liver,
shrimp, and crab)
Potassium content of selected foods percommon measure, sorted by nutrient
contentNational Nutrient Database for Standard Reference,Released 2012)

38. • Breads/Flours
Pumpernickel, buckwheat, and soy
• Miscellaneous
Chocolate, cocoa, brown sugar, molasses, nuts, peanu tbutter,
French fries, and whole milk

39. Potassium content in popular foods
and beverages
Food/beverage Pota8.6ssium content (mEq)
French fries 17.7
Small banana 8.6
White mushrooms 8.1
Orange juice (200 ml) 7.9
Whole milk (200 ml) 7.7
Broccoli 5.8
Potato chips 5.1
Green beans 3.9
Milk chocolate bar (20 g) 2.4
Onions, cooked 1.5
Coca-Cola (200 ml) 0.1
Potassium content of selected foods percommon measure, sorted by nutrient
contentNational Nutrient Database for Standard Reference,Released 2012)

40. Absorption
The intestines normally absorb approximately 90% of
ingested potassium. Most absorption occurs in the
small intestine, whereas the colon exchanges
body potassium for luminal sodium.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

41. Excretion
• There is some loss of potassium in sweat, but it is
normally minimal.
• The colon has the ability to eliminate some
potassium in the stool but most ingested potassium
is eventually excreted in the urine.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

42. Components of Potassium
Homeostasis
Intake ECF
ICF
Distribution
Excretion
90% Kidney
10% Colon
Insulin
Aldosterone

43. Regulation of potassium balance
(homeostasis)
• Short term regulation (internal K+ balance) –done
by transmembrane potassium flux
• Long term regulation (external K+ balance) –done
by kidney

44. Factors regulating transmembrane
potassium flux
Factor Function Effect on serum K+
Insulin Influx Hypokalemia
Aldosterone
Alkalosis
Acute potassium excess
B agonist (epinephrine)
A blocker
Glucagon Efflux Hyperkalemia
ECF hyperosmolarity
Acute potassium deficit
Acidosis
A agonist (norepinephrine)
B blocker
abc of medical biochemistry, Prof. md.
Mozammel Hoque

45. Increase K+ intake
Increase plasma K+
Adrenal
cortex
Increase aldosterone
KidneyIncrease K+ excretion
Negative
feedback

46. Hormone regulating potassium
secretion
• Aldosterone,
• Glucocorticoids,
• ADH
• Insulin
• Catecholamines
Nelson TEXTBOOK of PEDIATRICS EDITION 20

47. Potassium imbalance
• Deficit: hypokalemia
• Excess: hyperkalemia

49. HYPERKALEMIA
Hyperkalemia is defined as a serum or plasma
potassium that is higher than the upper limit of
normal potassium, which typically is considered to
be 5.5 mEq/L (mmol/L)
Causes, clinical manifestations, diagnosis, and evaluation of hyperkalemia in
children, Author:Michael J Somers, MD

50. Causes of Hyperkalemia
• Three basic mechanisms cause hyperkalemia
1. Increased intake
2. Transcellular shifts
3. Decreased excretion
4. Spurious laboratory value
Nelson TEXTBOOK of PEDIATRICS EDITION 20

51. Causes of Hyperkalemia
SPURIOUS LABORATORY VALUE
Hemolysis
Tissue ischemia during blood drawing
Thrombocytosis
Leukocytosis
Familial pseudohyperkalemia
INCREASED INTAKE
Intravenous or oral
TRANSCELLULAR SHIFTS
Acidosis
Rhabdomyolysis
Tumor lysis syndrome
Tissue necrosis
Hemolysis/hematomas/gastrointestinal bleeding
Succinylcholine

52. TRANSCELLULAR SHIFTS
Digitalis intoxication
Fluoride intoxication
β-Adrenergic blockers
Exercise
Hyperosmolality
Insulin deficiency
Malignant hyperthermia
Hyperkalemic periodic paralysis
DECREASED EXCRETION
Renal failure
DECREASED EXCRETION
Primary adrenal disease:
Acquired Addison disease
21-Hydroxylase deficiency
3β-Hydroxysteroid dehydrogenase deficiency
Lipoid congenital adrenal hyperplasia
Adrenal hypoplasia congenita
Aldosterone synthase deficiency

53. Hyporeninemic hypoaldosteronism:
Urinary tract obstruction
Sickle cell disease
Kidney transplant
DECREASED EXCRETION
Renal tubular disease:
Pseudohypoaldosteronism type I
Pseudohypoaldosteronism type II
Bartter syndrome, type 2
Urinary tract obstruction
Kidney transplant
Medications:
Angiotensin-converting enzyme inhibitors
Angiotensin II blockers
Potassium-sparing diuretics
Calcineurin inhibitors
Nonsteroidal antiinflammatory drugs
Trimethoprim
Heparin
Drospirenone (in some oral contraceptives)

54. Clinical Manifestations
The cardiac conduction system is usually the dominant
concern.
• Ventricular fibrillation
• Asystole
• Paresthesias,
• Fasciculations,
• Weakness
• Ascending paralysis
Nelson TEXTBOOK of PEDIATRICS EDITION 20

55. DIAGNOSIS
History
• initially focus on potassium intake,
• risk factors for transcellular shifts of potassium,
• medications that cause hyperkalemia, and
• the presence of signs of renal insufficiency, such as
oliguria and edema.
• Symptoms: weakness, paralysis
Physical findings: none specific

56. Initial laboratory evaluation should include
• S. Electrolytes: serum K+ > 5.5
• S. creatinine
• BUN, and
• Acid–base status.
• Electrocardiogram (ECG)

57. Electrocardiographic
manifestations for hyperkalemia
Serum
potassium
concentration
Electrocardiographic manifestations
5.5-6.5 mEq/L Tall, peaked, ‘‘tented’’ T waves, normal or decreased
QT, PR interval shortening
6.5-7.5 mEq/L Widening of QRS complex, increased PR interval
7.0-8.0 mEq/L Broad, low-amplitude P waves, QT prolongation,
ST elevation or depression
> 8 mEq/L P waves disappear, marked widening of QRS + ‘‘sine
wave’’ pattern, high risk for ventricular fibrillation or
asystole
Taketomo, Hodding, & Kraus (2013)and Sood, Sood, & Richardson. (2007). Emergency
management and commonly en-countered outpatient scenarios in patients with hyperkalemia.

58. Severity of hyperkalemia
• Mold: serum K+ 5.5-6.5 mmol/L
• Moderate: serum K+ 6.5-8 mmol/L
• Severe: serum K+ >8 mmol/L

59. Treatment
• Treatment of hyperkalemia depends on the serum
potassium level, as well as the presence or absence
of symptoms and ECG changes.
• Treatment is recommended when ECG changes are
present or when serum potassium levels are
greater than 6 to 6.5 mEq/L, regardless of the ECG
findings.

60. The treatment of hyperkalemia has 2 basic goals:
(a) to stabilize the heart to prevent life-threatening
arrhythmias and
(b) to remove potassium from the body
Nelson TEXTBOOK of PEDIATRICS EDITION 20

61. How to manage?
• Check sampling error and recheck value by sending
free flow of blood
• Identify and remove all sources of oral or
parenteral potassium intake(oral potassium
supplements and intravenous maintenance fluids
or parenteral nutrition must be considered) and
• evaluate drugs that can increase the serum
potassium level (e.g., potassium-sparing diuretics,
angiotensin-converting enzyme inhibitors, and
nonsteroidal antiinflammatory agents)

62. A. Mild hyperkalemia (<6mmol/L)
Restrict/avoid intake of extra potassium through
potassium containing food or fluid

63. B. Moderate to severe
hyperkalemia (>6mmol/L)
• Myocardial cell membrane stabilization
oCalcium gluconate (10%) dose: 0.5-1ml/kg IV slowly over
5-10 min
• Redistribution of extracellular K+ into cells
oInsulin (short acting) dose: 0.1 unit/kg, IV with 10% DA @
5ml/kg over 30 min
oSalbutamol nebulization dose: 2.5mcg (<25kg) or 5 mcg
(>25kg) with normal saline (2ml)
oSodium bi carbonate dose:1-2ml/kg, IV slowly over 10-15
min

64. • Enhance elimination of K+ from the body through
gut
oSodium polystyrene sulfonate resin (kayexalate)
Oral: 1mo-18 years
Dose: 125-250mg/kg (max 15gm) in 15-30ml 70% sorbitol, 3-4/day
Rectal: neonate – 18 years
Dose: 125-250mg/kg , dilute each gm resin in 5-10ml
methylcellulose or water, repeated as necessary, every 6-8hours
• Other ways to eliminate K+ from body (in
refractory cases)
oRenal replacement therapy
Peritoneal dialysis
haemodialysis

65. HYPOKALEMIA
• Hypokalemia is defined as serum level below the
normal value, which is usually defined as 3.5
mEq/L.
• It is common in children, with most cases related to
gastroenteritis.
UpToDate,
Hypokalemia in children Authors: Michael J
Somers, MD

66. Severity of hypokalemia
• Mild: 2.5 - 3.5 mmol/L
• Moderate: 2-2.5 mmol/L
• Severe: <2 mmol/L
Nelson

67. Gastrointestinal
Increased losses (diarrhea, vomiting, nasogastric drainage)
Decreased intake (anorexia, bulimia)
Increased potassium intracellular uptake
Alkalosis
Increased insulin activity
Beta-adrenergic agents (eg albuterol, epinephrine, dopamine)
Periodic paralysis
Genetic etiology
Hyperthyroidism
Other drugs
Barium
Antipsychotics
Chloroquine
Pediatric causes of hypokalemia

68. Increased urinary losses
Increased distal delivery of sodium to distal nephron
Diuretics
Osmotic diuretics (mannitol, hyperglycemia)
Non-re-absorbable anions (elevated serum bicarbonate level)
Tubular injury (Cisplatin)
Types I and II renal tubular acidosis
Increased mitochondrial activity
Hyperaldosteronism due to hypovolemia
Glucocorticoid remediable aldosteronism (GRA)
Apparent mineralocorticoid excess (AME)
Rare forms of congenital adrenal hyperplasia (17-alpha-hydroleses deficiency
and 11-beta-hydroxylase deficiency)
Tubulopathies (Bartter syndrome, Gitelman syndrome)
Amphotericin
Enhanced sodium reabsorption (Liddle syndrome)
Increased skin loss
Cystic fibrosis

69. Clinical manifestation
Clinical manifestation vary depending on the severity
of hypokalemia. Symptom does not become manifest
until the serum potassium level is below 3 mEq/L
unless there is a rapid significant fall in serum
potassium

70. A. Clinical features of hypokalaemia depend on
potassium level:
3.0 – 3.5mmol/L – Usually asymptomatic. Malaise,
weakness, constipation, muscle cramps, fatigue can occur.
2.5 – <3.0mmol/L - As above but more pronounced. Muscle
necrosis, arrhythmias in patients with underlying cardiac
problems.
<2.0mmol/L – It can cause life threatening cardiac
arrhythmias and respiratory muscles. It can also precipitate
rhabdomyolysis, myoglobinuria, acute renal failure and
paralysis of legs.

71. B. Clinical features of hypokalaemia depend on duration &
rapidity of onset:
• Acute:
• Skeletal & smooth muscle weakness – respiratory difficulty, paralytic ileus
• Cardiac arrhythmia: Sinus bradycardia, Ventricular tachycardia, AV block
• Rhabdomyolysis
• Chronic:
• Growth failure
• Tubulointerstitial & cystic changes
• Polyuria
• Metabolic alkalosis
• Impaired glucose tolerance

72. Diagnosis
History
• Acute GI illness with diarrhea or vomiting is the
most common cause of hypokalemia in otherwise
healthy children
• Decrease dietary potassium intake, may be an
exacerbating factor, particularly in children with
acute G illness and potassium loss.
• The use of medications that may promote
intracellular potassium uptake ( adrenergic agents
or exogenous insulin) or increase potassium
excretion ( eg diuretics)
UpToDate

73. Physical examination
• Cardiac rate and rhythm by auscultation to screen
for arrhythmia
• Muscle strength and tone
• Evaluation effective circulatory volume and status
UpToDate

74. • Laboratory investigation
oS. electrolytes
oBlood pH
oECG

75. Electrocardiographic
manifestations for hypokalemia
Serum potassium
concentration
Electrocardiographic
manifestations
< 3.5 mEq/L; does not
correlate
with specific
potassium levels
Increased P wave amplitude
Prolonged PR interval, ST
segment depression
QT prolongation, reduction
in T wave amplitude
T wave inversion, U waves
Taketomo, Hodding, & Kraus (2013)and Sood, Sood, & Richardson. (2007). Emergency management and
commonly en-countered outpatient scenarios in patients with hyperkalemia.

76. Principles of management
• Treatment of the cause
• Correction of deficit
• Ensure maintenance
• Correction of ongoing loss

77. Factors that influence the
treatment of hypokalemia include
• potassium level,
• clinical symptoms,
• renal function,
• the presence of transcellular shifts of potassium,
• ongoing losses, and
• the patient’s ability to tolerate oral potassium
Severe, symptomatic hypokalemia requires
aggressive treatment.
Nelson TEXTBOOK of PEDIATRICS EDITION 20

78. Oral correction:
- Asymptomatic patient
- Can take orally
- Mild or Moderate Hypokalemia
• oral dose: 2-4 mEq/kg/day with a maximum of
120-240 mEq/day in divided doses
Harrison
Nelson

79. Indication of IV correction:
- Symptomatic patient
- Can not take orally
- Severe Hypokalemia
Harrison

80. Steps of Correction
• Step: 1 = Calculate the deficit
• Step: 2= Calculate the maintenance
• Step : 3= Choose the route of administration of drug
• Step : 4 = Choose the Drug
• Step : 5 = Choose the Fluid if needed.
• Step: 6 = Consider other morbidity.

81. Correction of hypokalemia
• K+ deficit = (required K+ - observed K+) x body
weight in kg x 0.3
+
• Maintenance (1-3 mmol/kg/day)

82. Example: A 15 days old baby, weight 2 kg, has serum
K+= 2mmol/L. How to correct?
• K+ deficit =(3.5-2) x2x0.3 =0.9
• Maintenance= 2x2kg=4mmol/day
• Total requirement=0.9+4=4.9mmol
As 1ml=2mmol
So around 2.5 ml inj. KCl can be given in 24 hours of
IV fluid

83. Another way to remember
Serum K + Level Inj. KCl to be added in
100ml IV fluid
>3 meq/L 1.5 ml=3 meq
2.5-3 meq/L 2ml=4 meq
2-2.5 meq/L 2.5ml=5 meq
<2 meq/L 3ml=6meq
Acute Liver Failure : Management Update,
MD. WAHIDUZZAMAN MAZUMDER1, FAHMIDA BEGUM2, ASM BAZLUL KARIM3
,BANGLADESH J CHILD HEALTH 2017; VOL 41 (1): 53-59

84. About oral KCl
• Oral Syrup 5 ml = 6.7 mmol
• Trade name : KT, Electro K
• Adverse effect of Oral KCl:
- GIT irritation
- Esophageal and small intestinal
erosion and stricture.

85. About IV KCl
• Inj 1 ml = 2 mmol, 1 amp = 10ml
• Potassium solution should not exceed 40mmol/L
while giving through peripheral line
• The IV infusion rate should usually not exceed 1
mEq/kg/hr.
• It should not be mixed with dextrose solution

86. What I hear, I forget;
What I see, I remember.
What I do, I understand.
- Confusius, 451 BC
Thank you