This document discusses pediatric fluid therapy and body fluid compartments. It begins by describing the different fluid compartments in the body, including total body water, extracellular fluid, and intracellular fluid. It then focuses on neonatal fluid management, noting that extracellular fluid is initially greater than intracellular fluid at birth, and describing appropriate intravenous fluid volumes for neonates. The document also discusses fluid requirements in children, evaluation of intravascular volume, choice of fluid types including crystalloids, colloids, and blood products, and provides guidelines for fluid resuscitation in dehydrated children.

1. PEDIATRIC FLUID THERAPY
DR. VIJAY DIHORA

2. Body Fluid Compartments
TOTAL BODY WATER (60%)
EXTRACELLULAR FLUID
(1/3 TBW)
INTRACELLULAR FLUID
(2/3 TBW)
INTERSTITIAL FLUID
(3/4 ECF)
PLASMA
(1/4 ECF)
TRANSCELLULAR
FLUID
Accurate for children 6 months of age and older

3. Body Fluid Compartments
90
80
70
60
50
40
30
20
10
0
Preterm Term 6
months
1 year Adult
Total Body Water
Muscle Mass
Fat
B
o
d
y
C
o
m
p
o
s
i
t
i
o
n
(%)

4. Body Fluid Compartments
• ICF – 2/3 TBW
• The proportion of ECF is much greater to that
of the ICF in the preterm infants.
• Upon birth, there is gradual shift from the ECF
to the ICF

5. Neonatal Fluid Management
• At birth: ECF is greater than ICF
• A few days after birth:
ECF contraction and wt loss due to ANP induced diuresis 2°
to ↑ pulmonary blood flow & stretch of left atrial receptors
• This is followed by ↑ water and Na requirements to match
those of the growing infant
Implication: Fluids should be restricted until the postnatal weight
loss has occurred.

6. Neonatal Fluid Management
• If a baby requires IV fluids from birth, they shld be given 10%
dextrose in the following volumes
Day 1 60 ml/kg/day Day 4 110
Day 2 80 Day 5 120
Day 3 100
• Na+ 3 mmol/kg/day & K+ 2 mmol/kg/day shld be added after
the postnatal diuresis or if Na+ drops
• A premature neonate may require an additional 30 ml/kg/day
and additional Na+

7. Neonatal Fluid Management
• Fluid requirements are titrated to the:
patient’s changing weight
urine output
serum sodium

8. Evaluation of Intravascular Volume
• Physical Examination
• Laboratory Exam
• Hemodynamic Measurements

9. Clinical and laboratory assessment of the severity of
dehydration in children
Signs and
Symptoms
Mild
Dehydration
Moderate
Dehydration
Severe
Dehydration
Wt loss (%) 5 10 15
Fluid deficit
(ml/kg)
50 100 150
Vital Signs
Pulse Normal ↑, weak greatly ↑, feeble
BP Normal Normal to low ↓, orthostatic
Respiration Normal Deep Deep & rapid

10. Clinical and laboratory assessment of the
severity of dehydration in children
Signs and
Symptoms
Mild
Dehydration
Moderate
Dehydration
Severe
Dehydration
Behavior Normal Irritable Hyperirritable
to lethargic
Thirst Slight Moderate Intense
Skin turgor Normal Decreased Greatly ↓
Ant. fontanelle Normal Sunken Markedly
depressed
Urine flow
(ml/kg/hr)
<2 <1 <0.5
Urine SG 1.020 1.020 – 1.030 >1.030

11. Choice of fluids
• Crystalloids
• Colloids
• Blood products
– Whole blood
– pRBC
– FFP
– Platelets

12. Crystalloids
• sterile aqueous solutions which may contain
glucose, various electrolytes, organic salts and
nonionic compounds
• rapidly equilibrates with ECF

13. Composition of Crystalloids
Fluid Osmolarity pH Na K Cl Glucose
0.9%
NaCl
308 6.0 154 0 154 0
LR 273 6.5 130 4 156 0
D5W 252 4.5 0 0 0 50
D5LR 525 5.0 130 4 156 50
D5NR 547 5.2 140 5 0

14. Crystalloid Solutions
• 2 ways of classification
a. based on use
b. based on tonicity

15. Types
• Saline e.g. 0.9% saline, Hartmann’s solution
0.18% saline in 4% glucose.
• Glucose : e.g. 5% glucose, 10% glucose, 20%
glucose.
• Postassium chloride
• Sodium bicarbonate : e.g. 1.26%, 8.4%.

16. Crystalloid Solutions: Based on Use
• Maintenance-type solutions
– water loss
– hypotonic solutions
• Replacement-type solutions
– water and electrolyte losses
– isotonic electrolyte solutions

17. Type of IV solution
based on tonicity
Type of IV solution
Isotonic Hypotonic Hypertonic

18. Isotonic solution
 A solution that has the same salt
concentration as the normal cells of the body
and the blood.
 Ex:
1- 0.9% NaCl .
2- Ringer Lactate .
3- Blood Component .
4- D5W.

19. Hypertonic solution:
 A solution with a higher salts concentration
than in normal cells of the body and the blood.
 Ex:
1- D5W in normal
Saline solution .
2-D5W in half normal
Saline .
3- D10W.

20. Hypotonic solution
 A solution with a lower salts concentration
than in normal cells of the body and the
blood.
 EX:
1-0.45% NaCl .
2- 0.33% NaCl .

21. Crystalloid Solutions: Based on Tonicity
• Balanced salt solutions
– electrolyte composition similar to ECF
– Hypotonic with respect to Na
Fluid Osm pH Na K Other
LR 273 6.5 130 4 Lactate = 28
Normosol 295 7.4 140 5 Mg =3, acetate = 27,
gluconate = 23
Plasmalyte 298.5 5.5 140 5 HCO3 = 50

22. Crystalloid Solutions: Based on Tonicity
• Normal Saline
– isotonic (6.0) and isoosmotic (308)
– contains no buffers or electrolytes
– large volume:
dilutional hyperchloremic acidosis

23. Crystalloid Solutions: Based on Tonicity
• Hypertonic Salt Solutions
– Na concn range from 250 – 1200 meq/L
– Rapid volume expansion after infusion of small
amounts (e.g. 250 mL)
– t½: similar to isotonic saline
– may cause hemolysis at point of injection

24. Glucose containing solutions
• Glucose—given intravenously—is rapidly
metabolized, leaving free water behind
• distributes across all compartments rapidly

25. Sodium Bicarbonate
Type
• Isotonic sodium bicarbonate 1.26%
• Hypertonic sodium bicarbonate (1mmol/ml) 8.4%
Uses
• Correction of metabolic acidosis
• Alkalinisation of urine
Routes
• IV
25

26. Ion content of sodium bacarbonate (mmol/L)
Na+ K+ HCO3 C1 Ca2
1.26% sodium 150 150
Bacarbonate
8.4% sodium 1000 1000
bacarbonate
26

27. Crystalloids
• Advantages
– Inexpensive
– Very low incidence of adverse reactions
• Disadvantages
– Short lived hemodynamic improvement
(intravascular t½: 20 – 30 mins.)
– Peripheral/pulmonary edema

28. Crystalloids
• Best crystalloid
Isotonic crystalloids are preferred over
hypotonic crystalloids

29. Do we have to routinely give glucose containing
solutions?
• Routine dextrose administration is no longer advised.
• There is a growing consensus to selectively administer
intraoperative dextrose only in pts at greatest risk for
hypoglycemia and in such situations to consider the
use of fluids with dextrose concentrations

30. Colloids
– contains high MW substances - proteins, large
glucose polymers
– maintain plasma oncotic pressure
– intravascular t½: 3 – 6 hrs.

31. Colloids
Types
• Albumin: e.g. 5%, 20 % , human albumin solution
31
• Dextran: e.g. 6% Dextran
• Gelatin: e.g. 3.5% polygeline (Haemaccel), 4%
succinylated gelatin (Gelofusion)
• Hydroxyethyl starch: e.g. 6% hetastarch

32. Colloids: Classification
• Natural Protein Colloid
– Albumin or Plasma Protein fraction
• Synthetic Protein Colloids
– Hetastarch
– Dextrans
– Gelatins

33. Albumin
• Colloid “gold standard”
• Derived from human pool plasma → heated to 60 C for 10 hrs
→ ultrafiltration
• MW: 69 kDa
• Available as: 5% and 20%
• Albumin 5% osmotically equivalent to an equal volume of
plasma

34. Albumin
• Use with caution in patients with
increased intravascular permeability
(e.g. critically ill, sepsis, trauma, burn)

35. Albumin: Side Effect
• Rare
• Might still have weak anticoagulation effects through
platelet aggregation inhibition or heparin-like effects
on antithrombin III
• These effects are thought to be clinically insignificant
if volume replacement with albumin is kept below
25% of the patient’s blood volume.

36. Hetastarch
• modified natural polysaccharides
Amylopectin Hetastarch

37. Hetastarch
Described in terms of:
1. Concentration
2. Average mean MW
3. Molar substitution
4. C2:C6 ratio

38. Hetastarch: Concentration
• Definition – grams in 100 ml
• Available as: 6%

39. Hetastarch: average mean MW
1. Low - <70 kDa
2. Medium - 130 – 270 kDa
3. High - >450 kDa
higher MW ⇒ longer volume effect
⇒ greater side effect

40. Hetastarch: Molar Substitution
Definition: CH3CH2OH : glucose units
• Low (0.4 – 0.5)
• High (0.62 – 0.7)
higher MS ⇒ longer volume effect
⇒ greater side effect

41. Hetastarch: C2:C6 ratio
• Hydroxyethyl group attached at C2 hinder
breakdown
• Higher ratio of C2:C6 ⇒ in slower enzymatic
degradation and prolonged action without
increasing side effects.

42. HES Solutions Properties and Availability
HES HES HES
Trade Name Hespan Hextend Voluven
Concn 6 g 6 g 6 g
Volume effect (h) 5 – 6 5 – 6 2 – 3
MW 450 670 130
C2:C6 ratio 4:1 4:1 9:1

43. HES: Unwanted Side Effects
• Hypocoagulable effect
- seems to interfere with the function of vWF, factor VIII
and platelets
• Renal toxicity
- induce renal tubular cell swelling & create hyperviscous
urine
• Pruritus
- accumulation on HES molecules under the skin

44. Gelatins
• polypeptides produced by degradation of
bovine collagen
• ave MW: 30,000 – 35,000 kDa
• requires repeated infusions
• no dose limitation

45. Gelofusine: Pharmaceuticals Characteristics
Concentration 4%
Na 154
Cl 120
pH 7.4
Volume effect 100%
Duration of vol expansion 4 hrs

46. Gelofusine
• It has less anaphylactoid and coagulation
effect in comparison to HES.
• The data supporting use of gelatin in children
are limited.

47. Colloids
• Advantages
– Smaller infused volume
– Prolonged increase in
plasma volume
– Minimal peripheral
edema
• Disadvantages
– Expensive
– Coagulopathy
– Pulmonary edema
– Anaphylactoid reactions

48. Blood Product Transfusion
• What?
• When?
• How much?

49. Transfusion: pRBC
Indications:
As replacement fluid in acute blood loss.
As replacement in chronic anemia with a
hemoglobin level between 6 – 10 gm % considering
the following factors:
- The patient symptoms and signs (Tachycardia,
Tchypnea)
- Anemia.

50. Transfusion: FFP
• Indication:
replacement factor deficiencies,
replacement of factor in bleeding induced by warfarin
therapy,
coagulopathy asociated with liver disese
• Initial therapeutic dose: 10–15 mL/kg
• Goal: 30% of the normal coagulation factor
concentration

51. Transfusion: Platelets
• Indication:
pts with thrombocytopenia or dysfunctional
platelets in the presence of bleeding