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FLUID AND
ELECTROLYTE
THERAPY
Seblewongel Aseme
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Three basic principles of fluid therapy
• Correct Deficit
Severity of dehydration
Type of fluid deficit
Repair of deficit
• Supply maintenance fluid
• Replace ongoing /extraordinary losses
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DEFICIT THERAPY
Management of fluid and electrolyte losses that occur
before patients presentation
• Estimate severity of dehydration
• If a patient has Moderate (10%) to severe (15%)
dehydration fluid deficits are corrected gradually over
24 hours.
• %of dehydration x wt of a child
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Severe dehydration
• The child is given a fluid bolus,
usually 20 mL/kg of the isotonic fulid, over approximately
20 min.
• Colloid vs crystalloid
• rapid restoration of the circulating intravascular volume
and treatment
• Correction over 24 hr
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monitoring
• Heart rate
• Blood pressure
• Capillary refill
• Skin turgor
• Mucous membrane status
• Fullness of anterior fontanell
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• daily body weight:
• Intake and output Fluid balance should be followed
closely, hourly in the first few days
• Urine output
serum Electrolytes: for those on iv fluid should be
measure at least daily
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• Maintenance therapy:
• requirements for neutral balance.
• Replaces iwl and urinary and gi losses of water and
electrolyte
• The total requirement is estimated
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Daily fluid requirement in neonate
• Day 1: Term babies and babies with birth weight > 1500
grams.
• 60-70 ml/kg/day
. The initial fluids 10% dextrose with glucose infusion
rate of 4-6 mg/kg/min
• Day 2 - 7: Term babies with birth wt >1500 grams
increase by 15-20 ml/kg/day
till a maximum of 150 ml/kg/day
• .add Na and K after 48 hours of age and glucose infusion
should be maintained at 4-6 mg/kg/min
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Day 1: Preterm with birth wt 1000-1500 grams.
• 80 ml/kg/day of 10% dextrose
Day 2 – Day 7: Preterm babies with birth weight 1000-1500
grams
• Fluids need to be increased at 10-
15 ml/kg/day till a maximum of 150 ml/kg/day.
• Na and K should be added
after 48 hours and glucose infusion should be maintained
at 4-6 mg/kg/min
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Maintenance fluid therapy in children
BODY WEIGHT FLUID PER DAY
0-10 kg 100ml/kg
11-20kg 1000ml+50ml/kg for each>10kg
>20kg 1500mlkg+20ml/kg for each > 20kg
For body weight of 0-10 kg: 4 mL/kg/hr
For body weight of 10-20 kg: 40 mL/hr + 2 mL/kg/hr × (wt − 10 kg)
For body weight of >20 kg: 60 mL/hr + 1 mL/kg/hr × (wt − 20 kg)*
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Perioperative fluid management
• Assess the patient dehydration status
• Use isotonic fluids
• n deficits caused by fasting are calculated by multiplying
the hourly maintenance
requirements times the number of hours of fasting.
Of the total amount, 50% is replaced in the first hour and
25% each in the next 2 hours
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intraoperative
• calculate
• Maintenance fluid
• Estimate preoperative fluid defict
• Insensible losses
Estimated blood loss
• Fluid like NS and RL or less glucose concentration
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Postoperative fluid
• Avoid dehydration and correct hypovolemia
- isotonc fluid with consideration of energy requirement.
- Beware of hidden fluid administration
(drugs).
- Monitoring serum Na and glucose at least daily
Early oral intake
- If oral intake delayed, continue fluid therapy should :
Replace ongoing losses
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Replacement therapy
• Replace extraordinary looses
• Bleeding ,third space loses
• Replace fluid losses with balanced salt solution
• The replacement for third space losses
abdominal surgery 6 to 10 mL/kg /hr
4 to 7 mL/kg /hr intrathoracic surgery,
1 to 2ml/kg/hr supefrical surgeries
• Replacement of blood loss:Replace maximum allowable
blood loss (ABL) with
crystalloid 3:1
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• Electrolyte abnormality and therapy
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sodium
• Sodium is the dominant cation of the ECF
principal determinant of extracellular osmolality.
• Important for maintenance of intravascular volume
• Intake mainly by diet
• excretion occurs in stool, sweat, but kidney is the principal
site of sodium excretion and Na balance regulation
• Sodium is unique among electrolytes because water
balance, not
sodium balance, usually determines its concentration
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Hypernatremia….etiology
sodium concentration >145 mEq,
EXCESS Na
Ingestion
Iv administration
WATER DEFICIT
Nephrogenic diabetes insipidus
Central diabetes insipidus
Increased insensible losses
Premature infants
Radiant warmers
Phototherapy
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Inadequate intake:
Ineffective breastfeeding
Child neglect or abuse
WATER AND SODIUM DEFICIT
• GI losses
Diarrhea
Emesis/NG suction
Burns
Excessive sweating
Renal losses
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Clinical
• Mostly the children are dehydrated
• Patients are irritable, restless,
weak, and lethargic. Some infants have a high-pitched cry
• Brain hemorrhage
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treatement
• should not be corrected rapidly otherwise brain
edema will develop
• Water deficit (L) = serum Na /140 ×0.6xwt-(0.6xwt)
3-4 mL of water per kg for each1 mEq that the
current Na level exceeds 145 mEq
The goal is to decrease the serum sodium by
<12 mEq/L every 24 hr, a rate of not more than 0.5
mEq/L/hr.
In the child with hypernatremic dehydration, the
fist priority is restoration of intravascular
volume with isotonic fluid
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hyponatremia
• Hyponatremia
• is a serum sodium level <130 mEq/L
• occurs when there
is an excess of extracellular water relative to sodium.
• common electrolyte abnormality
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• normovolemic hyponatremia
• SIADH
• Water intoxication:hypotonic iv fluids
• hypovolemic hyponatremia
• Diuretics
• Decreased sodium intake
• GI losses
• Third space losses
• Renal losses
• Diuretics
• sweating or burns
• Hyperglycema
• Mannitol infusion
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Clinical signs
• . Neurologic symptoms
• anorexia, nausea, emesis, malaise, lethargy, confusion,
agitation, headache, seizures, coma, and decreased reflxes.
• Acute, severe hyponatremia can
cause brainstem herniation and apnea; respiratory support is
often
necessary.
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• avoidance of rapid normalization of the
serum Na concentration.
• Correct fluid status first
• serum sodium levels should be
gradually corrected with NaCl infusion, rate not exceeding
0.8 mEq/kg/hr.
• avoid correcting the serum sodium concentration by >12
mEq/L/24
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• Na deficit=
• mmol of Na = ( 130-present serum Na)x0.6 x Wt(kg)
• Correction should be stopped if child is
asymptomatic,or serum
sodium > 125meq/l
:
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• A patient with severe symptoms (seizures), should be
given a bolus of hypertonic
saline(3%)
the effect on serum osmolality leads to a decrease in
brain edema.
• Each mL/kg of 3% sodium chloride increases the serum
sodium by approximately 1 mEq/L. A child with active
symptoms ofteen improves after receiving 4-6 mL/kg of
3% sodium chloride
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potassium
• the principal intracellular cation
• The Na+,K+-ATPase maintains its diffusion from ICF to ECF
• The resulting chemical gradient is used to produce the resting
membrane potential
of cells.
• Important for the contractility of cardiac, skeletal, and smooth
muscle;
• Potassium is plentiful in food
1-2 mEq/kg is the recommended daily intake most ingested
potassium is eventually excreted in the urine
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• HYPERKALEMIA
• >5.5meq/L
because of the potential for lethal arrhythmias—is one
of the most alarming electrolyte abnormalities
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etiology
•
Increased intake
increased exogeneous adminstration
stored Blood transfusions
cell destruction: hemolysis, rhabdomyolysis,
Increased release
Acidosis
hyperglycemia or mannitol
Potassium-sparing diuretics
Renal failure
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• ECG finding
• peaking of the T waves.
• ST-segment depression,
• an increased PR
interval,
• flattening of the P wave, and widening of the QRS
complex.
ventricular fibrillation
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• The plasma potassium level, the ECG, and the risk of the
problem
worsening determine our approch
• prevent
life-threatening arrhythmias and
• to remove potassium from the
body
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to prevent life threatening cardiac arrhythmias
Remove exogenous source of potassium
• calcium gluconate - 100 mg/kg IV over 5-10 min. (generally used in
face of arrhythmia
• 0.05u /hr /kg of RI with 2ml/kg of 10% DW followed by continious
infusion of insulin 0.1u/kg/hr with2-4 ml/kg of 10%DW
• sodium bicarbonate
• Beta agonist : Nebulized albuterol
• furosemide 1 mg/kg
• dialysis
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Hypokalemia:
• common in children
• Less than 3.5meq/L
• etiology
Inadequate intake
Excessive potassium losses:diuressis,chronic diarrhea
GI losses
diarrhea,vomiting
Renal loss of potassium
DKA
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• The heart and skeletal muscle are especially vulnerable to
hypokalemia.
ECG changes include a flttened T wave, a depressed ST
segment ,U wave
• Ileus,muscle cramp
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• Potassium deficit (meqL-1)=Body weight x (Expected serum
K+ - observed serum K+) x 0.3
• For every decrease of serum K+ by .3 there is a deficit of
100 meq k+
• if possible and mild oral route is easier and preffered
• oral dose: 2-4 mEq/kg/day with a maximum of
120-240 mEq/day in divided doses).
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• The dose of intravenous potassium is 0.5-1.0 mEq/kg/dose, usually given
over 1 hr to 4 hrs
• pain and phelbitis can occur in peripheral adminstration
• Maximum concentration for peripheral iv in pediatrics40/meq/l upto 60-80
meq/l
• In mini bag adminstration
# 0.1 mEq/mL Peripheral
> 0.1 mEq/mL with a maximum
of 0.4 mEq/mL
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calcium
• Normal range 8.5-10.5 mg/dl or ionized of 4-5mg/dl
• Calcium plays important roles in enzyme activity, muscle
contraction and relaxation, the blood coagulation cascade, key
role in bone formation, in cell
division, growth,
bone metabolism, and nerve conduction
Serum calcium is distributed among three forms: protein bound
(40%), and ionized (50%) AND COMPLEXED WITH POSPHATE
• Less body content of calcium in children
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• Calcium hemostasis
• Receptors
• PTH
• Vitamin D
• Serum mg and phosphate level
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hypercalcemia
• above the normal range of 10.5 mEq/L or an increase
in the ionized calcium level above 5.6 mg/d
• Neurologic: Lethargy, irritability, coma.
2. GI: Anorexia, nausea, vomiting, constipation.
3. Cardiovascular: Hypertension
• mild Asymptomatic patients may not require immediate
treatement
• For severe(.14mg /dl IV saline hydration and
biphosphonate adminstration,calcitonin
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Hypocalcemia
• serum calcium
children level below 8.5 mg/dl or a decrease in the
ionized calcium
• In term infants <8mg/dl or ionized of less than 4.4 mg/dl
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• Prematurity,birth asphyxia,infants of DM mother.IUGR
• Phothotherapy
• Magnesium deficiencey
• Hypoparathyrodisim:gland hypoplasia
• Abnormality in vit D Production
• Hypomagnesemia
• Pancreatitis
• Critical illness
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clinical
• Seen usually in neonate
• Prematurity ,infant of diabetic mother,birth
asphyxia,sepsis,cow milk,
• Hypothyrodsim,vit D problem,hypomagnesemia
• CNS irritability and poor muscular contractility
• jitteriness, seizures, cyanosis, vomiting,poor feeding
twitching and myocardial depression,arrhtmia
• Tetany chvostek sign,trousseous sign lethargy
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management
Oral calcium for asympthomatic
Symptomatic hypocalcemia is treated
with 10% calcium gluconate (100mg/ml)administered
intravenously at a dosage of 1 to 2 mL/kg over 10 minutes
while monitoring the electrocardiogram
Correct hypomagnesemia
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magnesium
• The 3rd most comon intracellular cation
• Plays a role in cell functions and necessary cofactor many
metabolic ativitiesmembrane stabilization and nerve
conduction.in ATP
• Normal plasma concentration 1.5-2.3 mg/dL
• Hemostasis mainly be gi absorbtion and renal excretion
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• Detection requires a high index
of suspicion
• If a patient with hypocalcemia or hypokalemia does not respond to
therapy, magnesium defiiency should be suspected
• Gastrointestinal and renal losses are the major causes
• It usually occurs only
at magnesium levels <0.7 mg/dL. Th dominant manifestations of
hypomagnesemia are caused by hypocalcemia
treatment consists of magnesium sulfate solution,25 to 50 mg/kg IV or
im in neonates every 6 hours, until normal levelsare obtained
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• Nelson textbook of pediatrics 20t edition
• Coran pediatric surgery th edition
• Pediatric surgery comphrensive text for africa
• Pediatric fluid management guidelines
• Uptodate
• medescape
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