Basic Fluid Management

with references to the Harriet Lane

(because you have it with you)

Julie Story Byerley, MD, MPH

 Why does fluid management
matter?
Its basic pediatrics.
Pediatricians are supposed to be the experts of
fluid management.
It matters to just about every inpatient.
Fluid is often extremely effective therapy.
Incorrect fluid management can seriously hurt
patients.
Its not always as simple as you might think
but you can make it simple.
 Outline

Maintenance requirements
Management of dehydration
Normonatremic
Hyponatremic
Hypernatremic
A few little pearls
 Maintenance requirements
Chapter 10, Harriet Lane, p. 233

The two functions of maintenance fluids include

Solute excretion in urine

Heat dissipation through insensible losses of water

Insensible losses are about 2/3 skin and 1/3 lungs
Each can be considered as about 50% when
maintenance needs are exactly met and urine
concentration is 1.010
The kidneys are usually smart insensible losses come
first (less adjustable) and the kidneys can then adjust
how much water is in the urine
 Maintenance Requirements
Caloric Expenditure Method
Holliday-Segar Method
Body Surface Area Method

Remember that maintenance

requirements are over about 24 hours,
and dont have to be given evenly divided
over each hour
 Caloric Expenditure Method

Water and electrolyte needs parallel

caloric needs
Caloric needs depend on activity
For each 100 kcals,
100-120 cc water,
2-4 MEq Na, and
2-3 MEq K are needed
 Average Caloric Needs
See page 436 in Harriet Lane (table 20-1)

At normal activity
Infants approx. 100 kcal/kg/d
4-6yo approx. 90 kcal/kg/d
7-10yo approx. 70 kcal/kg/d
Teens approx. 50 kcal/kg/d
Caloric needs are based on resting energy expenditure and activity
Resting energy expenditure (REE) is based on size
Energy needs increase with injury, fever, growth, etc.

See p. 435 in Harriet Lane

REE (Resting Energy Expenditure)
+ REE X (Mtn + Injury + Activity + Growth)
Dont memorize it, just get the concept
 Example, Caloric Expenditure Method

10 yo boy with injuries and fever, 30kg

= REE + REE x (Mtn + Activ + Fever + Inj + Growth)
= 40 + 40 x(0.2 + 0.1 + 0.13 + 0.4 + 0.5)
= 40 + 40 x(1.33)
= 93 kcal/kg/d = 2790 kcal/d
Therefore, he needs 2790 cc water per day
water needs parallel caloric needs
3 MEq Na/(100 kcals) = 84 MEq Na total per day
2 MEq K/(100 kcals) = 56 MEq K total per day
 The Math what fluid?
D5 is standard
2790 cc of D5 has only 474 kcals
only 16 kcal/kg/d
people are malnourished when they only
receive IVF!
84 MEq Na/ 2790 cc = X / 1000; X = 30
Quarter NS = 38.5 MEq Na/L
56 MEq K/ 2790 cc = Y / 1000; Y = 20
Try D5 quarter NS with 20 KCl at 116 cc/hour
More fluid than using the 4:2:1 rule (70cc/h);
necessary because of injuries and fever
 Holliday-Segar Method

Estimates caloric and fluid needs from

weight alone
Can over-estimate fluid needs for infants
and under-estimate fluid needs in fever
and injury
Method we tend to use most commonly
4,2,1 rule
 Holliday-Segar Method
Weight cc/kg/d cc/kg/h

First 10 kg 100 4

Second 10 kg 50 2

Each additional 20 1
kg
Ex: 25 kg 1600 cc/d 65 cc/h
(1000+500+100)
 Holliday-Segar Method
Electrolyte Requirements
Na 3 MEq per 100 cc water
K - 2 MEq per 100 cc water

Example, 25 kg kid, 1600 cc/d

48 Meq Na, 32 Meq K
48/1600 = X/1000; X = 30
(Remember that quarter NS has 38.5 MEq/L Na)
32/1600 = Y/ 1000; Y= 20
D5 quarter NS with 20 MEq/L KCl (as Cl is your anion to
fill with)
 Sodium
Since the ratio of electrolytes needed to amount of
water does not change, the Na concentration in MIVF
does not need to change based on weight
Often people use D5 NS for small babies and D5
1/ NS for bigger kids and adults
2
This can give adults more sodium than needed
This error is based on the fact that fluid needs decrease as
size increases
Na should be calculated based on kcals, (therefore ccs not kg)
We decrease water needs as weight increases (the 4,2,1 rule),
but we tend to calculate Na needs as 3 MEq per kg per day.
Na needs are not linear. They should decrease like water
needs do.
Many argue that D5 NS with 20 K is an
appropriate maintenance fluid for all people.
 Body Surface Area Method

Method not used as frequently, but often

taught in nephrology
More difficult to use with small children
To calculate the BSA you need to know
height
Maintenance requirements are about 1500
ml/m2/day
Dehydration
 Background
Dehydration complicates many
acute illnesses
Accurate assessment is important
Consequences of under-
estimation
Consequences of over-estimation

Practice guidelines for evaluation

and management
 Dehydration

Initial resuscitation
Determining deficit
Adding in maintenance
Ongoing losses (dont forget!)
 Estimating degree of
dehydrationtraditional teaching
Recent weight changes
Physical exam findings
Dehydration Mild (5%) Moderate (10%) Severe (15%)
Turgor Normal Tenting None
Cap refill Brisk (< 2 sec) 2-4 sec >4 sec
Mucus membranes Moist Dry Parched/cracked
Eyes Normal Deep set Sunken
Tears Present Reduced None
Fontenelle Flat Sunken
CNS Consolable Irritable Lethargic/obtunded
Pulse Regular Slight increase Increase
Urine output Normal Decreased Anuric
 Caveatstraditional teaching
The previous chart applies to babies. For adults
it should be scaled back to 3%, 6%, and 9%.
Older kids show symptoms at a lower % dehydration
Hyponatremic dehydration looks worse clinically
exaggerated hemodynamic instability
Hypernatremic dehydration looks better clinically
circulation maintained at the expense of
intracellular volume
 Systematic Review of the
Published Data on History, PE,
and Labs in Dehydration

Mike Steiner, Darren DeWalt, Julie Byerley,

2002-3
 Historical Factors

Previous visit to PCP, or previous trial of

clears provided minimal but some increase
in the likelihood of dehydration

Physical exam signs less helpful than

previously taught
 Delayed Capillary Refill
Sensitivity Specificity LR Positive LR Negative

0.60 (0.30- 0.85 4.1 0.6

0.91) (0.72-0.98) (1.7-9.8) (0.4-0.8)

Limitations:
Inter-rater agreement only slight to fair
Kappa 0.01-0.35
Site of application, lighting and ambient
temperature
 Abnormal Skin Turgor
Sensitivity Specificity LR Positive LR Negative

0.58 0.76 2.5 0.7

(0.40-0.75) (0.59-0.93) (1.5-4.2) (0.6-0.8)

Limitations:
Inter-rater agreement fair to moderate
Kappa 0.36-0.55
Hypernatremia increases false negatives
 Abnormal Respirations
Sensitivity Specificity LR Positive LR Negative

0.43 0.79 2.0 0.7

(0.3-0.6) (0.7-0.9) (1.5-2.7) (0.6-0.9)

Limitations:
Inter-rater agreement of only chance to fair
Kappa 0.04 to 0.40
Varying measurements and definitions
 Less Useful Signs
Sign Comment
Sunken Eyes Pooled LR of 1.7
Dry MM Pooled LR of 1.7
Weak Pulse LR ranged from not significant to 3.1
sensitivity low (0.04-0.25), specificity high (0.89 to 1)
Cool Extremity LR ranged from not significant to 18.8
Absent tears Pooled LR CI crosses 1.0
Abnormal overall Pooled LR CI crosses 1.0
appearance
Tachycardia Pooled LR CI crosses 1.0
Weak Cry CI for LR crosses 1.0.
Sunken fontanelle LR actually below one, CI crosses 1.0
 Combinations of Signs
Vega evaluated the standard dehydration
table
Severe classification
LR 3.4 for 5% dehydration
Mild or Moderate classification
No increase in likelihood of dehydration
Gorelick found an LR of 4.9 when 3/10
signs of dehydration present
 Results: Laboratory Tests
BUN
Study of hospitalized patients with gastroenteritis
BUN >45, specificity: 1.00, LR positive of 46.1

BUN cutoffs of 8, 18, and 27 yielded mixed results in

four other studies
Acidosis
One study found no statistical increase in likelihood

Four studies found significant positive LRs between

1.5 and 3.5
 Discussion
Poor to moderate inter-observer agreement
History and parental report have limited
value
Best individual tests
Prolonged capillary refill
Abnormal skin turgor
Abnormal respirations
Groups of positive signs are helpful
Extremely abnormal lab tests are helpful
 Implications

Focus on symptoms and signs with

proven utility
Ability to estimate exact degree of
dehydration is limited
Support change to none, some, or
severe classification scheme
 Oral Rehydration
Recommended by the AAP, WHO, and
CDC
Appropriate for mild-moderate (some)
dehydration
Goal is 50-100 cc/kg over 4 hours for
mild-moderate dehydration
5 cc every 1-2 minutes
Solution containing 40-60 MEq/L Na
 The Fluid Used Matters

Solution CHO (g/dL) Na (mEq/L) K (mEq/L) mOsm

Pedialyte 2.5 45 20 250
Rehydralyte 2.5 75 (1/2/NS) 20 310
WHO 2 90 20 310
Gatorade 5.9 21 2.5 377
Apple juice 12 0.4 26 700
Gingerale 9 3.5 .1 565
Coke 11 4 .1 656
 Fluid Management in Shock
Initial boluses of 20 cc/kg over 30 min
20 cc/kg is 2% of body weight therefore it should
take a 10% dehydrated baby to only 8% dry
One bolus is not enough when someone is 15% dry
Use isotonic solutions (NS, LR)
Consider blood, other fluids and/or pressors in
special circumstances
Trauma or blood loss
Nephrotic syndrome
Septic and cardiogenic shock
 Fluid Composition
Fluid CHO Cal/L Na K Cl CO3 Ca
g/100cc

D5W 5 170

NS 154 154
(0.9%
NaCl)
LR 0-10 0-340 130 4 109 28 3
 Rehydration
First resuscitate out of shock restore perfusion
Calculate maintenance, including ongoing losses,
and deficit
Run maintenance as usual
Replace ongoing losses
Typical is to replace deficit over 24 hours
Half in first 8 hours
Other half over 16 hours
 Where the dehydration comes
fromtraditional teaching
In a brief duration of illness (<3 days), 80% of
the deficit is typically from the ECF
More than 3 days of illness and the deficit from
the ICF increases to about 40% (therefore 60%
from ECF)
This matters because ECF contains a lot of
sodium (135-145 mEq), and intracellular fluid
contains a lot of potassium (150MEq)
But rememberNo walls, no sparks
Example Calculations, normal Na
(See table 10-7 in Harriet Lane on page 237.)
7 kg infant with 10% dehydration that accumulated over >3d.

24 Hours H2O Na K
Maintenance 700 21 14
(Hol.-Seg.)
Deficit 700
(10% of 7 kg)
ECF (60%) 61
420 (145MEq/L x
0.42L)
ICF (40%) 42
280 (150MEq/L x
0.28L)
Total 1400cc 82MEq 56MEq
 First 8 hours
MIVF for 8 hours plus 50% of the deficit
H2O Na K
1/ Maint 233 7 5
3

Deficit 350 31 21
Total 583 38 26
583/8=73 cc/h; 38/0.583=65MEqNa/L = 0.42NS
(65/154); 26/0.583=45MEqK/L
Roughly D5halfNS plus 40 KCl at 75 cc/h
 Next 16 hours
MIVF for 16 hours plus other 50% of the deficit
H2O Na K
2/ Maint 467 14 9
3

Deficit 350 30 21
Total 817 44 30
817/16=51 cc/h; 44/0.817=54MEqNa/L =
0.35NS (54/154); 30/0.817=37MEqK/L
Roughly D5halfNS plus 40 KCl at 50 cc/h
 Simplified what fluid, normal Na
(Roberts method)
Usually after boluses with NS or LR, D5halfNS is
an appropriate rehydration fluid
After urine output is assured, give K as 20
MEq/L
That is usually safe
Often you dont need to fully replete K losses acutely
Watch the rate of fluids regarding K and dont give
more than 1 MEq/kg/h
 Simplified what rate
(Roberts method)
If a child is 10% dehydrated -
Give a 20 cc/kg bolus of NS
Restores hydration 2%
Next give 10 cc/kg/h of D5halfNS with 20 KCl for
8 hours
Restores hydration 8%
Next give 1.5 times MIVF using D5quarterNS
with 20KCL for 16 hours
That days maintenance
 Example, the Roberts method

7kg child with 10% dehydration

Bolus of 140 cc NS
70 cc/h of D5halfNS with 20 KCL for 8
hours, then
40 cc/h of D5quarterNS with 20 KCL for
16 hours
 Hyponatremia

Always measure the sodium.

Hyponatremic patients look more
dehydrated than they probably are.
Example calculation, hyponatremia
(7kg with 10% dehydration, Na 115, >3 d
duration)
Table 10-8 on p. 238
Fluid deficit same as before
10% of 7 kg=700 ml total fluid deficit
60% from ECF, 40% from ICF
Na deficit (from dehydration) same as before
ECF Na x 60% of total fluid deficit
145 mEq/L x .6 x .7L = 61mE
Excess Na deficit (because hyponatremic)
(Desired Na Actual Na) x distribution factor x wt
(CD-CA) x fD x weight
(135-115)MEq/L x 0.6L/kg x 7kg = 84 mEq Na
Replace excess Na deficit over 24 hours
Replace Na faster if symptomatic
 K deficit (same as before)
ICF K x 40% of total fluid deficit

150mEq/L x 0.4 x 0.7L=42 mEq

Make a table!
Component H2O Na K
(mL) (mEq) (mEq)
Mainenance Na=3mEq/100ml 700 21 14
K=2mEq/100ml
Deficit 700
60% ECF x 700 61
= 420
40% ICF x 700 = 42
280
Excess Na (135-115) x .6 x 84
deficit 7kg
24 hour 1400 166 56
totals
 First 8 hours, hyponatremia
MIVF for 8 hours plus 50% of the deficit
H2O Na K
1/ Maint 233 7 5
3

Deficit 350 72 21
Total 583 80 26
583/8=73 cc/h; 80/0.583=137MEqNa/L =
0.89NS (137/154); 26/0.583=45MEqK/L
Roughly D5halfNS plus 40 KCl at 75 cc/h
 Next 16 hours, hyponatremia
MIVF for 16 hours plus other 50% of the deficit
H2O Na K
2/ Maint 467 14 9
3

Deficit 350 72 21
Total 817 86 30
817/16=51 cc/h; 86/0.817=105MEqNa/L =
0.68NS (105/154); 30/0.817=37MEqK/L
Roughly D5halfNS plus 40 KCl at 50 cc/h
 Practical Interpretation,
Hyponatremia
In adults, rapid correction of hyponatremia may
be associated with central pontine myelinoysis.
Correct the Na fast only if the patient is
symptomatic (seizing or particularly irritable)
For asymptomatic patients, the goal should be
to increase the Na no faster than 1 MEq/L per
hour
Start with NS boluses and then D5NS or
D5halfNS
Follow Na carefully
 Hypernatremia

Always measure the sodium

 Hypernatremia
In hypernatremia, rehydrate more slowly to avoid fluid
shifts that could cause cerebral edema or intracranial
bleeding
Remember that the hypernatremic patient doesnt
always look as dry as they are because the intravascular
volume is protected
The hypernatremic dehydrated patient is still sodium
depleted, but in addition has lost free water
Free water losses must be calculated and subtracted
from total deficit to calculate the solute deficit
Example calculation, hypernatremia
(7kg with 10% dehydration, Na 155, >3 d
duration)
Table 10-9 on p. 239
Same fluid deficit, maintenance fluid and electrolytes as before, in
isotonic dehydration example
FW deficit
=(measured Na ideal Na)x 4cc/kg x wt
FW def = (155-145) x 4 x 7 = 280 cc
Replace free water deficit evenly over 48 h
Give only half of FW deficit in first day
Drop Na less than 15 MEq/L/day
Follow lytes closely every 4 hours at first
Subtract the free water deficit from the total
deficit to determine Na deficit
Chart for Hypernatremia, first 24 h
H2O Na K

MIVF 700 21 14

Free water
deficit = 140
280cc/2 days
Def remaining
(solute) =420cc
(700-280=420)
ECF (60%)
252 37
ICF (40%)
168 25
Total, 24 hr 1260 58 39
 Fluid choice, Hypernatremia
Need in 24 hours,
1260 cc water
58 Meq Na
39 MEq K
1260/24 = 52.5 cc/h
58/1.260 = 46 MEqNa/L = 0.3 NS (46/154)
39/1.260 = 31MEqK/L
Roughly D5halfNS with 30KCl at 50 cc/h could
also use D5quarterNS half is more
conservative
 Practical Interpretation,
Hypernatremia
Still bolus the hypernatremic patient with NS if
needed
You want to lower the Na slowly so you can
start with D5halfNS and remeasure
The calculations almost always come out to
something near quarter NS, and you should not
give more dilute fluid than that, so that is also a
reasonable starting point
The important thing is to follow the sodium
carefully and adjust as necessary
 Practical Approach,
Replacing the Deficit
Isotonic dehydration
1/2 NS
Hyponatremic dehydration
3/4 or NS
Hypernatrmic dehydration
1/4 NS
Follow I/Os, weights, lytes carefully q 4
hours, you can follow on VBGs
 Even EasierRun Maintenance
and Deficit Separately
Maintenance (calculate using Holliday-Segar)
Y in Deficit
Ongoing losses (calculate by shift or anticipate)

Use the same calculations as above to calculate

the deficit, but hang different fluids
Generally easier to manage than having unusual
fluids mixed by pharmacy
 Ongoing losses

Dont forget losses into third spaces

Pay attention to In-Out sheets

Replace shift to shift if output is large

Check electrolytes on output prn

 Ongoing losses!
Fluid Na K Cl
Gastric 20-80 5-20 100-150
Illeostomy 45-135 3-15 20-115
Diarrhea 10-90 10-80 10-110
Burns 140 5 110

Usually replace GI losses with half normal

Radiant losses are usually just water

See table 10-11, p.240, for other specific situations

 Special situations

Symptomatic hyponatremia (szs)

10-12mL/kg of 3% saline over 60 minutes
Increased insensible losses
When the kidneys are not smarter than
you!
Electrolyte abnormalities
THE END
 Other Equations, Anion Gap
Anion gap = Na (Cl + HCO3)
Normal gap 12 +/- 4
AG increased in acid production or decreased
acid excretion
Ketones, lactic acidosis, inborn errors of metabolism
Renal failure
AG normal in hyperchloremic acidosis
GI loss of bicarb
Renal loss of bicarb
 Other Equations, Osmolality

Osmolality is number of particles per liter

Approximated by:
2(Na) + (glu/18) + (BUN/2.8)
Where glucose and BUN are in mg/dl
Normal is 285-295
A Pearl about Blood Transfusion

See p. 319 in Harriet Lane (table 15.7)

Vol PRBC needed to transfuse =

EBV (cc) multiplied by (desired HCT

actual HCT)/ HCT of PRBCs
Ex: Transfuse a 6 mo old with HCT 20%
with 87.5 cc to get their HCT to 30%
cc PRBC = 75cc/kg(7kg)(.10)/0.60