A FEW THOUGHTS ABOUT FLUIDS IN KIDS

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A FEW THOUGHTS ABOUT FLUIDS IN KIDS

• William Primack, MD
• UNC Kidney Center
• Chapel Hill NC USA
• August 21, 2006

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HOMEOSTASIS

• The living organism does not really exist in the
  milieu exteriour (the atmosphere it breathes,
  salt or fresh water if that is its element) but
  in the liquid milieu interior formed by the
  circulating organic liquid which surrounds and
  bathes all the tissue elements, this is the lymph
  or plasma, the liquid part of the blood which in
  the higher animals is diffused through the
  tissues and forms the ensemble of the
  intercellular liquids which is the basis of all
  local nutrition and the common factor of all
  elementary exchanges.
• The stability of the milieu interior is the
  primary condition for the freedom and
  independence of existence, the mechanism which
  allows of this is that which ensures in the
  milieu interior the maintenance of all the
  conditions necessary to the life of the elements.
• Claude Bernard

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Body spaces
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Body spaces by age
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Maintenance fluids

• Holliday M and Segar W
• Pediatrics 195719824
• 100 kcal100ml
• Their data led to the 1005020 protocol for the
  AVERAGE hospital patient

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Maintenance fluids

• Holliday M and Segar W
• Pediatrics 195719824
• 100 kcal100ml
• Their data led to the 1005020 protocol for the
  AVERAGE hospital patient
• We never admit any kids like that!!!

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MAINTENANCE FLUIDSWhat makes up 100 ml/kg
Water (ml/100 kcal)
Respiratory 40-50
Sweat 0-5
Urine 50-75
Stool water 5-10
Hidden intake Water of oxidation (10-15)
Totals 100-125
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MAINTENANCE FLUIDSAbnormal losses
Water (ml/100 kcal) Abnormal losses Range (ml/kg)
Respiratory 40-50 25-200
Sweat 0-5 0-25
urine 50-75 0-300
Stool water 5-10 0-100
Hidden intake Water of oxidation (10-15)
Totals 100-125
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Maintenance fluidsAdjustments to 1005020 rule

• Increase maintenance fluids
• By 12 for each degree C of fever
• Insensible losses from 45 to 50-60 ml/100cal for
  hyperventilation
• Decrease maintenance fluids
• Insensible losses from 45 to 0-15 ml/100cal for
  high humidity ( ventilator)

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Maintenance fluids

• Unless you know what you are replacing and why,
  using maintenance plus (e.g. 1 ½ x
  maintenance) is illogical

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Maintenance fluidsAn alternative approach

• Based on body surface area
• Use estimated insensible losses and replace all
  other fluid losses based on volume and content
• Recalculate as often as needed q6h-q24h
• Probably more accurate for PICU type patients

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BODY SURFACE AREA

• BSA (M2) of average proportioned
• Newborn0.25
• 10 kg infant 0.5
• 30 kg child 1.0
• 70 kg adult 1.73
• If average proportioned 3-30 kg
• BSA(wt 4)/30

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MAINTENANCE FLUIDSDaily water requirement
Water (ml/100 kcal) Water looses per M2 BSA
Respiratory 40-50 400-600
Sweat 0-5 0-50
urine 50-75 750
Stool water 5-10 50-100
Hidden intake Water of oxidation (10-15) (150)
Totals 100-125 1300-1500
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Continuing losses

• NO MATTER WHICH SYSTEM YOU USE
• It is essential to regularly reassess child for
  continuing losses.
• Regularly reevaluate effectiveness of your fluid
  prescription and modify it p.r.n.
• May need to recheck labs more than q.d.
• Reweigh more than q.d. if appropriate

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Contents of abnormal lossesmeq/liter
Fluid Na K Cl HCO3
gastric 20-80 5-20 100-150 0
pancreatic 120-140 5-15 40-80 40-60
small bowel 100-140 5-15 90-130 25-40
bile 120-140 5-15 80-120 20-40
ileostomy 45-135 3-15 20-115 20-50
diarrhea 10-90 10-80 10-110 5-35
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Comparison of Electrolyte Composition of Diarrhea
Caused by Different Organisms
Etiology Electrolytes (mMol/L) Electrolytes (mMol/L) Electrolytes (mMol/L) Electrolytes (mMol/L) mOsmols
Na K Cl HCo3
Cholera 88 30 86 32 300
Rotavirus 37 38 22 6 300
ETEC 53 37 24 18 300

Molla et al. J Pediatr 1981 98 835
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MAINTENANCE FLUIDSFluids based on BSA
Water (ml/100 kcal) Water (ml/M2) Na MEQ/M2 K MEQ/M2
Insensible loss 45 400-600 0 0
Sweat 0-25 0-200 20 20
urine 50-75 750 0-200 5-100
Stool water 5-10 100 30 30
Hidden intake (10-15) (150) 0 0
Totals 100-125 1300-1500 50-250 55-155
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Case 1

• 1 y.o., 10 kg, child develops vomiting for 12
  hours and then diarrhea for 24 hours
• On exam decreased turgor, dry mouth, BP 90/60,
  wt 9 kg.
• Labs Na140, K4, HCO317, BUN30,
  creatinine0.4.
• Receives 10-20 ml/kg bolus and makes some urine

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Isotonic dehydration
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Isotonic dehydrationcorrection
water Na K HCO3
maint 1000 25 20 0
deficit

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Isotonic dehydrationcorrection
water Na K HCO3
maint 1000 25 20 0
deficit 1000 75 75 20
total 2000 100 95 20
½ in first 8 hrs, remainder over 16
hours Reassess for and replace continuing losses
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Case 2

• 1 y.o., 10 kg, child develops vomiting for 12
  hours and then diarrhea for 24 hours
• Given clear fluids.
• On exam decreased turgor, dry mouth, BP 80/50,
  wt 9 kg.
• Labs Na125, K4, HCO315, BUN40,
  creatinine0.4.
• Receives 10-20 ml/kg bolus and makes some urine

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Hypotonic dehydration
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Hypotonic dehydrationcorrection
water Na K HCO3
maint 1000 25 20 0
deficit 1000 75

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Hypotonic dehydrationcorrection

• (Desired Na measured Na) X TBW
• (135 125) meq/l X .6 l/kg 6 meq/kg
• Thus deficit 60 meq Na

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Hypotonic dehydrationcorrection
water Na K HCO3
maint 1000 25 20 0
deficit 1000 75 60 75 30
total 2000 135 95 30
½ in first 8 hrs, remainder over 16
hours Reassess for and replace continuing losses
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Case 3

• 1 y.o., 10 kg, child develops vomiting for 12
  hours and then diarrhea for 48 hours
• Continues to drink cows milk
• On exam nl to woody turgor, moist mouth, BP
  90/50, wt 9 kg.
• Labs Na170, K4, HCO318, BUN25,
  creatinine0.4.
• Receives 10-20 ml/kg bolus and makes some urine

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Hypertonic dehydration
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Hypertonic dehydrationcorrection
water Na K HCO3
maint 750 25 20 0
deficit 1000
total
Lower maintenance water requirement as high ADH
will decrease UO
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Hypertonic dehydration initial day correction
water Na K HCO3
maint 750 25 20 0
deficit 1000 75-6510 25 20
total 1750 35 45
Target is to drop Na by 10 meq/day. Lower
maintenance requirement as high ADH will decrease
UO Reassess for and replace continuing losses
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Hypertonic dehydrationcorrection

• Lower maintanence requirment as high ADH will
  decease UO
• Goal is to decrese Na by 10 meq/day
• (Desired Na measured Na) X TBW
• (165 175) meq/l X .6 l/kg 6 meq/kg
• Thus sodium surplus 60 meq Na

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Comparison of Effect of Glucose on Net Stool Rate
with Galactose and Fructose in Perfusions
Delivered Uniformly throughout Most of the Small
Intestine via Multilumen Tube
12-HOUR PERIODS
Adapted from Hirschhorn N et al. N Engl J Med
1968 176
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Na-glucose co-transport Intestinal brush border
Duggan C JAMA 20042912628
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Outcome of Oral Treatment of 216 Patients with
Rotavirus
Initial Treatment Success Failure
Oral (n 197) 188 (95) 9 (5)
Intravenous (n 19) 17 (89) 2 (11)
Total (n 206) 205 (95) 11 (5)
Requiring unscheduled treatment
intravenously. Percentages are given in
parentheses.
Taylor PR et al. Arch Dis Child 1980
55(5)376-379
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ORAL vs IV REHYDRATION IN MODERATE DEHYDRATION
Spandorfer et al.Pediatrics 115 (2) 295. (2005)
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ORS

• 30-50 ml/kg over 3-4 hours of ORS
• If vomiting give in sips (Pedialyte pops)
• May also add 5-10 ml/kg per diarrheal stool for
  ongoing losses
• Expect increased stool content
• After rehydration, CHO rich foods
• Continue nursing

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ORS and other clear liquids
CHO g/l Na Meq/l K Meq/l Cl Meq/l base Meq/l mOsm/kgH20
Pedialyte 2.5 45 20 35 30 250
WHO ORS 2.0 75 20 65 30 280
Gatorade 5.9 21 2.5 17 0 377
Apple juice 11.9 0.4 26 -- -- 700
Coca cola 10.9 4.3 0.1 -- 13.4 656
OJ 10.4 0.2 49 -- 50 654

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