FLUID, ELECTROLYTE, AND ACID–BASE

IMBALANCES
 The GI system plays a major role in maintaining fluid, electrolyte, and acid–base balance.
 It is the main route by which substances are taken into the body and can be a major source of
loss if vomiting or diarrhea occurs (Holliday, Ray, & Friedman, 2007).
 greater importance in the body chemistry of infants than that of adults
 because fluid constitutes a greater fraction of the infant’s total weight.
 In adults, body water accounts for approximately 60% of total weight.
 In infants, it accounts for as much as 75% to 80% of total weight
 in children, it averages approximately 65% to 70%.
 Fluid is distributed in three body compartments:
(a) intracellular (within cells), 35% to 40% of body weight;
(b) interstitial (surrounding cells and bloodstream), 20% of body weight
(c) intravascular (blood plasma), 5% of body weight.
 The interstitial and the intravascular fluid together are often referred to as the
extracellular fluid (ECF), totaling 25% of body weight.
 In infants 45% of total body weight.
 In young children is 30%
 Adolescents is 25%.
 Fluid is normally obtained by the body through oral ingestion of fluid and by the water formed in
the metabolic breakdown of food.
 fluid is lost from
 urine and feces.
 insensible losses due to evaporation occurs from:
 skin
 lungs
 saliva (of little importance except in children with tracheostomies or
those requiring nasopharyngeal suction).
 Infants do not concentrate urine as well as adults because their kidneys are immature.
RESULT: they have a proportionally greater loss of fluid in their urine.
 In infants, the relatively greater surface area to body mass also causes a greater
insensible loss.
 Fluid intake is altered when a child is nauseated and unable to ingest fluid or is vomiting
and losing fluid ingested.
 When diarrhea occurs, or when a child becomes diaphoretic because of fever,
the fluid output can be markedly increased.
 Dehydration occurs when there is an excessive loss of body water
 In an adult’s weighing 70 kg, the extracellular fluid volume is approximately 14,000 mL.
  Each day, the well adult’s ingests approximately 2000 mL of fluid and excretes
approximately 2000 mL as urine.
 This means that approximately 14% of the adult’s total ECF (2000 mL of
14,000 mL) is exchanged each day.
 Adults, when they do not eat for a day because of a GI upset, and
whose kidneys continue to excrete at the normal rate, will have 14%
less fluid in the extracellular space by the end of the day.
 A 7-kg infants have an ECF volume of only 1750 mL.
 They ingest approximately 700 mL daily and excrete approximately 700 mL daily.
 they exchange approximately 40% of their volume daily.
 RESULT of this increased exchange rate------ infants’ fluid balance may
be more critically affected when they are ill. I
 nfants who do not eat for a day (providing kidney function remains
constant) will be 40% short of ECF by the end of the day.
 dehydration is always a more serious problem in infants than in older
children and adults.
 Requirements of fluid for infants and children are shown in Table 45.1.

TABLE 45.1 ✽ A Method to Calculate Fluid Requirement

Body Weight Fluid Requirement per 24 h
Up to 10 kg 100 ml/kg
11–20 kg 1000 ml 50 ml/kg for each additional kg over 10 kg
More than 20 kg 1500 ml 20 ml/kg for each additional kg over 20 kg

FLUID IMBALANCES

 water and salt are lost in proportion to each other (isotonic dehydration).
 water is lost out of proportion to salt or water depletion or hypertonic dehydration occurs.
 electrolytes are lost out of proportion to water (hypotonic dehydration).

1. Isotonic Dehydration
 When a child’s body loses more water than it absorbs (as with diarrhea) or absorbs less fluid
than it excretes (as with nausea and vomiting).......
first result will be a decrease in the volume of blood plasma.
The body compensates for this rapidly by shifting interstitial fluid into the blood vessels.
The composition of fluid in these two spaces is similar
o so the replacement by this fluid does not change plasma composition.
o replacement phenomenon can proceed only until the interstitial fluid reserve is
depleted—a danger point for a child because it is difficult for the body to
replace interstitial fluid from the intracellular fluid (the fluids in these two
compartments have different electrolyte contents).
o If an infant continues to lose fluid after this point, the volume of the plasma will
continue to fall rapidly, resulting ultimately in cardiovascular collapse.
 o signs and symptoms of dehydration are summarized in Table 45.2.

TABLE 45.2 ✽ Signs and Symptoms of Dehydration

Isotonic Hypotonic Hypertonic
Thirst Mild Moderate Extreme
Skin turgor Poor Very poor Moderate
Skin consistency Dry Clammy Moderate
Skin temperature Cool Cool Warm
Urine output Decreased Decreased Decreased
Activity Irritable Lethargic Very lethargic
Serum sodium level Normal Reduced Increased

2. Hypertonic Dehydration
 Water is lost in a greater proportion than electrolytes
---------when fluid intake decreases in conjunction with a fluid loss increase
o occur in a child with:
 nausea (preventing fluid intake)
 fever (increased fluid loss through perspiration)
 profuse diarrhea - where there is a greater loss of fluid than salt
 renal disease - associated with polyuria such as nephrosis with diuresis.
 In these instances, fluid loss is out of proportion to the loss of electrolytes, and, with
such an increased loss of fluid, electrolytes concentrate in the blood.
 Fluid shifts from the interstitial and intracellular spaces into the bloodstream (from areas of less
osmotic pressure to areas of greater pressure).
 Dehydration occurs in the interstitial and intracellular compartments.
 The red blood cell count and hematocrit will be elevated
-------- because the blood is more concentrated than usual.
 Increase Levels of electrolytes such as sodium, chloride, and bicarbonate
 Additional signs and symptoms are summarized in Table 45.2.

3. Hypotonic Dehydration
 there is a disproportionately high loss of electrolytes relative to fluid lost.
 The plasma concentration of sodium and chloride will be low.
 This could result from:
 excessive loss of electrolytes by vomiting
 low intake of salt associated with extreme losses through diureses
 in diseases ---- adrenocortical insufficiency or diabetic acidosis.
 When low levels of electrolytes occur:
 the osmotic pressure inextracellular spaces decreases.
 The kidneys begin to excrete more fluid to decrease ECF volume and bring the
proportion of electrolytes and fluid back into line.
  This may lead to a secondary extracellular dehydration (see Table 45.2).

Overhydration

 serious as dehydration
 because the ECF overload can lead to cardiovascular overload and cardiac failure.
 It generally occurs in children who are receiving IV fluid.
 The excess fluid in these instances is usually extracellular.
 When large quantities of salt-poor fluid (hypotonic solutions) such as tapwater are ingested or
are given by enema, the body transfers water from the extracellular space into the intracellular
space to restore normal osmotic relationships.
 This transfer results in intracellular edema manifested by headache, nausea, vomiting,
dimness and blurring of vision, cramps, muscle twitching, and seizures.
 intracellular edema may occur is when tap water enemas are given to a child with
aganglionic disease of the intestine.

ACID–BASE IMBALANCE

The GI system often is involved with two severe acid–base imbalances:

a. metabolic acidosis
b. metabolic alkalosis.
o These imbalances occur with severe diarrhea or vomiting.
 When dealing with acid–base balance, a key component is pH.
 The abbreviation “pH”== refers to two French words that mean the “power of hydrogen.”
 pH denotes whether a solution is acid or alkaline, determined by the proportion of hydrogen
(H) ions in relation to hydroxide (OH) ions—the two substances that disassociate when water is
broken down into its basic composition.
 A solution is acid (pH below 7.0) if it contains proportionately more Hions than OH ions.
 It is alkaline (pH above 7.0) if the proportion of OH ions exceeds that of H ions.
 body serum is becoming acidotic
 determined by analyzing a sample of arterial blood for blood gases.
 The pH of blood is normally slightly alkaline, ranging from 7.35 to 7.45.
 PCO2 (the amount of dissolved carbon dioxide in arterial blood) is normally 35 to 45 mm
Hg.
 The level of bicarbonate (HCO3) in arterial blood is normally 22 to 26 mEq/L.

a. Metabolic Acidosis
 result from diarrhea.
 When diarrhea occurs, a great deal of sodium is lost with stool.
 --------The excessive loss of Na = causes the body to conserve Hions in an
attempt to keep the total number of positive and negative ions in serum
balanced.
------- result:
 a child becomes acidotic as the number of Hions in the
blood increases proportionately over the number of OH
ions present.
 arterial blood gas analysis will reveal a decreased pH (under
7.35)
 low HCO3 value (near or below 22 mEq/L).
-------The lower the HCO3 value is, presumably the more Na
ions that have been lost or the more extensive the diarrhea
has been.
 To correct this problem (a pH too low is incompatible with life):
 the body uses both its kidney and respiratory buffering systems.
 The respiratory buffering system attempts to correct the imbalance
quickly.
 Hions combine with HCO3 ions to form carbonic acid.
------This, in turn, is broken down into CO2 and water, which is
then eliminated by the lungs during expiration.
-------This process works immediately, and, as it continues for a
time, the bicarbonate level in the serum falls lower and
lower as the body uses up its bicarbonate store.
 In the kidneys:
 H ions are excreted directly or combine with other substances
like:
phosphate
ammonia

Assessment:

 The child breathes rapidly (hyperpnea) to “blow off” CO2 to prevent it from combining
with H2O and reforming HCO3.
 Urine becomes more acid as ammonia formation in the urine is increased.

b. Metabolic Alkalosis
 With vomiting, a great deal of hydrochloric acid is lost.
 a secondary electrolyte problem often occurs.
 As the kidneys begin to help conserve Hions ====Kions are exchanged
for Hions—that is, Kions are excreted in order to retain Hions.
====As a result of this loss of Kinto the urine, low K levels
(hypokalemia) invariably accompany metabolic alkalosis.
  When Cl ions are lost this way
 the body has to decrease the number of Hions present so the number
of positive and negative charges remains balanced.
 This causes the child to become alkalotic as the number of Hions
becomes proportionately lower than the number of OH ions present.
 To further reduce the number of Hions
 the lungs conserve CO2 and water by slowing respirations
(hypopnea).
 The excessive CO2 retained by this maneuver dissolves in the
blood as carbonic acid and then is converted into excessive
Hand HCO3
 With metabolic alkalosis, the serum HCO3 invariably will be high.
 The higher the value, presumably the more Cl ions have been lost or the more
extensive the vomiting has been.

Assessment:

 The child will breathe slowly and shallowly

 pH will be elevated (near or above 7.45)
 HCO3 level will be near or above 28 mEq/L.

✔Checkpoint Question 45.1

Barry has frequent bouts of vomiting. What secondary electrolyte problem often occurs when metabolic
alkalosis results from vomiting?

a. Acidosis.

b. Hyponatremia.

c. Hypokalemia.

d. Hyperchlorosis.