Pediatric Fluid and Electrolyte Therapy

Pediatric Fluid and Electrolyte
Therapy
Nanda Cendikia
112014228
Fluid Therapy
Maintenance
Deficit
Replacement
Maintenance Fluids
Maintenance Fluids are given to compensate for ongoing
losses.
Sensible losses : Urine output, fecal water (majority of on
going losses)
Insensible losses: Respiration, perspiration
Requirements for children are higher than adults, because:
1.
2.
3.
The higher metabolic rate of children.

Children especially infants, have a much higher body surface area to weight ratio.
Children, especially infants, have higher respiratory rates.
Respiratory Rates in Chilldren

Age
(months)
Mean Respiratory Rate

(breaths per minute)
<2
48
2 to <6
44,1
6 to <12
39,1
12 to <18
34,5
18 to <24
32
24 to <30
30
30 to 36
27,1
Patients suffering from fever, burn injuries, pain,

asthma, pneumonia, and increased intestinal losses
may all have elevated maintenance fluid
requirements
Patient with mild to moderate dehydration may be
rehydrated with oral therapy, even if diarrhea and
vomiting continues.
5o mL/kg over 4 hours for mild dehydration
100 mL/kg over 4 hours for moderate
dehydration
140 mmol/L of carbohydrate, 45 mmol/L (mEq)
of sodium, 20 mmol/L (mEq) of potassium
Holliday-Segar Method for Calculating

Maintenance Fluid Requirements in
Children
Holliday-Segar Method
Holliday-Segar
Estimate
First 10 kg
100 mL/kg/day
4mL/kg/hr
Second 10 kg
50 mL/kg/day
2mL/kg/hr
Every kg thereafter
20mL/kg/day
1mL/kg/hr
Deficit Fluids
Fluid lost prior to medical care are termed deficit fluids.
Examples: gastrointestinal illness with vomiting and diarrhea,
traumatic injuries with significant blood loss, and inadequate
intake of fluids over a period of time.
Clinical sign of dehydration which can be use is weight loss.
So, we have to know the pre-illness weight.
The degree of dehydration calculated should always be
compared to the clinical signs, which may better indicators of
dehydration status and are also especially useful when a preillness weight is unknown.
Clinical Sign of Dehydration

Clinical Sign
Mild Dehydration
Moderate
Dehydration
Severe
Dehydration
Weight loss (%)
3-5
6-9
10
Behavior
Normal
Normal to listless
Normal to lethargic
Thirst
Slight
Moderate
Intense
Mucous Membranes
May be normal
Dry
Dry
Anterior fontanelle
Flat
Sunken
Sunken
Eyes
Normal
Sunken
Deeply sunken
Skin turgor
Normal
Decreased
Decreased
Blood preasure
Normal
Normal
Normal to decreased
Heart rate
Normal rate
Increased
Increased
Urine output
decreased
Markedly decreased
Anuria
Degrees of Dehydration
Mild
dehydration
Moderate
dehydration
Severe
dehydration
Older child
3% (30 mL/kg)
6% (60 mL/kg)
9% (90 mL/kg)
Infant
5% (50 mL/kg)
10% (100 mL/kg)
15% (150 ml/kg)
Type of Dehydration, Define by Serum

Sodium concentration
> 135 mEq/L
: Hypotonic dehydration
135-145 mEq/L : Isotonic dehydration
> 145 mEq/L
: Hypertonic dehydration
Method for Calculating Rehydration Fluid in

Isotonic or Hypotonic
Rehydration Phase
Fluid Volume
Example 10-kg Child

with 1-kg weight loss
(deficit = 1000 mL)
Phase I
Emergency Phase
20 mL/kg
May repeat if necessary
200 mL (Remaining
deficit = 800 mL)
Phase II
First 8 hours
remaining deficit + 1/3

daily maintenance
400 mL + 333 mL = 733

733 mL /8 hr =
92 mL/hr
Phase II
Next 16 hours
remaining deficit + 2/3 400 mL + 666 mL = 1066

daily maintenance
1066 mL /16 hr =
67 mL/hr
During phase II, 5% dextrose with 0,45% sodium

chloride should be used, with 20-30 mEq / L of
potassium chloride added only if patient has
voided
During phase III, 5% dextrose with 0,2% sodium
chloride should be used, with 20-30 mEq / L of
potassium chloride added only if patient has
voided
Rehydration Fluid in Hypertonic

The deficit fluid volume should be added to the maintenance fluid
volume needed for 48 hours, and the total should be administered over
48 hours.
Administering the deficit fluid faster causes osmotic fluid shift, which can
result in cerebral edema and convulsions.
Serum sodium corrected by no more than 10 mEq/L/day.
Serum sodium should be checked frequently (every 2 to 4 hours) to
ensure the rehydration is not occurring so quickly as to cause an overly
rapid decreased in serum sodium.
The fluid used should be hypotonic, such as 5% dextrose with 0,2
sodium chloride.
Replacement Fluids
Defined as those given to meet ongoing losses due to the medical
treatment.
Example of clinical situations where replacement fluids are needed
include patients with chest tube in place, or externalized cerebrospinal
fluid shunts.
Each of these examples demonstrates a situation where there is an
ongoing loss which would not be met by administering only maintenance
fluids.
Replacement fluid are different from deficit fluids in that they are
ongoing, as opposed to a loss of fluid that occurred prior to receiving
medical treatment.
Electrolytes Abnormalities
Severe Hyponatremia
- Patient with serum sodium of less than 125 mEq/L
are at high risk for serious central nervous symptoms;
lethargy followed by seizures is common.
- Th/ boluses with hypertonic saline, usually 3% sodium
chloride (desired serum sodium concentration
current serum sodium concentration) x 0,6 x (weight
in Kg)
Hyperkalemia
- Serum potassium of gretaer than 6 mEq/L
- In emergencies, agent which cause a rapid influx
of potassium intracellularly are useful as they
provide an acute decrease in serum levels. These
medications include insulin and beta
adrenergic agonist such albuterol.
- less emergency situations: Sodium
polystyrene sulfonate is an exchange resin
which exchange sodium for potassium in the gut.
Determining Maintenance Fluids, Step by

Step.
Description of Steps
Example
Determine the appropriate fluid and delivery rate for maintenance fluids and
electrolytes for a 28-kg child
Calculation
Answer to each step

1660 mL = 1,66 L
Step 1
Determine daily maintenance fluid

requirement. Using the Holliday-Segar
method, determine the patients fluid
requirements (volume in liters) for 24 hours
a.
b.
c.
100 mL/kg x 1st 10 kg = 1000 mL

50 mL/kg x 2nd 10 kg = 500 mL
20 mL/kg x each additional kg (8) =
160 mL
Step 2
Deliver appropriate dose of electrolytes.

Choose a commercially available fluid and
determine how much sodium and potassium
will be delivered considering the volume that
will be administered.
Sodium requirements:
3 mEq/kg x 28 kg = 84 mEq sodium
a.
D5 NS x 1,66L = 38,5 mEq
sodium/L x 1,66L = 63,9 mEq Sodium
b.
D5 NS x 1,66L = 77 mEq sodium/L
x 1,66L = 128 mEq Sodium
c.
D5 NS x 1,66L = 154 mEq sodium/L x
1,66L = 255,6 mEq Sodium
Potassium requirements:
2 mEq/kg x 28kg = 56 mEq Potassium
d. 10 mEq/L x 1,66L = 16,6 mEq
Potassium
e. 20 mEq/L x 1,66L = 33,2 mEq
Potassium
f. 30 mEq/L x 1,66L = 49,8 mEq
Potassium
g. 40 mEq/L x 1,66L = 66,4 mEq
Potassium
Step 3
Choose a fluid. Pick a commercially available

fluid that delivers the desire amount of
electrolytes.
Step 4
Monitoring. Monitor patient fluid status and

electrolytes and adjust the rate and fluid type
accordingly
D5 NS provides the most appropriate

amount of sodium for this patient.
Generally, when beginning fluid therapy,

more conservative potassium amounts, in
this case 20 mEq/L , are used due the risk of
accumulation, particularly in hospitalized
children.
Answer
D5 NS with 20 mEq KCl per Liter at 69
mL/hr
Pengganti Cairan Intra operatif

Terapi cairan intraoperatif meliputi kebutuhan cairan dasar dan
penggantian deficit cairan preoperative seperti halnya kehilangan cairan
intraoperative ( darah, redistribusi dari cairan, dan penguapan).
Untuk semua prosedur yang lain Ringer Lactate biasa digunakan untuk
pemeliharaan cairan. Idealnya, kehilangan darah harus digantikan dengan cairan
kristaloid atau koloid untuk memelihara volume cairan intravascular
( normovolemia).
Pada kehilangan darah dapat diganti dengan transfuse sel darah merah.
Transfusi dapat diberikan pada Hb 7-8 g/dL (hematocrit 21 - 24%). Hb <
7 g/dL cardiac output meningkat untuk menjaga agar transport Oksigen tetap
normal. Hb 10 g/dL biasanya pada pasien orang tua dan penyakit yang
berhubungan dengan jantung dan paru-paru.
Perkiraan Volume Darah Rata-rata

Umur
Volume darah
Neonates
Premature
Full term
95 ml/kg
85 ml/kg
Infants
80 ml/kg
Adult
Men
Woman
75 ml/kg
65 ml/kg
Banyaknya transfusi dapat ditentukan dari

hematocrit preoperatif dan dengan perkiraan
volume darah.
Pasien dengan hematocrit normal biasanya
ditransfusi hanya setelah kehilangan darah >1020% dari volume darah mereka.
Tergantung daripada kondisi pasien dan
prosedur dari pembedahan
Jumlah darah yang hilang untuk penurunan

hematocrit sampai 30%, dapat dihitung sebagai
berikut:
1. Estimasi volume darah dari tabel sebelumnya.
2. Estimasi volume sel darah merah (RBCV) hematocrit
preoperative (RBCV preop).
3. Estimasi RBCV pada hematocrit 30% ( RBCV30%),
untuk menjaga volume darah normal.
4. Memperkirakan volume sel darah merah yang hilang
ketika hematocrit 30% adalah RBCV lost = RBCV
preop - RBCV 30%.
5. Perkiraan jumlah darah yang hilang = RBCV lost X 3
Contoh
Seorang anak perempuan 20 kg mempunyai suatu
hematocrit preoperatif 35%. Berapa banyak jumah darah
yang hilang untuk menurunkan hematocritnya sampai
30%?
Volume Darah yang diperkirakan = 80 mL/kg x 20 kg =
1600 ml.
RBCV 35 % = 1600 x 35 % = 560 mL.
RBCV 30% = 1600 x 30 % = 480 mL
Kehilangan sel darah merah pada 30% = 560 - 480 = 80
mL.
Perkiraan jumlah darah yang hilang = 3 x 80 mL = 240 mL.
Guidelines for Fluid Administration of Balanced

Salt Solution in Children According to the Age and
to the Severity of Tissue Trauma
First hour
25 mL/k g in children aged 3 yr and under

15 mL/kg in children aged 4 yr and over
All other hours
Maintenance + trauma = basic hourly fluid

Maintenance volume = 4 ml/kg/h
Maintenance + mild trauma = 6 ml/kg/h
Maintenance + moderate trauma = 8ml/kg/h
Maintenance + severe trauma = 10 ml/kg/h
Blood replacement
1:1 with blood or colloid or 3:1 with crystalloid
Redistribusi dan evaporasi kehilangn

cairan saat pembedahan
Derajat dari Trauma Jaringan
Penambahan Cairan
Minimal (hemioraphy)
0-2 ml/kg
Sedang (cholecystectomi)
2-4 ml/kg
Berat (reseksi usus)
4-8 ml/kg
Menggantikan Hilangnya Cairan

Redistribusi dan Evaporasi
Sebab kehilangan cairan ini dihubungkan dengan
ukuran luka dan tingkat manipulasi dan
pembedahan, dapat digolongkan menurut derajat
trauma jaringan. Kehilangan cairan tambahan ini
dapat digantikan menurut tabel di atas, berdasar
pada apakah trauma jaringan adalah minimal,
moderat, atau berat. Ini hanyalah petunjuk, dan
kebutuhan yang sebenarnya bervariasi pada masingmasing pasien.

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Pediatric Fluid and Electrolyte Therapy

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Pediatric Fluid and Electrolyte

The higher metabolic rate of children.

Respiratory Rates in Chilldren

Mean Respiratory Rate

Patients suffering from fever, burn injuries, pain,

Holliday-Segar Method for Calculating

Clinical Sign of Dehydration

Weight loss (%)

10% (100 mL/kg)

15% (150 ml/kg)

Type of Dehydration, Define by Serum

135-145 mEq/L : Isotonic dehydration

> 145 mEq/L

Method for Calculating Rehydration Fluid in

Example 10-kg Child

remaining deficit + 1/3

400 mL + 333 mL = 733

remaining deficit + 2/3 400 mL + 666 mL = 1066

During phase II, 5% dextrose with 0,45% sodium

Rehydration Fluid in Hypertonic

Determining Maintenance Fluids, Step by

Answer to each step

Determine daily maintenance fluid

100 mL/kg x 1st 10 kg = 1000 mL

Deliver appropriate dose of electrolytes.

Choose a fluid. Pick a commercially available

Monitoring. Monitor patient fluid status and

D5 NS provides the most appropriate

Generally, when beginning fluid therapy,

Pengganti Cairan Intra operatif

Perkiraan Volume Darah Rata-rata

Banyaknya transfusi dapat ditentukan dari

Jumlah darah yang hilang untuk penurunan

Guidelines for Fluid Administration of Balanced

25 mL/k g in children aged 3 yr and under

All other hours

Maintenance + trauma = basic hourly fluid

1:1 with blood or colloid or 3:1 with crystalloid

Redistribusi dan evaporasi kehilangn

Berat (reseksi usus)

Menggantikan Hilangnya Cairan

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