Fluids (prepared by Dr.

Zane Kevin Ko Gervacio)

disclaimer: Readers are advised to verify the recommended dose or formula and to check the
package insert for each drug for any change in indications, dosages, and warnings.

Preserve tissue perfusion first, osmolarity second.

Resuscitate rapidly, rehydrate rationally, replace regularly.

1. IV Fluids
  Lactate is used instead of bicarb because it because it’s more stable in IVF during
storage. Lactate is converted readily to bicarb by the liver.
 To make D5 0.45, use equal amounts (via piggyback connection) of D10W and 0.9 NSS or
D5W + D5NSS, or incorporate 10.8 mL of 2.5 mEq/mL NaCl in 1L D5 0.3 NaCl

2. Formulas

 computing running rate:

ugtts/min (microset) or cc/hr = mL/day (= maintenance + deficit) / 24

= (cc/kg/day or “ckd” x wt x 24)

gtts/min (from Latin word gutta meaning drop) (macroset)

= ugtts/min x (1hr/60min x 20 drops/mL) = ugtts/min ÷3
= ugtts/min x (1hr/60min x 15 drops/mL) = ugtts/min ÷4
= ugtts / drop factor constant

 computing amount of fluids given:

ckd = (ugtts/min x 24 hours) / wt in kg
ckh = ckd / 24 = (cc/hr)/wt

L/day = volume of IV bottle / hours x 24

ex. D5 IMB 500 mL to run for 6 hours: 0.5 L / 6 x 24 = 2 L/day

 = for 1 liter bottle: 24/hours; for 500 mL bottle: 24/hours/2

ex. PNSS 1L to run for 16 hours: 24/16 = 1.5 L/day

3. Maintenance

 IVF to Use:
 Maintenance fluids usually contain 5% dextrose (D5), which provides 17 calories/100 mL
and nearly 20% of the daily caloric needs. This is enough to prevent ketone production
and helps to minimize protein degradation, but the child will lose weight on this
regimen (0.5% to 1% of real weight each day).
 Usually hypotonic
 Anacleto: maintenance Na 3-4 mEq/kg/day; K 2-3 mEq/kg/day
 Avner: Na and Cl 2-3 mEq and K 1-2 mEq/100 mL of daily water requirement

 Nelson 19th Ed: < 10 kg - D5 0.2 NS + 20 mEq/L KCl

larger children and adults - D5 ½ NS + 20 mEq/L KCl
 th
Nelson 20 : NPO and does not have fluid depletion or risk factors for nonosmotic ADH
production - D5 ½ NS + 20 mEq/L KCl
 With volume depletion, baseline hyponatremia, or at risk for nonosmotic ADH
production (pneumonia, bronchiolitis, CNS infection) – D5NS + 20 mEq/L KCl

 Anacleto: SIADH- NS 75% maintenance

 surgical patients during surgery to 6-8 hours post op – NS or LR with dextrose if
indicated then subsequently D5 NS or LR + 10-20 mEq/L KCl (but avoid isotonic if with
third spacing)

 for neonates:
  term infants – “usually begun at 60–70 mL/kg on day 1 and increased to 100–120 mL/kg
by days 2–3”
 smaller, more premature infants - may need to start with 70–80 mL/kg on day 1 and
advance gradually to 150 mL/kg/day

ex. Compute maintenance fluid requirement for a term baby weighing 3 kg on day 2 of life.

80 ckd x 3 / 24 = 10 cc/hour or ugtts/min

Order: IVF: D5W 500cc release 120 cc into soluset every 12 hours to run at 10 cc/hr.

 GIR in mg/kg/min = mL per hour x dextrosity x 0.167 / wt in kg

= ckd x dextrosity / 144
= (mL/hr x dextrosity) / (6 x wt in kg)

z: rationale for 0.167

mL per hour x ___ g glucose per 100 mL / wt / 60 minutes (to get /min)
mL per hour x ___ x 1000 mg per 100 mL / wt / 60
mL per hr x ____ / wt x (1000/100/60 = 0.167)

 Increasing dextrosity / “to make” formula:

 (Desired – actual) / (highest which is D50 - actual) x cc release = cc of D50 needed
 Total IVF release – cc D50 = cc of current IVF

 z: checking dextrosity
 [(cc D50 W x 50) + (cc D10W x 10)] / cc IV per release

 Holliday-Segar method:
 Loss of water is function of energy expenditure: 100 mL/100 kcal

NOT for neonates less than 14 days old

Anacleto: commonly results in overestimation of actual energy expenditure, overestimates

water requirement in children, underestimates sodium requirement in children
(desalination, natriuretic hormones, urodilantin, gut-related natriuretic peptide, ADH)

 Crawford body surface area method – more practical than UO method

I: accurate for children with BW > 10 kg and can be used in diseases with abnormal losses
- 1500 mL/m2 BSA: UO approx. 1000 mL/m2/day + insensible losses 500 mL/ m2/day

 urine output method

 oral maintenance requirements:

20-25% higher because of the associated increase in solute load with the accompanying diet

 factors modifying fluid requirements:

Avery: There is increased intestinal and insensible water loss during phototherapy which must
be compensated for by an increase of about 25% above the estimated fluid need.
Fanaroff and Martin:

Nelson: 10–15% increase in maintenance water needs for each 1°C increase in T above 38°C

Current Diagnosis and Treatment 19th Ed.

 Filston Quadrant Scheme: maintenance volume + ¼ for each quadrant of the abdominal
cavity involved with an inflammatory or obstructive disease + ¼ for each quadrant
significantly traumatized by the procedure
4. Deficit Therapy

dehydration – plasma free water deficit disproportionate to loss of sodium -> ECF and ICF loss;
slow careful infusion

hypovolemia – Na and H2O loss -> dec. effective circulating volume; rapid fluid replacement

Fluid losses occurring in fewer than 3 days are between 75-100% from the ECF; between 3 to 7
days, the figure is closer to 60-75%; longer than 7 days 50%.

sodium disorders -> volume disorder -> affects ECF -> cardiovascular symptoms

water disorders -> osmolarity disorder -> affects ICF -> neurologic symptoms
 isotonic and hyponatremic dehydration:
A. Phase 1 / Emergent / Acute Stage: Restore intravascular volume.

I: hypovolemia, severe dehydration

PNSP:

PLR PNSS
Not for liver failure Not for RTA
Leads to lactic acidosis Leads to hyperchloremic metabolic acidosis

Near physiologic due to chloride content
(Na:Cl = 2:1)
pH 6.5
Greater response in MAP and BP
Lowers PT, PTT, and increases fibrinogen
levels
Greatest impact on volume replacement
with fewest metabolic derangements
Not similar to plasma due to high Cl
(Na:Cl = 1:1)
pH 5.5
good for metabolic alkalosis
Greater response in urine output
Good for trauma since it moderates
coagulation

 Isotonic saline or less often colloid (Anacleto: no dextrose for resuscitation but okay for
hydration) in increments of 20 mL/kg titrated to normalize blood pressure and heart
rate, improve urine output, perfusion, and mental status
 60-80 mL/kg or more
 Unless rales or hepatomegaly develop
 rate of volume administration: pressure bag > push > gravity; faster rate less mortality

B. Phase 2 or Rehydration Stage

1. Compute volume of deficit.

calculated assessment: L = pre-illness weight in kg – current weight

clinical assessment: “clinically determining the percent dehydration and multiplying this
percentage by the patient's weight” ; cc deficit = (10 cc/kg per %) x (% deficit) x (weight)
 Nelson 20th:

Feigin: skin fold – instant recoil, recoil in < 2 seconds, recoil in >2 seconds

IMCI:
2. Calculate the rate.

Friedman rapid rehydration therapy: 40 mL/kg of isotonic fluids over 1-2 hours with an
additional 10-20 mL/kg (max 1 liter) over 2 hours to normalize cardiovascular signs ->
maintenance fluid requirement using Holliday-Segar formula with D5 0.45% saline
subsequently over 24 hours

Ludan: ¼ to 1/3 of the computed volume to be quickly given as a bolus in 1 hour while
the remaining infused over 5-6 hours
Nelson:

ex. wt 23 kg (previous wt unknown) moderate dehydration

(maintenance + deficit – bolus) / 24 hours

(1380+ 1560 - 0) / 24 = 2940/24 hours /drop factor 3 = 40 or 41 ggts/min

Harriet: 1st 8 hrs: (deficit / 2) + (maintenance / 3) – bolus

next 16 hours: (deficit /2) + (maintenance x 2/3)

1st 8 hrs: ( 23 x 60 = 1380) + (1560) = 690 + 520 – 0 = 1210 cc

1210cc / 8 hours/ drop factor 3 = 50 or 51 gtts/min

“sequential method”: cc deficit / 6 or 8

 Call PROD after _(cc per hour x 6 or 8)_ is consumed

After 6 to 8 hours, decrease rate to maintenance…

mild dehydration 23 kg: 30 x 23 kg / 6 hours / drop factor 3 = 38 or 39 gtts/min

Call PROD once 700 cc (total deficit) is consumed.

WHO, 2005:

3. IVF to use: Anacleto: “If kidney, liver, heart functions are normal, D5NR is the
recommended IVF. If abnormal, D5 .45 is advised”

Anacleto 2012 - Correcting only dehydration – saline or LR

Providing maintenance fluids at the same time – D5 0.45

 hypernatremic dehydration: see electrolytes

 SIADH: decreased UO with concentrated urine -> euvolemic hyponatremia (dilutional
hyponatremia) -> restrict fluids

-> hypernatremia (depletional) -> hydrate

5. Replacement

 IV replacement:

Harriet Lane:

Anacleto: isotonic losses: bilious drainage, pancreatic drainage, jejunal losses, ileal losses, blood

hypotonic losses – diarrhea, urine, vomitus

Nelson 20th: The child should receive an appropriate maintenance fluid that does not consider
the GI losses. The losses should then be replaced after they occur, using a solution with the
same approximate electrolyte concentration as the GI fluid. The losses are usually replaced
every 1–6 hr, depending on the rate of loss.
surgical patients:
 oral replacement:

ORS (Berman Decision Making): 10 mL/kg for each watery stool; 2 ml/kg for each episode of
emesis

For simplicity, children less than 10 kg can be given 60 to 120 ml (CDC) or 50-100 (WHO) ORS
for each episode of vomiting or diarrhea, and those greater than 10 kg given 120 to 240 ml
(CDC) or 100-200 mL (WHO).

6. Hypervolemia

normal serum Na but increased ECFV – correct faulty sodium control mechanism

both hypervolemia and dysnatremias – fluid restriction, salt limitation, fluid mobilization with
diuretics

References:
Anacleto, F.E. (2012). Bedside Pediatric Nephrology Water & Electrolytes. QC: HOPEMED Ltd.
Co.

Avner, E.D. et al. (2009). Pediatric Nephrology 6th Ed. Heidelberg: Springer.

Engorn, B. and Flerlage, J. (2015). The Harriet Lane Handbook 20th Ed. PA: Elsevier, Inc.

Kliegman, R.M., et al. (2016). Nelson Textbook of Pediatrics 20th Ed. PA: Elsevier, Inc.

Perkin, R.M., et al. (2012). The PICU Book. NJ, Word Scientific Publishing Co. Pte. Ltd.

Sio, J.O. and Alfiler, C.A. (2000). Fluid & Electrolyte Management in Pediatric Handbook. Manila,
Express Types and Prints.

1st IPNA-PNSP Teaching Course on Fluid & Electrolytes