Fluids and Electrolytes

PALS DISCUSSION
26 April 2018
Dr Tan May Loong
 Declaration

This is not intended to replace any classes

you may have on this topic in any of your
rotations.
Your attendance at all those classes are still
mandatory.
 Question 1
• The maintenance regime in adult that we learnt from the ward is
generally:
– Water: 30ml/kg/day
– Sodium : 2 mmol/kg/day
– Potassium : 1 mmol/kg/day
This regime is different from what stated in the NICE guidelines.

The main confusion is about the amount of potassium that we should

give to the patient in the maintenance regime.
 Normal Fluid Intake and Loss
• Normal adults are considered to have a minimal
obligatory water intake or generation of approximately
1600 mL per day, composed of the following:
• ●Ingested water – 500 mL
• ●Water in food – 800 mL
• ●Water from oxidation – 300 mL
• The sources of obligatory water output in normal adults
are composed of the following:
• ●Urine – 500 mL
• ●Skin – 500 mL
• ●Respiratory tract – 400 mL
• ●Stool – 200 mL
 Maintenance versus Replacement
• Maintenance: replace losses from
– Urine
– Sweat
– Breathing
– Metabolism
• Replacement: replace losses from GI tract
(diarhoea/vomiting), urine, burns, blood loss,
third space loss
 From NICE guidelines CG174
• Weight-based potassium prescriptions should
be rounded to the nearest common fluids
available (for example, a 67 kg person should
have fluids containing 20 mmol and 40 mmol
of potassium in a 24-hour period).
• Potassium should not be added to intravenous
fluid bags as this is dangerous.
• K+ 1 gm = 13 mmol
 Question 2
• Difference between Hartmann’s solution,
normal saline and half saline (aside from the
content; i.e. Indications and contraindications
for each)
 Indication and contraindications
• Tonicity = iso/hypo/hyper-tonic
• Osmolality
• Buffering – lactate/acetate – to buffer
acids/excess chloride
• Glucose
• Potassium
Fluid Requirement: Not one size fits all
Hypovolaemic
shock
GI surgery
Peri/post
Adults
operative
Neurosurgery
Renal
Children
impairment

Neonates
 Question 3
• When to use crystalloids, when to use colloids?

Crystalloids Colloids

NaCl Human Albumin

Hartman Solution Blood

Ringer’s Lactate Hemacell

Dextrose Gelufundin
 Colloids versus crystalloids for fluid resuscitation in critically ill
patients

Cochrane Database of Systematic Reviews

28 FEB 2013 DOI: 10.1002/14651858.CD000567.pub6
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000567.pub6/full#CD000567-fig-00101
 Question 4
• Life threatening issues regarding fluid
management that are crucial to know in
practice i.e. Absolute and relative
contraindications of using certain fluids in
specific situations
• Plasma osmolality — The plasma osmolality
(Posm) is determined by the ratio of plasma
solutes and plasma water. Most of the plasma
solutes are sodium salts with lesser
contributions from other ions (eg, potassium,
calcium), glucose, and urea. The normal Posm
is 275 to 290 mosmol/kg.
• Plasma tonicity, also called
the effective plasma osmolality, is the
parameter sensed by osmoreceptors and
determines the transcellular distribution of
water. Water can freely cross almost all cell
membranes and moves from an area of lower
tonicity (higher water content) to an area of
higher tonicity (lower water content).
Sodium and tonicity & osmolality
 Hyponatraemia
• Hyponatremia = fall in plasma tonicity, which
results in osmotic water movement from the
ECF into the cells, including brain cells, and
can contribute to the neurologic symptoms of
hyponatremia. In this setting, both the plasma
tonicity and plasma osmolality are reduced.
 Hypernatraemia
• Hypernatremia = increase in plasma tonicity,
which results in osmotic water movement out
of the cells, including brain cells, and can
contribute to the neurologic symptoms of
hypernatremia. In this setting, both the
plasma osmolality and plasma tonicity are
increased.
 Osmotic Demyelination Syndrome (ODS)
• Chronic hyponatremia is associated with the loss of osmotically active organic osmolytes (such as myoinositol,
glutamate, and glutamine) from astrocytes, which provide protection against brain cell swelling.
• However, organic osmolytes cannot be as quickly replaced when the brain volume begins to shrink in response
to correction of the hyponatremia [7-9]. As a result, brain volume can fall from a value that is initially somewhat
above normal to one below normal with rapid correction of hyponatremia.
• The mechanism by which a rapid fall in brain volume results in demyelination has not been established. One
possible mechanism is that osmotic shrinkage of endothelial cells opens the blood-brain barrier, allowing the
entry of complement and other cytotoxic plasma components. Another proposed mechanism is that, during
recovery from hyponatremia, the loss of cell water coupled with the movement of potassium and sodium
back into the cells lead to an initial increase in cell cation concentration that occurs before the repletion of
organic osmolytes [7,8,11]. These combined changes may directly injure and induce apoptosis of astrocytes,
leading to a disruption in the function of myelin-producing oligodendrocytes, release of inflammatory cytokines,
and activation of microglia [12].
• The osmotic demyelination syndrome (ODS) primarily occurs with overly rapid correction of severe
hyponatremia (serum sodium concentration almost always 120 meq/L or less) that has been present for more
than two to three days,
• Usually at presentation, Na <105
• Thus, because there is no proven advantage to correcting hyponatremia by more than 4 to 6 meq/L per day, we
and other authors recommend that the rate of correction of hyponatremia should not exceed 6 to 8 meq/L in
any 24-hour period [38].
• Overly rapid correction of hyponatremia can result from two general mechanisms: following therapy that is
specifically directed at raising the sodium concentration (such as hypertonic saline or initiation of a vasopressin
antagonist); and following cessation of a reversible stimulus to antidiuretic hormone (ADH) release or cessation
of exogenous dDAVP therapy. If renal function is normal, removal of a stimulus to ADH release results in a urine
osmolality that is usually below 100 mosmol/kg, leading to rapid excretion of the excess water (called
autocorrection).
 Take home Message
• Hyponatraemia = use Isotonic solution
• Go slow, especially when the Na < 105mmol/l
and it has been there for more than 2 days
• In some cases of hyponatraemia – it is
dilutional, treat the underlying cause eg. Heart
failure
 Hypernatraemia
• Correction of hypernatremia requires both the
administration of dilute fluids to correct the water deficit
and, when appropriate, interventions to limit further water
loss. Many pediatric patients also have a concurrent
volume isotonic deficit usually due to gastrointestinal
losses. Such patients with hypernatremia will require
replacement of both water and electrolyte deficits. In these
patients, it is important to assess the volume status as in
the setting of significant hypovolemia, because in patients
with moderate to severe hypovolemia, fluid resuscitation
with isotonic fluid to restore intravascular volume and
tissue perfusion takes precedence over correction of the
hypernatremia.
• Isotonic crystalloid is recommended for emergent volume resuscitation in pediatric patients [1].
Isotonic saline (0.9 percent saline solution or normal saline) is the isotonic solution of choice to
restore the circulatory volume. Rapid administration of hypotonic or hypertonic crystalloid
solutions for emergent volume expansion can result in serious complications, including
dysnatremias, cerebral edema, and, in children with marked hyponatremia, cerebral
demyelination
• Children with a serum sodium concentration above 155 mEq/L who are corrected too rapidly are
at greatest risk of neurologic sequelae, particularly seizures [23,24]. This adverse response to
therapy primarily occurs when the hypernatremia is corrected too rapidly at a rate exceeding
0.7 mEq/L per hour [24]. In comparison, no neurologic sequelae appear to occur if the plasma
sodium concentration is lowered at a rate of ≤0.5 mEq/L per hour [25]. (See "Hypernatremia in
children", section on 'Treatment'.)
• Thus, the goals of therapy in children with hypovolemia and serum sodium above 155 mEq/L are
correction of the volume deficit and gradual correction of the hypernatremia at a rate of less than
12 mEq/L per day (less than 0.5 mEq/L per hour). The overall fluid deficit in hypernatremic
hypovolemia is a combination of the free water deficit that raised the serum sodium and an
isotonic fluid deficit from the abnormal volume losses (which may be large in children with
gastroenteritis and minimal in children with diabetes insipidus who have mainly free water loss).
Copyrights apply
 Take home Message
• Hypernatraemia = use Isotonic or hypotonic
solution
• Go slow – fast correction would lead to
seizures
• In children, correction of fluid loss is also
important
 Glucose and resuscitation
• Glucose (D5% or D10%) is a hypotonic
solution
• Infusion of glucose would result in excess free
water
• Cerebral oedema can occur if large volumes of
hypotonic solutions are used in resuscitation
(movement of water into the cells)
 Fluid in operative patients (adults)
• Normal saline (0.9%) is particularly useful in cases of chloride and volume loss as well as alkalosis (eg, vomiting). It
contains the greatest concentration of sodium, repletes chloride loss, and will reverse contraction alkalosis.
• Normal saline (0.9%) is used in association with blood transfusion, particularly rapid transfusion, because it does not
contain additives like calcium, potassium, or magnesium. Lactated Ringers and Plasma-Lyte contain these additives,
which may not be compatible with all blood products and can result in red blood cell lysis, clot formation in the tubing,
and electrolyte chelation [13].
• Normal saline (0.9%) is used for head-injured patients, in whom hypernatremia is preferable to hyponatremia or
lowering the serum osmolarity. The brain does not tolerate edema well; maintaining a normal (or elevated) sodium
ensures that cerebral edema is minimized.
• Lactated Ringer's and Plasma-Lyte should be avoided in patients with hyperkalemia as they both contain potassium.
Similarly, in patients with poor renal function, these choices are typically avoided in order to avoid hyperkalemia.
• Large volumes of normal saline are undesirable as they will result in hyperchloremic acidosis and renal vasoconstriction
[14,15]. A restrictive approach to fluid resuscitation, using isotonic fluid, may reduce the incidence of renal sequelae
[16]. In cases of renal and/or liver dysfunction, a provider may have no other choice but to use 0.9% saline.
• For patients with bicarbonate loss (eg, pancreatic fistula, bladder-drained pancreas transplant), bicarbonate
replacement therapy may be administered intravenously in a continuous fashion. Sodium bicarbonate is commonly
added to replacement fluids in increments of 50 mEq/L. The fluid vehicle is chosen to achieve the desired fluid sodium.
For example, 150 mEq/L of sodium bicarbonate will provide 150 mEq of sodium per liter, which is nearly equivalent to
0.9% saline (154 mEq/L). As such, it is mixed in sterile water or 5% dextrose in water to avoid further sodium
administration.
• Hypertonic saline (3% sodium chloride) is being used for the resuscitation of trauma patients whose abdomens are
maintained open with a temporary abdominal closure device. In this highly selective population, volume overload
results in delayed primary fascial abdominal closure and complications of open abdomen (eg, enteroatmospheric
fistula). Inspired by a promising early report [17], similar encouraging reports have suggested that the complications
associated with hypertonic saline resuscitation (hyperchloremia, hypernatremia, hyperosmolar acidosis) are well
tolerated in this patient population [18]. Although this is not the standard of care, it remains a promising alternative to
standard resuscitation and is supported by one systematic review [19].
 Question 5
• How much fluid should we give STAT when
resuscitating hypovolemic patients? Any
formula to remember?
 Fluid resuscitation in Adults and
Children
• Only apply to patients in shock
• Adults: 500 – 1000 mls as quickly as possible
• Children: 10-20mls/kg as quickly as possible
• Use isotonic solution
 References
• NICE guidelines CG174 (adult)
• NICE guidelines NG29 (children)
• UptoDate
– Maintenance and replacement fluid therapy in adults
– Overview of postoperative fluid therapy in adults
– Treatment of hypernatremia
– Hypernatremia in children
– Osmotic demyelination syndrome (ODS) and overly
rapid correction of hyponatremia