CLIN PHARM - Fluids and Electrolytes
CLIN PHARM - Fluids and Electrolytes
CLIN PHARM - Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
SELECTION ASSESSMENT
D5 ½ NS (D5 0.45 NS) + 20 mEq/L KCl Before starting IV fluids, baseline serum electrolytes (Na,
D5 0.2 NS + 20 mEq/L KCl K, glucose, urea, creatinine) should be measured.
o For children weighing < 10kg Patients undergoing day surgery where the IV is
o Higher water needs discontinued at the end of the case do not need their
But the available in the country is D5 .9 NS electrolytes measured.
o Dilute D5 .9 NaCl with water to prepare for D5 ½ NS o Elective cholecystectomy (managed as
o For every 100ml solution of D5 ½ NS: 50ml of PNSS (or outpatient)- no need for post op electrolytes
0.9 NS) + 50 ml D5 water o Ruptured appendicitis- needs post op elec
For the current guideline does not recommend D5 IMB
anymore, D5 ½ NS and D% 0.2 NS are recommended PRESCRIPTION OF IV FLUID THERAPY
instead. 5% Dextrose in water
o A carbohydrate solution that uses glucose(sugar) as
Example: if the maintenance fluid for a 10kg child is D5 ½
the solute dissolved in sterile water. Five percent
NS, how would you prepare it?
dextrose in water is packed as an isotonic solution but
becomes hypotonic once in the body because the
For every 100ml solution of D5 ½ NS:
glucose (solute) dissolved in sterile water is
50ml of PNSS (or 0.9 NS) + 50 ml D5 water
metabolized rapidly by the body’s cells.
Colloid solutions
GENERAL PRINCIPLES
o IV fluids containing large proteins and molecules that
Any hospitalized child requiring IV fluids should be
tend to stay within the vascular space (blood vessels).
considered at risk of non-physiological (inappropriate)
o Commonly used colloid solutions include plasma
ADH secretion.
protein fraction, salt poor albumin, dextran, and
Groups particularly at risk identified in published case hetastarch.
series include : o D5 water
o Children undergoing surgery and those with acute
Crystalloid solutions (LRS, NSS, D5 IMB, D5 NM)
medical illnesses including meningitis, encephalitis,
o Are the primary fluid used for prehospital IV therapy.
bronchiolitis and pneumonia
o Crystalloids contain electrolytes (e.g., sodium,
In the absence of a need to correct a fluid deficit in these potassium, calcium, chloride) but lack the large
patients, IV fluids should be administered at the rate of proteins and molecules found in colloids.
60-70% of the usual calculation for normal maintenance o Crystalloids come in many preparations and are
requirements and in the form of isotonic saline or Ringer's classified according to their “tonicity.”
Lactate. o Crystalloid’s tonicity describes the concentration of
Proprietary enteral fluid preparations and TPN solutions electrolytes (solutes) dissolved in the water, as
are low in sodium (<40 mmol/L) and maybe a substantial compared with that of body plasma (fluid surrounding
source of electrolyte free water. the cells).
Patients on long term TPN and who are not acutely ill are Isotonic
not at increased risk for the development of acute Hypotonic
hyponatremia. Hypertonic
Infants and young children have limited glycogen stores Lactated Ringer’s
and saline solutions with added dextrose are required to o An isotonic crystalloid solution containing the solutes
prevent hypoglycemia and ketosis. sodium chloride, potassium chloride, calcium chloride,
Children with cardiac failure, renal failure and hepatic and sodium lactate, dissolved in sterile water
failure with ascites have chronically low PNa values (solvent).
because of water retention and/or abnormalities of the Normal saline solution
renin/angiotensin mechanism. o An isotonic crystalloid solution that contains sodium
These patients have chronic hyponatremia and are not at chloride (salt) as the solute, dissolved in sterile water
risk for the development of cerebral edema. (solvent).
Patients who are at increased risk for cerebral edema are o The specific concentration for normal saline solution
those with acute hyponatremia (symptoms occurring is 0.9%.
<48hrs).
FLUID Na Cl (mEq) K (mEq) Ca Lactate
Example: 3 y/o child with pneumonia. How will you (mEq) (mEq)
regulate the fluid of this patient using Holliday-Segar NSS 154 154
method? 0.45% NaCl 77 77
Requirement= 1200ml/day 0.2% Normal 34 34
Because of the presence of an acute medical illness: Saline
1200ml x (.60) = 720ml should only be given Ringer’s 130 109 4 3 28
Lactate
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
Pre illness weight: (13kg x 100) = 14.4kg Diagnosis: Pneumonia with Dehydration
100 – 10 o Signs of dehydration: Sunken eyes and marked
tenting of the skin (poor skin turgor)
o Since the patient is not in shock, no need to give IV
bolus.
o Patient also has hyponatremia due to dehydration.
Pre-illness (14kg x 100) = 14.9kg
Weight 100 – 6
Maintenance Holliday-Segar Method:
Fluid 1000 + (50ml x 4.9) = 1245ml
Maintenance Na 4 x 14.9 = 60
Water Fluid (14.9 x 6% dehydration) x 1000ml =
Deficit 894ml
*0.06 = 6% dehydration
*1000 is constant because it is 1L
ECF Na Loss 894 ml x 0.60 x 145) = 78
1000
*0.60 = 60% fluid deficit from ECF
because the duration of illness is 3 days
(refer to table about “percent fluid
deficit as related to duration of
illness”).
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
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CLINICAL PHARMACOLOGY – Fluids and Electrolytes
Treatment
The goal is to decrease the serum Na by < 12mEq/L every
24 hours, a rate of 0.5 mEq/L/hr.
In the child with hypernatremic dehydration, as in any
child with dehydration, the first priority is restoration of
intravscular volume with isotonic fluid.
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