Disturbance of Fluid and Electrolytes

Dr . Khalid Al Noaim Pediatric Department KFU

 Amount of body fluids losses
Body
BussI, asI Fluids
Electrolytes 6i;81'j! ss, 1
Loss

Sensible fluid loss : Insensible fluid loss

- Urine 60 % 35%
- Stool 5% - Lung
- Skin

Insensible fluid loss calculations : either

- 1/3 maintenance
- Body surface area x 300
Maintenance Potassium is 20 meq / L
Examples

Calculate the maintenance fluids for a child , weight is 8 kg.

8 x 100 = 800 8 x 4 = 32
= 800 ml/day = 32 ml / hour
Examples

Calculate the maintenance fluids for a child , weight is 15 kg.

10 x 100 = 1000 10 x 4 = 40
5 x 50 = 250 5 x 2 = 10
1000+250 = 1250 ml/day 40+10 = 50 ml / hour
Examples

Calculate the maintenance fluids for a child , weight is 35 kg.

10 x 100 = 1000 10 x 4 = 40
10 x 50 = 500 10 x 2 = 20
15 x 20 = 300 15 x 1 = 15
1000+500+300 = 1800 ml/day 40+20+15 = 75 ml / hour
Dehydration
There are 3 degrees of dehydration depend on the % of body fluids loss
Mild Moderate Severe
Infant 5% 10% 15%
Child 3% 6% 9%

Each 1% of dehydration = 10 ml / kg fluid deficit

There are 3 types of dehydration depend on Serum Na level:

Isonatremic dehydration Hyponatremic dehydration Hypernatremic dehydration
Na 135 - 145 Na < 135 Na > 145
 Mild Moderate Severe
Head: - Irritable
- Normal - lethargic/coma
- LOC Slightly
- Normal Sunken
- Fontanel depressed

Eyes: - Reduced - absent

- Normal
- Tears - depressed - Sunken
- Normal
- Shape

Mouth Moist Dry Very dry

CVS:
- Normal - Tachycardia - Tachycardia
- HR
- Present - Present (week) - Decreased
- Pulse
- Normal - Normal - Hypotension
- BP
- < 2 seconds - 2 - 3 seconds - > 4 seconds
- CR

Kidney Normal Oliguria Anuria

Skin: - Reduced
- Normal - Slight reduction
- Turgor - Cold
- Temperature
- Normal - Normal

Thirsty Thirsty Thirsty

Examples
Ahmed is 6 months old , his wt 8 kg, came with hx of recurrent
diarrhea and vomiting last 48 hours, O/E: lethargic, tachycardia,
hypotension, sunken eyes, Sunken fontanel and CR time 5 seconds.
How many ml his fluids deficit ?

Age 6 moths ( 5% , 10% or 15% )

Severe dehydration = 15 %

Each 1% of dehydration = 10 ml / kg fluid deficit

15 % x 10 x 8 kg = 1200 ml
Examples
Mohammed is a 4 year old , his wt 16 kg, came with hx of recurrent
diarrhea and vomiting last 48 hours, O/E: irritable, tachycardia, normal
BP, depressed eyes, decreased tears and CR time 3 seconds.
How many ml his fluids deficit ?

Age 4 years ( 3% , 6% or 9% )

Moderate dehydration = 6 %
Each 1% of dehydration = 10 ml / kg fluid deficit
6% x 10 x 16 kg = 960 ml
Essential Nelson Methods

% of dehydration X weight = Deficit ( liters )

Examples
Ahmed is 6 months old , his wt 8 kg, came with hx of recurrent
diarrhea and vomiting last 48 hours, O/E: lethargic, tachycardia,
hypotension, sunken eyes, Sunken fontanel and CR time 5 seconds.
How many ml his fluids deficit ?

Age 6 moths ( 5% , 10% or 15% )

Severe dehydration = 15 %
Deficit ( Liter ) = % of dehydration X weight
0.15 X 8 = 1.2 liters
Examples
Mohammed is a 4 year old , his wt 16 kg, came with hx of recurrent
diarrhea and vomiting last 48 hours, O/E: irritable, tachycardia, normal
BP, depressed eyes, decreased tears and CR time 3 seconds.
How many ml his fluids deficit ?

Age 4 years ( 3% , 6% or 9% )

Moderate dehydration = 6 %
Deficit ( Liter ) = % of dehydration X weight
0.06 x 16 kg = 0.96 liter
Rapid correction of Hypernatremia leads to
Cerebral edema

Rapid correction of Hyponatremia leads to

central pontine myelinolysis
 ·Bing

-9514
Hyponatremia
 Hyponatremia

Osmolality Normal
High
280 295 (Pseudohyponatremia)
-- Hyperglycemia
- Mannitol - Hyperlipidemia
- Hyperproteinemia

Hypovolemic Hyponatremia Low

(True)
Hypervolemic Hyponatremia
Renal Loss: ( Urine Na )
e
- Thiazide or loop diuretics ~
- Congestive heart failure
W
- Postobstructive diuresis - Cirrhosis
Euvolemic Hyponatremia
- Renal tubular damage
~
- Nephrotic syndrome
- SIADH - Capillary leak
Non Renal Loss:
- GI (emesis, diarrhea) w
- Water intoxication
w
- Hypoalbuminemia
- Acute / Chronic renal failure
- Skin ( sweating or burns )
Clinical manifestations
- Brain cell swelling is responsible for most of the symptoms
of hyponatremia.

- Neurologic symptoms of hyponatremia include:

Anorexia. Agitation.
Nausea. Headache.
Emesis. Seizures ( less than 120).
Malaise. Coma.
Lethargy. Decreased reflexes.
Confusion.
Laboratory
Serum osmolality.
Urine Na.
Urine Specific gravity.
Urine osmolality.
Managements
Rapid correction of hyponatremia can produce central pontine
myelinolysis. (No correction more than 12 mEq / 24 hous).

If seizure : give 2 ml/kg of 3% Nacl. ( Emergency )

Treating the underlying cause.

Hypovolemic/ Isovolemic hyponatremia treating by replacing the losses by

D5% ½ NS ( as hyponatremic dehydration ).

SIADH or Hypervolemic hyponatremia treating by fluids restriction.

 Hypernatremia

Water loss water > Na

loss
Na
Low Urine Output:
Intake/Reabsorption
- GI losses

a Low Urine Osmolality: (Diarrhea, Emesis)

- Cutaneous losses
- Diabetes insipidus.
e
- Improper formula feeding. (Burns, Excessive sweating)
High Urine Osmolality
- Dehydration u- Iatrogenic. High Urine Output:
a
- Phototherapy. - Osmotic diuretics
- Prematurity. - Sea water ingestion. (mannitol)
- Diabetes mellitus
~
- Hyperaldosteronism - Chronic kidney disease
W
- Polyuric phase of ATN
- Postobstructive diuresis
Clinical Manifestations
Most children with hypernatremia are dehydrated and have the typical
signs and symptoms of dehydration .

Children with hypernatremic dehydration tend to have better preservation

of intravascular volume owing to the shift of water from the ICS to the ECS.

Abdominal skin of a dehydrated, hypernatremic infant has a doughy feel.

Patients are irritable, restless, weak, lethargic and some infants have a
high-pitched cry and hyperpnea.

Brain hemorrhage is the most devastating consequence of hypernatremia.

Laboratory
Urine Na.
Urine Osmolality.
Urine specific gravity.
Urine output (volume).
Management
Rapid correction of hypernatremia can produce cerebral edema.
(No correction more than 12 mEq / 24 hous).

Frequent monitoring of the serum sodium to adjust the fluids.

Treat the dehydration according to the level of Na.

Central DI : ADH analogue ( desmopressin )

Peripheral DI: reduced sodium intake, thiazide diuretics, and NSAIDs.
X
over

48 - 96
Ha5
 Hypokalemia Transcellular shift
Decrease intake
e- Alkalosis
- Iatrogenic. E- Insulin
a
- Anorexia nervosa Increase e- -Adrenergic agonists
Excretion e- Refeeding syndrome

Renal Causes
Non Renal Causes
Metabolic Acidosis
W- RTA ( proximal and distal )
- Diarrhea - DKA
Metabolic Alkalosis
- Laxative abuse e- Gitelman syndrome and Bartter syndrome
- Loop and thiazide diuretics
u
-
- Cystic fibrosis
- Sweating
W- Pyloric stenosis

*- Sodium polystyrene sulfonate

w- Hyperaldosteronisms (HTN)
- Renovascular disease (HTN)
(Kayexalate) - Renin-secreting tumor (HTN)
- Cushing syndrome (HTN)
 Clinical Manifestations

- ECG changes.
- Arrhythmia.
- Weakness.
- Paralysis.
- Urine retention.
- Poor growth ( Chronic )
Diagnosis
History and physical examination ( BP ).
Serum chemistry and renal function.
Blood gas.
Urine electrolyte.
ECG.
Management
Oral supplements ( Kcl ).
IV Supplement ( with caution ).
Potassium sparing diuretics.
 Transcellular shift
Hyperkalemia L
- Acidemia.
Increase intake - Rhabdomyolysis.
w
- Tumor lysis
- Iatrogenic. syndrome.
W
- Blood transfusion. Decrease - Tissue necrosis.
Excretion e
- Hemolysis.
- Insulin deficiency.
Medications
Renal Causes
- ACE inhibitors a
- Renal failure.

-
&- Primary adrenal disease.
- Angiotensin II blockers - Hypoaldosteronism.
~
- Pseudohypoaldosteronism type 1.
- Potassium-sparing diuretics -
- Pseudohypoaldosteronism type 2.
- Urinary tract obstruction.
⑲
- Cyclosporine - Sickle cell disease.
factitious - Kidney transplant.
- NSAIDs - Lupus nephritis.
hyperkalemia
- Congenital adrenal hyperplasia.
- Trimethoprim
Clinical Manifestations
--

ECG changes leads to

( VF , Asystole ).
Paresthesias.

x*-
Weakness.
Tingling. -

-
X
Diagnosis
Confirm the result ( rules out factitious ).
ECG.
Serum electrolytes and glucose.
Renal function.
Blood gas.

W
Management V
Stop K intake.
Abnormal Ca gluconate IV
ECG Normal No need for Ca gluconate

B-agonist nebulization
K shifting to ICF Sodium bicarbonate if severe acidosis (limited cases)
Insulin and glucose infusion

Oral or rectal Kayexalate

K Execration Loop diuretics
Dialysis
CO2 = Acidosis
CO2 = Acid
CO2 = Alkalosis

HCO3 = Alkalosis
HCO3 = Alkaline
HCO3 = Acidosis
Increase Decrease
CO2 Bicarbonate

Decrease Increase
CO2 Bicarbonate
PH 7.35 - 7.45 *
7.45 Alkalosis
7.35 Acidosis
PCO2 35 - 45 &

45 R. Acidosis
35 R. Alkalosis
HCO3 20 28 *

28 M. Alkalosis
20 M. Acidosis
Main Types of Abnormalities
Respiratory Acidosis PH CO2

8
Metabolic Acidosis PH HCO3

Respiratory Alkalosis PH CO2

Metabolic Alkalosis PH HCO3

Mixed
Compensatory mechanism
 PH
> 7.45 < 7.35
Alkalosis Acidosis

Respiratory Metabolic Respiratory Metabolic

PCO2 < 35 HCO3 > 28 PCO2 > 45 HCO3 < 20

Metabolic Respiratory Metabolic Respiratory

Compensation Compensation Compensation Compensation
HCO3 < 20 PCO2 > 45 HCO3 > 28 PCO2 < 35
Anion Gap ( Metabolic Acidosis )
Anion gap = [Na + ] [CI ] [HCO3 ]

Normal level:
E. Nelson: 3 11
Other recourses: 8 - 16
-
- v

3.
v

=
AGE
W

X
RTA
fistula S
Case 1 W

5 years old with asthma and severe respiratory distress

Blood gas: PH: 7.30 PCO2: 50 HCO3: 29,
What is the abnormality?
1- PH:
Acidosis -
2- Type:
Respiratory, because increase of PCO2
3- Compensation:
Yes, because increase of HCO3 pr Dx
&
".
Respiratory acidosis compensated by metabolic alkalosis
at
Case 2
3 years old with ARDS , on mechanical ventilation on high ventilation rate.
Blood gas: PH: 7.50 PCO2: 28 HCO3: 23,
What is the abnormality?
1- PH:
Alkalosis
v
2- Type:
Respiratory, because decrease of PCO2
3- Compensation:
No, because no decrease of HCO3

Respiratory Alkalosis without compensation

Case 3
3 years old with recurrent chest infection , diagnosed as cystic fibrosis
Blood gas: PH: 7.50 PCO2: 48 HCO3: 33,
What is the abnormality?
1- PH:
Alkalosis v
2- Type:
Metabolic, because increase of HCO3
3- Compensation:
Yes, because increase of PCO2

Metabolic Alkalosis compensated by Respiratory Acidosis

Case 4
4 years old with DM1 , came with picture of DKA , Na: 140 Cl: 110
Blood gas: PH: 7.25 PCO2: 26 HCO3: 11,
What is the abnormality?
1- PH:
Acidosis
2- Type: v
Metabolic, because decrease of HCO3
3- Compensation:
Yes, because decrease of PCO2
4- Anion gap:
140 110 11 = 19 ( High )

High AG Metabolic Acidosis compensated by Respiratory Alkalosis

Reading Material

Section 7
Chapter 32
Chapter 33
Chapter 35
Chapter 36
Chapter 37