Disorders of sodium and

fluids

Patrick D Brophy, MD, MHCDS

Director Pediatric Nephrology
Professor
The University of Iowa
 Objectives
1. Understand cellular fluid shifts.

2. Understand maintenance/deficit fluids and

calculations.

3. Understand hyponatremic, isonatremic

hypernatremic dehydration and therapy.
TBW changes with Age
Total Body Water

% Total body water (TBW) s with

age
Preterm infants: 80%
Neonates & infants: 70-80%
Toddlers & young children: 60-70%
Older children & adults: 60%
calculate TBW: 0.6 x weight(kg) in adults
Total Body Water

Two main fluid compartments

Intracellular space
Extracellular space

Maintained through water and sodium

balance
Extracellular Fluid (ECF)

Fluid outside of cells

1/3 of TBW
s with age
ECF divided into 2 sub-compartments
interstitium
15-20% of TBW
vascular space
5-10 % of TBW
Extracellular Fluid-
Components
Na+ is principal cation in the ECF
Cl- & HCO3- are principal anions in the
ECF
Regulation of ECF is primarily related
to Na+ balance
Total body Na+ affects ECF status
Intracellular Fluid

ICF consists of fluid w/in cells

True ICF is difficult to calculate
K+ is principal cation in ICF
HPO4-2 & proteins are principal anions
in the ICF
Regulation of ICF: through regulation
of plasma osmolality through changes
in water balance
Osmolality

Osmolality
A measure of all solute particles per
weight of solvent, including:
impermeable: Na+, Cl-, mannitol, or glucose
permeable: urea, ethanol

Calc. Osmolality = 2x [Na+](mEq/L) +

BUN(mg/dL)/2.8 + Glucose(mg/dL)/18
Normal osmolality= 280-295 mOsm/kg
Tonicity

Tonicity
Measure of the effective osmols
(impermeable) in a particular weight of
solvent
Effective Osm: determined by solutes
that hold water in the ECC: (Na, glucose,
not urea)
H2O moves across cell membrane from
low tonicity to high tonicity
ICF & ECF Relationship

ICF separated from ECF by cell

membrane
Cell membrane highly permeable to H2O
Cell membrane impermeable to solutes
Osmolality at equilibrium b/w ICF &
ECF
 Osmotic Forces

H2O moves passively across the

cell membrane according to the
osmotic gradient

K+140 meq/L Na+ 140 meq/L

280 milliosmoles/L 280 milliosmoles/L
High osmolality outside the cell =
shrinkage

K+ 140 meq/L
280 milliosmoles Na+ 150 meq/L
300 milliosmoles/L
Low osmolality outside the cell = swelling
H2O

K+ 140 meq/L
280 milliosmoles/L Na + 120 meq/L
240 milliosmoles/L

Rupture
 The Rules of the Road
Cells require adequate circulation (vascular
volume) and a stable isoosmotic milieu to
function
Maintenance fluid has been calculated by
understanding:
Metabolic rate
Body size
It assumes:
All homeostatic mechanisms are intact
Lungs and kidneys are functional and
there is adequate circulating volume
BUT
The Rules of the Road..

If these assumptions are not met (ie Renal

failure), you must:
Calculate insensible losses
Calculate fluid and electrolyte loss
Calculate fluid rate based on above
 TABLE 1
INSENSIBLE WATER CALCULATIONS
Basal Calorie Expenditure for Infants and
Children* = water loss
Age Weight Surface H2O
Area Expenditure
(kg) (M2) (cc/kg/24 hr)

Newborn 2.5-4 0.2-0.23 50

1 week- 3-8 0.2-0.35 65-70
6 months
6-12 months 8-12 0.35-0.45 50-60
1-2 years 10-15 0.45-0.55 45-50
2-5 years 15-20 0.6-0.7 45
5-10 years 20-35 0.7-1.1 40-45
10-16 years 35-60 1.5-1.7 25-40
Adult 70 1.75 15-20

*Water expenditure equals 1 ml/cal.

Calculation of Insensible
Losses
Insensibles=500 ml/m2
To calculate m2:
BSA (m2)= sq root of [height (cm) x
weight (kg)/3600]
Alternatively based on wt:
BSA= 4 x wt (kg) + 7/ 90 + wt (kg)
Approach to Fluid
Calculations
Calculate.
1. Maintenance

2. Deficit

3. Ongoing losses
Concepts

Fluids are DRUGS!!

We wouldnt prescribe morphine
without checking the dose or thinking
it through (side effects, allergies etc.)
Why do we do this with fluids?
Maintenance Fluids

Based upon usual losses of H2O &

solutes under normal conditions
Fluid requirements may be calculated
by:
Metabolic requirements (Holliday-Segar)
Body surface area (BSA)
Body weight
 Holiday & Segar (1957)
Based on studies of normal, healthy
infants and children
100 mL/100 kCal/day fluid requirement = 1 mL/1
kCal/day:

IV fluids are calculated based on weight

and metabolic reqts:
0-10 kg: 100 mL/kg/day
10-20 kg: 1000 mL plus 50 mL/kg/day
>20 kg: 1500 mL plus 20 mL/kg/day
Max 2500cc/24 hr
Maintenance Electrolytes

Electrolyte requirements:
Na+: 2.5-3.0 mEq/100 kCal/day
K+: 2.0-2.5 mEq/100 kCal/day
Cl-: 4.5-5.5 mEq/100 kCal/day

Based on these calculations, all

children receive hypotonic fluids
 TABLE II
Holliday Segar calculation of maintenance fluids and
electrolytes

Water Electrolytes

(cc/kg) (per 100 cc H2O)

1st 10 kg body weight 100 Na 3mEq

2nd 10 kg body weight 50 C1 2mEq

Each additional kg 20 K 2mEq

through 70 kgm
EX: Therefore in a 22 kg 4-year-old, the maintenance
fluid could be calculated by:
10 kg x 100 cc/kg = 1,000 cc
100 kg x 50 cc/kg = 500 cc
2 kg x 20 cc/kg = 40
Total H20 - 1,540 cc
Na=3 meq/100 cc = 45 meq in 1.5 liters = 30 meq/Liter
K=2 meq/100 cc = 30 meq in 1.5 liters = 20 meq/Liter

These calculations can be made with a maximum

weight of 70 kg or a total volume of 2,500 cc/24 hr.
In order to utilize prepared IV solutions, you round
off the electrolyte requirements to the closest
solution available. All orders must be written
with the quantities per liter as a standard.
This makes it easy to compare the IV solution to
what you know is in plasma water. You know
D5.2NaC1 contains 38 meq of NaC1 per liter,
so this is an effective fluid to use.

For the 22 kg boy, your order would read:

D5.2 NaCl with 20 meq/KCl/liter @ 64 cc/hr.
Maintenance Concepts

The Holliday Segar calculation was derived

at a very different time in the history of
caring for children:
The severity of illness of kids has changed
We understand more about hormonal (ADH)
control water and electrolyte homeostasis
This formulation has stood the test of time and
is still useful for general treatment of well
children
Maintenance Calories

Caloric requirements (to prevent

severe ketosis & tissue catabolism):
20% of daily caloric requirements
sufficient
5 gm dextrose 20 kCal
Each 100 mL of maintenance fluid should
contain 20 kCal (5 gm dextrose)/100 mL
D5W (50 gm dextrose/1 Liter)
 Composition of Standard
IVF
Solution Na+ K+ Cl- HCO3- Osmolality
(mEq/L) (mEq/L) (mEq/L) (mEq/L) (mOsm/kg)
5% Dextrose in 0 0 0 0 278
H2O (D5W)
Isotonic Saline 154 0 154 0 308
(0.9% NSS)
D5W w/ 0.45% 77 0 77 0 432
Saline
D5W w/ 0.225% 38.5 0 38.5 0 355
Saline
Lactated Ringers 130 4 109 28 272
Abnormal Maintenance
Increased Maintenance fluid requirement:
Fever (12.5% per degree > 38C)
Increased sweating
Hyperpnea
Vomiting
Diarrhea
High environmental temperature
Hyperosmolar states (dehydration, DKA)
Hyperventilation (asthma, RSV)
Decreased maintenance fluid requirements:
Decreased renal function
Increased environmental humidity
Hypothermia
Hypometabolic states
Approach to Fluids contd

1. Maintenance

2. Deficit..
Deficit Therapy-Approach

Before correcting a fluid deficit, one

must answer the following:
1. Does a significant volume deficit exist?
If so, how much?
2. Does an osmolar disturbance exist?
3. Does an acid-base disturbance exist?
4. Does a disturbance of K+ exist?
5. What is the state of renal function?
1. Volume Deficit

Dehydration:
refers to a negative body water or water
balance
No definite laboratory test will assess this
Assessing % dehydration depends
upon:
Bedside examination & clinical findings
Knowledge of prior well weight
Signs & symptoms
Deficit Therapy

When treating deficits, remember:

Deficits are dynamic
Account for both maintenance & deficit
fluids
Deficit assumed to be due to a
decrease in ECF
1. Volume Deficit-
Estimation
Severity of dehydration (estimates):
Mild: 5% (3% for older child)
Moderate: 10% (6% for older child)
Severe: 15% (9% for older child)
Shock: inadequate tissue perfusion

Well wt - Ill wt = fluid deficit (kg)

1. Volume Deficit-
Estimation
Mild Dehydration (3-5%)
Normal BP, HR, pulses, fontanel, skin turgor, slightly dry
mucous membranes, UOP
Moderate Dehydration (6-10%)
Normal BP, increased HR, pulses, sunken fontanel,
depressed MS, skin turgor, UOP, dry mucous
membranes
Severe Dehydration (9-15%)
Normal to BP, pulses, sunken fontanel, depressed MS,
skin turgor, oliguria/anuria, dry mucous membranes
Shock (> 10-15%)
Sign BP/pulses, impaired organ perfusion/failure,
decreased mentation
1. Volume Deficit-
Calculation
Severity of dehydration (calculation):
Requires prior knowledge of well
weight
% dehydration = [(well weight- ill
weight)/well weight] x 100%

ie 12 kg child with current wit 10.8kg

12-10.8/12 x 100%= 10% deficit
Volume Deficit:
Replacement
Severe dehydration of signs of
decreased perfusion
Appropriate therapy is the administer 10-
20cc/kg NS bolus and reassess
Note: Hypotension is a late sign in
children
Volume Deficit

Replacement
Initial IV fluid bolus as needed (NS)
Calculate remaining deficit
Total deficit- fluid bolus vol
Replace in first 8 hrs
Replace remainder in next 16 hrs
Do not forget to add maintenance
2. Osmolar Disturbance

Measuring serum Na+:

Severe hypotonic: < 120 mEq/L
Hypotonic (hyponatremic): 120-130
mEq/L
Isotonic (eunatremic): 130-150 mEq/L
Hypertonic (hypernatremic): > 150
mEq/L
Not always necessary to measure
serum osmolality
 mgm/dl mgm/dl
Serum osmolality = serum Na+ X 2 + BUN + glucose
2.8 18

Urea - moves passively across the cell and

therefore does not cause an osmotic
gradient
Glucose - in diabetes cannot move
intracellularly and therefore is an osmotic
gradient and dilutes the sodium effect
 Types of Dehydration

Isonatremic - cells neutral

Hypernatremic - cells shrunken and
can have rebound
Hyponatremic - cells swollen
 Types
Isonatremic
80% of all dehydration
Proportional loss of salt and water
Treatment
Calculate deficit from decreased weight
Replace intravascular volume with isotonic

solution such as lactated ringers

Calculate maintenance

From tables calculate estimate of water,

sodium and potassium deficit
 Orders Standard
Isotonic rehydration 10-20 cc/kgm (more
important to restore vascular volume)
Calculate deficit
Give over 8 hours
Give over 16 hours
Calculate maintenance
Run piggyback
Calculate ongoing losses
Replace hourly
 Orders In Reality
Emergency Room - isotonic rehydration
10-20 cc/kg or until looks better
Home on oral rehydration solution
5cc/minute = 300 cc/hour
Key is to restore intravascular volume
Oral Rehydration Therapy
Preferred for mild/moderate dehydration
Recommended by the AAP, WHO, CDC
Advantages of ORT:
Less expensive/fewer complications than IV therapy
Applicable in any patient care setting
Contraindications to ORT:
Severe dehydration, intractable vomiting shock, impending
shock
Lack of personnel to administer ORT
ORT Failure

Indications of ORT failure

Clinical deterioration
Failure to rehydrate in 8 hours
Intractable vomiting/high purging rate
Institute IV therapy
Use of IV therapy does not preclude
resumption of ORT after rehydrated
 Appropriate Fluids
CHO/mmol/L Na K Base Osmo

WHO formula 140 45 20 48 265

Pedialyte 140 45 20 30 250

Not appropriate:
Cola 700 2 0 13 750
Apple juice 690 3 32 0 730
Chicken broth 0 250 8 0 500
 Hyponatremia
USUALLY means
Serum osmolality is below normal except for
Hyperlipidemia
Hyperglycemia/mannitol - which adds osmoles
Na+ Lipid measured at
140 meq/L 130 meq/L
because total
Na+ aliquot
140 meq/L is used to divide
even though
Na+ is only
distributed in
the water, not
the lipid
 TABLE VIII
body wt
HYPONATREMIA body wt

Wt neutral or slightly
Deficit of total body water Excess total body sodium
and larger deficit of total body Excess total body water and larger excess of total body
sodium water

ECF volume depletion Modest ECF volume excess ECF volume excess
(No edema) (edema)

Renal losses Extrarenal losses 1.Glucocorticoid Nephrotic syndrome. Acute and

Diuretic excess. Mineralo- Vomiting. Diarrhea. deficiency. Cirrhosis. Cardiac chronic renal
corticoid deficiency. Salt- third space burns. 2 Hypothyroidism. failure. failure
losing nephritis. Bicarbonaturia Pancreatitis. 3. Syndrome of
(renal tubular acidosis. Metabolic traumatized muscle Inappropriate ADH
alkalosis). Ketonuria, osmotic secretion.
diuresis (glucose, urea, Mannitol)

Urinary sodium Urinary sodium Urinary sodium Urinary sodium Urinary sodium
concentration concentration concentrations concentration concentration
>20 meq/l <10 meq/l >20 meq/l <10 meq/l >20 meq/l

Isotonic saline Water restriction Water restriction

NORMONATREMIA
Berl T,, et al. Kidney Int 10:117, 1976
 Hyponatremic dehydration
5% of all dehydration
Usually occurs with a child who has high GI
losses accompanied by water replacement
(Jello/pop, etc.)
Water shifts into the intracellular space to balance
osmoles, so child looks sicker since ECF is
compromised
Causes significant neurological problems as brain
swells Seizures
If Na <120 meq/L - can cause permanent myelinolysis
 If Na is above 120 meq/L
Replace intravascular volume with isotonic
solution
Calculate Na deficit
desired Na - measured Na X TBW
(TBW = 0.6 X body wt.)
Use D5 1/2 NaC1 = 75 meq/liter of Na to
replace deficit
Do not change serum more than 0.5-1 meq/L/hr
Add in maintenance +/- potassium
Hyponatremia: Correction

Ex: Na 120, in 15 kg child want to correct

to 135
Calculate Na deficit
(135-120) x .6 (15) = 135 meq
D5W.45 = 75meq/L =1.8L
Correct total 15 meq over 24 hrs
Run at 75cc/hr + maintenance
Check Na q2-4 Hr and MAKE ADJUSTMENTS
 If Na<120 meq/L, assess
hydration very carefully
If dry, give 20 cc/kgm of Isotonic solution
You may use hypertonic saline if CNS
signs are evident = 3% NaCl
514 meq/liter = 1028 mosm/L or
0.5 meq NaCL per cc
Risk of seizures
 Calculate deficit of sodium to
get you to 120
In a 10 kg child with a sodium of 110
(CD-CA) X 0.6 wt/kg
(120-110) X .6 X 10
10 X .6 X 10 = 60 meq
60 meq NaC1 = 120 cc of 3% NaCl
Give over 1-2 hours rechecking Na+ every
30 minutes
 Hypernatremia (Na > 150
meq/L)
ALWAYS means

Serum osmolality is above normal

 TABLE VII
HYPERNATREMIA
body wt body wt body wt

Na+ + H20 losses H20 losses Na+ addition

Low total body sodium Normal total body sodium Increased total body sodium

Renal losses Extrarenal losses Renal losses Extrarenal losses Primary hyperaldos-
Osmotic diuresis. Excess sweating. Nephrogenic Respiratory and teronism. Cushings
Mannitol, glucose, Diarrhea and/or diabetes insipidus. normal insensible Syndrome. Hypertonic
urea vomiting in Central diabetes losses dialysis. Hypertonic
children. insipidus. sodium bicarbonate.
Hypodipsia and Sodium chloride tablets.
partial diabetes
insipidus.

Iso- or Hypotonic Hypertonic urine Hypo-, Iso-, or Hypertonic urine Iso- or Hypertonic
urine (Urinary (Urinary Na+<10 Hypertonic urine (Urinary Na+ urine (Urinary Na+ >20
Na+>20 meq/l) meq/l) (Urinary Na+ variable) variable) meq/l)

Hypotonic saline or Water replacement diuretics and water

isotonic saline depending on replacement
intravascular volume
NORMONATREMIA
Berl T, et al. Kidney Int 10:117, 1976
 Hypernatremic dehydration
15% of all dehydration
Seen in children with deprivation of water
Breast-feeding failure
Children with losses replaced by high sodium foods
(broth, etc.)
Water moves out of the intracellular space and the ICF is
compromised
Na+ > 160 meq/L causes CNS effects
With shrinking of the brain there can be tearing of
bridging blood vessels causing subarachnoid or subdural
bleeds.
 Treatment -- SLOW!!!
If child is stable and hypernatremic and got that way
over weeks, you may take a week to correct
If child is in shock, give isotonic solution 10-20 cc/kg
to get out of shock
Calculate water deficit
4 cc/kg for every meq that serum Na exceeds 145
i.e. Na 160 in 10 kg child
4X 10 X 15 = 650 cc water or 1300 cc of 1/2 NaCl
Correct no faster than 0.5-1 meq/hr
Run as 1/2 NaCl over 30 hrs = 1300 cc = 43 cc/hr
30
Deficit Replacement-
Hypertonic
Hypernatremic dehydration
Clinically, the most difficult & dangerous
to tx
Treat shock w/ 0.9% NSS (20 mL/kg) IVB
over 1/2-1 hr
Then, D 5 0.45% NSS w/ 20-40 mEq/ L
KCL
Deficit Replacement-
Hypertonic
Duration of correction based on serum
Na:
Serum Na+ 150-170 mEq/L : correct over 48 hrs
Serum Na+ > 170 mEq/L : correct over 72 hrs
Serum Na+ > 200 mEq/L: dialysis
Deficit Replacement-
Hypertonic
Hypernatremic dehydration
Complications:
Cerebral swelling/brainstem herniation
Hyperglycemia: unclear why, decrease
dextrose to 2.5%
Hypocalcemia: unclear why, supplement Ca
Gluconate to IVF
Approach to fluids contd

Maintenance

Deficit

Ongoing losses.
 Ongoing Losses:
Need Replacement
Electrolyte concentration of various body fluids
Fluid Na K C1 Protein
(mEq/l) (mEq/l) (mEq/1) (g/dl)
20-80 5-20 100-150 -
Gastric
Pancreatic 120-140 5-15 40-80 -
Small Bowel 100-140 5-15 90-130 -
Bile 120-140 5-15 80-120 -
Ileostomy 45-136 3-15 30-115 -
Diarrhea 10-90 10-80 10-110 -
Burns 140 5 110 3-5
Third space
fluid 140 5 110 Variable
 Summary
Cells need adequate circulating volume
to survive: always assess and maintain
adequate vascular volume which is part
of the extracellular space

Cells are at risk with rapid shifts in

osmolality. Rapid fluid expansion
should always occur with isotonic fluid
 Additional References
Finberg L, Kravath ER, Hellerstein S, editors. Water and Electrolytes
in Pediatrics: physiology, pathophysiology, and treatment. 2nd ed.
Philadelphia: W.B. Saunders Company; 1993.
Feld LG, Kaskel FJ, Schoeneman MJ. The Approach to Fluid and
Electrolyte Therapy in Pediatrics. Adv Pediatr 1988;35:497-536.
Chesney RW, Batisky DL. Fluid and Electrolyte Therapy in Infants
and Children. In: Arieff AI, DeFronzo RA, editors. 2nd ed. New York:
Churchill Livingstone; 1995. p. 877-904.
Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte
Disorders. 5th ed. New York: McGraw-Hill; 2001.
Winters RW. Principles of Pediatric Fluid Therapy. Chicago: Abbott
Laboratories.
THANKS to Kevin McBryde MD -Childrens National Medical Center-
for the use of some of his slides and cases