MAINTENANCE

&
REPLACEMENT
FLUID THERAPY

Moderated By Dr.Madhuri Engade

Presented By Dr.Akshay
OBJECTIVES
 To know the difference in physiology of children.

 To know the Goals of maintenance fluid therapy.

 Able to Calculate total fluid requirement & do

monitoring of the patient.

 To know Variations in maintenance water &

electrolytes.

 To order Replacement fluids in “common”

situations.
WHY THE INFANTS ARE MORE VULNERABLE?*
 Physiological inability to concentrate urine.

 Higher metabolic rate & larger surface area.

 Cant express thirst for more fluids.

 Larger turnover.

*IAP text book of Pediatrics 5th edition

WHOM TO GIVE MAINTENANCE FLUIDS?
 Infants who are sick & whose oral intake is
uncertain.

 Babies who are kept NBM for the surgery, with

respiratory distress etc.

 neonates kept under radiant warmer.

GOALS OF MAINTENANCE FLUIDS*
 Prevent dehydration

 Prevent electrolyte disturbance

 Prevent ketoacidosis

 Prevent protein degradation

*Nelsons Text book of pediatrics 19th edition

AT BIRTH…
75 % of the total body weight
Next 2 – 3 Days Obligatory diuretic phase

65 % of the total body weight

At the end of Ist year

60 % of the total body weight

BACK TO PHYSIOLOGY…

Total Body Water 60%*

Intra cellular fluid Extra cellular fluid

(ICF) (ECF)
40% 20%

Interstitial Intravasular
15% 5%

*IAP text book of Pediatrics 5th edition

 What osmolarity means…

 What tonicity means…

DISTRIBUTION OF BODY WATER
Intravascular (5%)

ECF
Na+ Interstitial (15%)
Cl-

K+ Intracellular (40%)
ICF
ELECTROLYTE CONCENTRATIONS

Component ECF ICF

Na+ High Low
K+ Low High
Ca++ Low Low (higher
than ECF)
Proteins High High
KEY LEARNING POINT*

 Sodium is the Principle electrolyte in ECF

[140mEq/L (+/- 5)]

 Potassium is the Principle electrolyte in ICF

[150mEq/L (+/- 5)]

*IAP text book of Pediatrics 5th edition

 Maintenance fluids consists of-
i. Water
ii. Glucose
iii. Sodium
iv. Potassium

 Advantages –
 Simplicity, long shelf life, low cost, compatibility.

 Prototypical maintenance therapy fluid doesn’t

provide calcium, phosphorus, magnesium or
bicarbonate.*

*Nelsons Text book of pediatrics 19th edition

FLUID LOSSES IN INFANTS
LUNGS

URINE, FECES SKIN

CONCEPT OF MAINTENANCE OF WATER

 Crucial component of maintenance fluid therapy.

 Maintenance water = Measurable loss of water 65%

(Urine 60%, stools 5%) + Insensible of water 35% (skin
& lungs)
FOR NEONATES
 Day 1 60 ml/kg/day

 Day 2 90 ml/kg/day

 Day 3 120 ml/kg/day

 Day 4 150 ml/kg/day (maximum for term infants)

 Day 5 to 3 months 150 ml/kg/day

MAINTENANCE REQUIREMENTS*

Weight Requirement

0-10 kg 100cc/kg/24hr

11-20 kg 1000 +
50cc/kg/24hr
>20 kg 1500 +
20cc/kg/24hr
Upper limit 2400cc/24hrs

*Nelsons Text book of pediatrics 19th edition

 Maintenance Fluids
Hourly Maintenance Fluid Requirement*

“4 - 2 -1 rule”
WEIGHT FLUID
0 - 10 kg 4 ml/kg/hr

10 - 20 kg 40ml/hr + 2 ml/kg/hr

> 20 kg 60ml/hr + 1 ml/kg/hr

Upper limit 100cc/hr

*Nelsons Text book of pediatrics 19th edition

CONCEPT OF MAINTENANCE OF
ELECTROLYTES
 Insensible water loss contains no electrolytes*

 So, sodium & potassium present in the urine, stools

& sweat would be the amount to be replaced plus
the sodium & potassium required for normal
metabolism of the body.

 3mEq of sodium in 100 cc of fluid

&
 2mEq of potassium in 100 cc of fluid

*IAP text book of Pediatrics 5th edition

CONCEPT OF MAINTENANCE OF GLUCOSE*
 Maintenance fluids usually contains 5% dextrose (5
gm/100ml) providing 17 calories/ 100 ml of fluid.

 Which is approx. 20% of the daily caloric needs.

 Prevents ketone production.

*Nelsons Text book of pediatrics 19th edition

 COMMONLY USED FLUIDS FOR
MAINTENANCE*
I. 0.9% Normal Saline – Think of it as ‘Salt and water’
 Principal fluid used for intravascular resuscitation and replacement of
salt loss e.g diarrhoea and vomiting

 Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l; K+ - Absent, But

K+ is often added

 IsoOsmolar compared to normal plasma

 Distribution: Stays almost entirely in the Extracellular space

 Does not provide free water or calories. Restores NaCl deficits.

*The Harriet Lane Handbook 19th edition

CONTENTS OF IV FLUID PREPARATIONS*
Na K Cl HCO3 Dextrose mOsm/L
(mEq/L) (mEq/L) (mEq/L) (mEq/L) (gm/L)

NS 154 154 308

DNS 154 154 50 564
½ NS 77 77 143
5%D + 77 77 50 350
1/2NS

D5W 50 278

Ringers 130 4 109 28 50 273

Lactate
(RL)
Iso P 23 20 23 30 50 367

Iso M 37 35 37 30 50 415.5

*The Harriet Lane Handbook 19th edition

 COMMONLY USED FLUIDS FOR MAINTENANCE
II. Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L.

 Contains 130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate, and 4
mEq/L K+, 3 mEq/L Ca++

 Lactate is used instead of bicarb because it's more stable in IVF

during storage.

 Lactate is converted readily to bicarb by the liver.

 Has minimal effects on normal body fluid composition and pH. More
closely resembles the electrolyte composition of normal blood serum.

 Does not provide calories.

HOW TO CHOOSE?*
0.9% sodium chloride Suitable for initial volume resuscitation in hypovolaemia
and for ongoing fluid therapy in older children with
normal serum glucose. Fluid of choice in patients with
head injury

5% dextrose + 0.9% Suitable for ongoing fluid therapy in infants and

sodium children, including post-operative cardiac patients. Use
chloride in head injured patients with hypoglycaemia.

5% dextrose + 0.45% Suitable for ongoing fluid therapy in infants and

sodium children, including post-operative cardiac patients
chloride

10%dextrose + 0.45% Suitable for ongoing fluid therapy in neonates or older

sodium infants who are hypoglycaemic, including post-operative
chloride cardiac patients

*Leeds Teaching Hospitals NHS Trust Paediatric Intensive Care Units

MONITORING WHILE ADMINISTERING FLUIDS*
 Child should be weighed prior to the commencement of
therapy, and daily afterwards.

 Children with ongoing dehydration/ongoing losses may

need 6 hourly weights to assess hydration status

 All children on IV fluids should have serum electrolytes

and glucose checked before commencing the infusion
(typically when the IV is placed) and again within 24 hours
if IV therapy is to continue.

*Royale Children’s Hospital Melbourne Guidelines

MONITORING WHILE ADMINISTERING FLUIDS*
 For more unwell children, check the electrolytes and
glucose 4-6 hours after commencing, and then according
to results and the clinical situation but at least daily.

 Pay particular attention to the serum sodium on measures

of electrolytes. If <135mmol/L (or falling significantly on
repeat measures) If >145mmol/L (or rising significantly on
repeat measures)

 Children on iv fluids should have a fluid balance chart

documenting input, ongoing losses and urine output.

*Royale Children’s Hospital Melbourne Guidelines

MAINTENANCE FLUIDS & HYPONATREMIA*
 Production of ADH leading to water retention
leading to water intoxication.

 Patients producing ADH due to subtle volume

depletion can be safely treated with fluids
containing higher sodium concentration, decrease
in fluid rate or the combination of both.

 Persistent ADH production due to underlying

disease requires less than total maintenance fluids

 Individualization & careful monitoring is must.

*Nelsons Text book of pediatrics 19th edition

 VARIATIONS IN MAINTENANCE WATER &
ELECTROLYTES
Source Causes of increased water Causes of decreased water
needs needs
Skin Radiant warmer Incubator
Phototherapy
Fever
Sweat
Burns
lungs Tachypnea Humidified ventilator
Tracheastomy
GI tract Diarrhea
Vomiting
Nasogastric secretion
renal Polyuria Oligo/anuria
Misc. Surgical drain hypothyroidism
Third spacing
REPLACEMENT FLUIDS*
 In addition to normal maintenance fluid
requirements, unwell children may need:

 Fluid resuscitation for shock

 Replacement of pre-existing fluid losses

 Replacement of ongoing fluid losses

*Royale Children’s Hospital Melbourne Guidelines

REPLACEMENT FLUIDS*

 GI losses are accompanied with loss of potassium,

bicarbonate leading to metabolic acidosis.

 Impossible to predict the loses for next 24 hrs, so

measure & replace excess GI losses as they occur.

 So each ml of the diarrheal stool or the vomitus

should be replaced by the same amount every 1 to
6 hourly.

*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Diarrhea*
Average composition of Diarrheal stools (except cholera)

Na 55 mEq/l
K 25 mEq/l
Bicarbonate 15 mEq/l

Approach to Replacement of Ongoing Losses

D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl

Replace stools ml/ml every 1 to 6 hrs

*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Emesis or Nasogastric losses*
Average composition of Gastric Fluid

Na 60 mEq/l
K 10 mEq/l
Chloride 90 mEq/l

Approach to Replacement of Ongoing Losses

NS + 10 mEq/l KCl

Replace Output ml/ml every 1 to 6 hrs

*Nelsons Text book of pediatrics 19th edition

REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria / Anuria

Place patient on insensible fluids (25 to 40% of maintenance)

Replace Urine output ml/ml by half NS

Polyuria

Place patient on insensible fluids (25 to 40% of maintenance)

Measure urine electrolytes

Replace Urine output ml/ml by solution based on measured urine

electrolytes
*Nelsons Text book of pediatrics 19th edition
CASE I
 5 day old baby boy weighing 3 kg having total
billirubin 18.0 is to be kept under phototherapy.
Baby having no other risk factors & accepts DBM
well.

 What fluid at what rate should we prescribe?

 Rate Day 5 (150 ml/kg/day)
 Weight 3 kg

 So,
 150 * 3 = 750 ml is the total maintainence.

 For the babies under phototherapy we should give

half of the maintainence.

 So 375 ml/24 hrs i.e 125 ml / 8hrly

 Fluid of choice is 5% dextrose + 0.45% NS or iso P
will also be suitable.
CASE II
 7 year old girl (weight 20 kg) admitted for
bronchopneumonia with respiratory rate of 44/min &
fever of 102 F. later developed 4 episodes of
vomiting (each of 25 ml quantity) & loose stools 3
episodes (each of 80 ml quantity)
 Weight 20 kg.
 So, Total maintenance fluid will be

 (100*10) + (50*10) = 1500 ml/ day i.e 500 ml / 8 hrly

 Choice of fluid will be 0.45% DNS + 20mEq/L KCl

 Replacement fluid for vomiting (each of 25 ml quantity) =

25 * 4 =100 ml of NS + 10 mEq/l KCl

 Replacement fluid for loose stools (each of 80 ml

quantity) = 80 * 3 =240 ml of 0.2% DNS + 20 mEq/l
sodium bicarbonate + 20 mEq/l KCl.
TACHYPNEA
 Respiratory Alkalosis

 Increase in rate and

depth of breathing

 Loss of CO2

Causes of hyperventilation (tachypnea): Fear, pain, fever, CHF,

anemia
FEVER
 Each degree of fever increases basal
metabolic rate (BMR) 10%, with a
corresponding fluid requirement
VOMITING
 Metabolic Alkalosis
 Loss of acid from stomach

 pH
 HCO3
 H+

 Treatment: Prevent further losses and replace lost

electrolytes
DIARRHEA
 Metabolic Acidosis
 loss of HCO3 from G.I. Tract

 pH
 HCO3
 Treatment: Correct base
deficit, replace losses of
with NaHCO3
TAKE HOME MESSAGE
 Fluid is like “prescription” so give it with caution.

 Children are more vulnerable for rapid fluid loss.

 Maintenance calculation by “4-2-1” rule or Holliday Segar’s

formula.

 Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM

SODIUM CONCENTRATION while giving fluid is must.

 As far as possible try to give maintenance fluid requirement

orally.

 0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children

requiring maintenance therapy.

 Replacement of fluids should be prompt & appropriate.

!! THANK YOU !!