Fluid Replacement in

Pediatric Clients
Based on the Consensus Statements on Parenteral Fluid Therapy in
Infants, Children, & Adolescents by the Philippine Pediatric Society (PPS)

Roger Carlo P. Pineda, M.D.

Post-Graduate Intern
FUMC-Department of Pediatrics
 For Fluid Therapy during
Resuscitation please refer to the
lecture presentation of
Dr. Greggy Aaron M. Sison.
Parenteral Fluid Therapy
on Rehydration and
Redistribution
 Parenteral Fluid Therapy on
Rehydration and Redistribution

• GENERAL RULE:

• Previously healthy and well-nourished pediatric pt

requiring initial parenteral fluid rehydration, use a
dextrose-containing crystalloid solution (Na: 77-140
mmol/l)*

• CALCULATE: DAILY TOTAL VOLUME = Antecedent

net deficit fluid loss PLUS maintenance water
requirement
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• CAUTION:

• Dextrose-containing sol’ns with Na < 77 mmol/l as initial parenteral

fluid therapy for > 24 hrs. may cause DEC. of SERUM NA esp. in
conditions with non-osmotic release of vasopressin. Such as in:

• ECF contraction
• Hypoxia
• Perioperative states
• Neurologic disorders
• Pulmonary diseases
• Hema-onco conditions
• Anesthetics and anti-Ca drugs
• Fever, stress, pain and nausea
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• CAUTION:

(+) Risk of
• Dextrose-containing water retention
sol’ns with Na assoc.
< 77 mmol/l as initial parenteral
fluid therapy for > 24 hrs. may cause DEC. of SERUM NA esp. in
with
conditions with said
non-osmoticconditions use:
release of vasopressin. Such as in:

• ECF contraction
• Hypoxia
Dextrose-containing
• Perioperative states crystalloid
• Neurologic disorders
solution
• Pulmonarywith
diseases Na 130-140 mmol/l at
• Hema-onco conditions
full
• maintenance
Anesthetics and anti-Ca drugs and deficit rate
• Fever, stress, pain and nausea
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• CALCULATE:

• Antecedent net deficit fluid loss = Approximate fluid

deficit MINUS initial resuscitation fluid bolus

MILD MODERATE SEVERE

AGE
(3-5% fluid deficit) (6-10% fluid deficit) (9-15% fluid deficit)

INFANT 50 ml/kg 100 ml/kg 150 ml/kg

CHILD/ADOLESCENT 30 ml/kg 60 ml/kg 90 ml/kg

 Parenteral Fluid Therapy on
Rehydration and Redistribution

• ADMINISTER:

• 50% of net fluid deficit PLUS 1/3 of estimated

maintenance water requirement in the FIRST 8
HOURS

• The remaining volume is administered in the next 16

HOURS
 Parenteral Fluid Therapy on
Rehydration and Redistribution

• CALCULATE:

• DAILY MAINTENANCE WATER REQUIREMENT:

“ Maintenance fluid replacement therapy: restoring daily

losses of water and electrolytes occurring via
physiologic processes which normally preserve
homeostasis. These losses come from urine, sweat,
stool, and respiration.”
 Parenteral Fluid Therapy on
Rehydration and Redistribution

• CALCULATE:

• DAILY MAINTENANCE WATER REQUIREMENT

1. Crawford Body Surface Area Method

2. Holliday-Segar Weight-Based Method

3. Ludan (Modified Finberg) Basal Caloric

Expenditure Method
 Parenteral Fluid Therapy on
Rehydration and Redistribution

• DAILY MAINTENANCE WATER REQUIREMENT

1. Crawford Body Surface Area Method:

1500 ml/m2

where m2=

weight (kg) x length (cm)

3600
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• DAILY MAINTENANCE WATER REQUIREMENT

• Crawford Body Surface Area Method:

• assumes caloric expenditure = surface area

• accurate in children with BW > 10 kgs.

• can be used in diseases with abnormal losses (e.g.,

critically-ill, AKI, CKD, malignancy and severe sepsis)

• did not gain popularity due to difficulty but is most

precise
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• DAILY MAINTENANCE WATER REQUIREMENT

2. Holliday-Segar Weight-Based Method:

WEIGHT COMPUTE:

1-10 kgs 100 ml/kg

1000 ml + 50 ml/kg for each

11-20 kgs kg > 10 kg

1500 ml + 20 ml/kg for each

> 20 kgs
kg > 20
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• DAILY MAINTENANCE WATER REQUIREMENT

• Holliday-Segar Weight-Based Method

• Rate of expenditure of hospitalized children = weight with the

needs for water at 100 ml per 100 calories

• Assumes energy use of sick children is roughly midway bet.

basal and normal metabolic rates

• Based on evidence, overestimates energy expenditure by

more than half.

• Not for NB < 14 d/o, pts. w/ abn’l urine or GI losses, obese

children or those w/ inc. metabolism due to severe infections.
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• DAILY MAINTENANCE WATER REQUIREMENT

3. Ludan (Modified Finberg) Basal Caloric

Expenditure Method
WEIGHT COMPUTE:

3-10 kgs 100 ml/kg

10-20 kgs 75 ml/kg
20-30 kgs 50-60 ml/kg
30-60 kgs 40-50 ml/kg
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• DAILY MAINTENANCE WATER REQUIREMENT

• Ludan (Modified Finberg) Basal Caloric Expenditure

Method

• Needs for water at 100 ml per 150 calories

• The overestimation is to account for changes in

dynamic activity, growth, body temperature and
respiration

• More conservative than H-S but is only applied

locally
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• CAUTION:
Infants and children with AGE, consider net
•fluid deficit as sol’ns
Dextrose-containing rapid
withrehydration
Na < 77 mmol/l asin 6 hours.
initial parenteral
fluid therapy for > 24 hrs. may cause DEC. of SERUM NA esp. in
conditions with non-osmotic release of vasopressin. Such as in:
Mild DHN: dextrose-containing crystalloid
• ECF contraction
solution (DCCS) with Na: 51-77 mmol/l for max.
• Hypoxia
• Perioperative states 6 hrs.
• Neurologic disorders
• Pulmonary
Mod. to [Link]
DHN: give 1/4-1/3 in 1 hr. of DCCS
•
with
Hema-onco conditions
Na: 130 mmol/l; remaining 3/4-2/3 in the
• Anesthetics and anti-Ca drugs
next
• Fever, 5-6pain
stress, hrs.
andwith
nauseaNa: 51-77 mmol/l
 Parenteral Fluid Therapy on
Rehydration and Redistribution
• CALCULATE:

• Identify factors that affect insensible water loss and

adjust total fluid requirement accordingly.

INCREASED DECREASD
% CHANGE % CHANGE
Losses Lossess

Hyperventilation 20-30 Use of humidified air 15-30

Increased activity 5-25 Decreased activity 5-25
Hyperthermia 12% per C Hypothermia 5-15
Sedation 5-25
 Parenteral Fluid Therapy on
Rehydration and Redistribution
Patients with protracted course of
illness of 3 days or > and unable to
take anything P.O.:

Consider incorporating 20 mmol of

KCL per liter in the maintenance
sol’n with adequate urine output
Fluid Therapy on
Replacement
 Fluid Therapy on
Replacement
• GENERAL RULE:

• Previously healthy and well-nourished pediatric pt with

on-going fluid losses, attempt replacement via the
ENTERAL ROUTE first using reduced osmolarity
ORS.

• To be given volume per volume every 1-4 hours or

until concurrent losses cease.

• AVOID sports drinks/non-physiologic soln’s as

replacements.
 Fluid Therapy on
Replacement
• CALCULATE:

• VOLUME OF ORS for DIARRHEAL LOSSES

AGE (YEARS) Volume of ORS to be given in ml

CHILDREN < 2 years 50-100 ml per loose stool

2-10 years 100-200 ml per loose stool
10 years and older As much as they want
 Fluid Therapy on
Replacement

• ADMINISTER:

• ORAL REHYDRATING SOLUTION:

“ A solution of glucose-based salt solution used in oral

rehydration therapy, to treat or prevent dehydration from
diarrhea.”
Fluid Therapy on
Replacement

Source: WHO
Fluid Therapy on
Replacement

Source: WHO
 Fluid Therapy on
Replacement
• IF
CAUTION:
the ENTERAL ROUTE is NOT FEASIBLE or
• Dextrose-containingNOTsol’nsTOLERATED:
with Na < 77 mmol/l as initial parenteral
fluid therapy for > 24 hrs. may cause DEC. of SERUM NA esp. in
conditions with non-osmotic release of vasopressin. Such as in:
Use a dextrose-free crystalloid sol’n (DFCS) with
• ECF contraction
Na: 130-154 mmol/l given volume per volume
• Hypoxia
every
• 1-4 hrs.
Perioperative or
states until ongoing losses cease.
• Neurologic disorders
•Choice
Pulmonaryof replacement sol’n is based on
diseases
• Hema-onco conditions
electrolyte composition of ongoing body fluid
• Anesthetics and anti-Ca drugs
loss
• Fever, stress, pain and nausea
 Fluid Therapy on
Replacement
• ADMINISTER: RECOMMENDED REPLACEMENT
FLUID FOR THE TYPE OF BODY FLUID LOSS

Fluid Loss Replacement Fluid

Gastric via vomiting and nasogastric losses 0.9% NaCl +/= 10 mmol/l KCL

Diarrhea or excess colostomy loss Lactated Ringer’s

Surgical drains (pancreatic drain or fistula, small

0.9% NaCl or Lactated Ringer’s
bowel stoma or fistula, bile drain) & chest tubes
0.9% NaCl or Lactated Ringer’s
Third space losses (burns)
or 5% Albumin

Polyuria 0.9% NaCl +/= KCL

Lactated Ringer’s, Sterofundin

Blood loss (if blood products are unavailable)
or 0.9% NaCl KCL
 Fluid Therapy on
Replacement
• CAUTION:
IF there is EXCESSIVE LOSSES
• Dextrose-containing sol’ns with Na < 77 mmol/l as initial parenteral
and
fluid therapy for > 24CONCOMITANT
hrs. may cause DEC. of SERUM NA esp. in
conditions with non-osmotic release of vasopressin. Such as in:
LABORATORY
• ECF contraction
DERANGEMENT
UNRESPONSIVE to initial
• Hypoxia
• Perioperative states
measures:
• Neurologic disorders
• Pulmonary diseases
• Hema-onco conditions
•
REFER TO PEDIATRIC
Anesthetics and anti-Ca drugs
SPECIALIST
• Fever, stress, pain and nausea
Fluid Therapy on
Removal
Fluid Therapy on Removal
• GENERAL RULE:

• Previously healthy and well-nourished pediatric pt with

on parenteral fluid > 24 hrs., asses the need for
continued IVF therapy.

• STOP bolus administration if the child shows:

• circulatory improvement

• develop signs of fluid overload (worsening resp.

status, rales, gallop rhythm and hepatomegaly)
Fluid Therapy on Removal

• GENERAL RULE:

• Base succeeding parenteral fluid prescription based

on:

• weight

• blood pressure

• serum Na and glucose levels

Fluid Therapy on Removal
• GENERAL RULE:

• If there is (+):

• Increase in pre-illness weight > 5%

• Hypertension

• Edema

• What to do?

• Decrease Na content of current IVF

Fluid Therapy on Removal
• GENERAL RULE:

• If pt. is EUVOLEMIC but serum Na < 135

• What to do?

• Decrease drip rate to 50-80% of maintenance water

requirement

• If pt. is EUVOLEMIC but serum Na > 145

• What to do?

• Decrease Na content of current IVF to < 77 mmol/l and infuse

maintenance rate plus 30-50 ml/kg for 48 hrs.
Fluid Therapy on Removal
• GENERAL RULE:

• For excessive URINARY LOSSES:

• What to do?

• Initially replace volume per volume

• If input = urine output, decrease volume replacement to 50-75% or

measured urine volume

• If there is POSITIVE FLUID BALANCE, INC. PRE-ILLNESS WEIGHT or EDEMA

• What to do?

• Discontinue any volume per volume replacement or consider giving

diuretics
Fluid Therapy on Removal
• CAUTION:
Maximum volume in a 24-hr
• Dextrose-containing sol’ns with Na < 77 mmol/l as initial parenteral
fluid therapy for > 24 [Link]:
may cause DEC. of SERUM NA esp. in
conditions with non-osmotic release of vasopressin. Such as in:

• ECF contraction
• Hypoxia 2500 ml
• Perioperative states
• Neurologic disorders
• Pulmonary diseases
• Hema-onco conditions2000 ml
• Anesthetics and anti-Ca drugs
• Fever, stress, pain and nausea
Fluid Therapy on Removal
When to DISCONTINUE?

Pt. is able to tolerate at least 75%of maintenance

water requirement via:

Enteral fluids

Able to eat

Or has an appetite
Fluid Therapy on Removal
Always remember R.O.S.E.

Resuscitation phase:
bolus; salvage treatment; life-saving; bolus fluid; IV
Optimization phase:
unstable; compensated shock; tissue perfusion;
fluid over hours; IV
Stabilization phase:
stable; volume per volume; organ support; Oral
Evacuation phase:
fluids removed; organ recovery; negative fluid balance
TAKE HOME MESSAGE:

• Know when to resuscitate

• Know when to stop giving fluids
• Know when to de-resuscitate
• Give the right fluid
• At the right time
• And the right manner
 Thank you very much!

For questions, comments, suggestions:

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