FETUS TERM INFANT PREMATURE INFANTS 1ST YEAR OF LIFE PUBERTY

high TBW 75% of the weight higher TBW than term infants 60% of the body weight until puberty the fat content of girls increases more than boys who acquire more muscle mass; 60% in boys, 50% in girls.

TOTAL BODY WATER HAS 2 COMPARTMENTS:

1.) INTRACELLULAR FLUID (ICF) 2.) EXTRACELLULAR FLUID (ECF)

FIGURE 45 2:

Intracellular (30 40%)

Interstitial (15%)

Extracellular (20 25%)

Figure 45-2. Compartments of total body water, expressed as a percentage of body weight, in an older child or adult

Plasma (5%)

DIFFERENCE
- between anions in the ICF and the ECF is largely determined by the presence of intracellular molecules that do not cross the cell membranes

OSMOLALITY
- clinically, the primary process is usually a change in the osmolality of the ECF with a resultant shift of water into the ICF if the ECF osmolality decreases OR a shift of water out of the ICF if the ECF osmolality increases.
- plasma osmolality is normally 285 295 mOsm/kg OSMOLALITY = 2 x [Na] + [Glucose] / 18 = [BUN]/2.8

EFFECTIVE OSMOLALITY = 2 x [Na] + [Glucose] /18

- tonicity - determines the osmotic force that is mediating the shift of water between the ECF and ICF - normally the measured osmolality and the calculated osmolality are within 10 mOsm/kg

OSMOLAL GAP
- difference between measured and calculated osmolality, the measured osmalality is > 10 mOsm/kg than calculated osmolality - if present is a clinical clue to the presence of unmeasured osmoles in poisoning with methanol and ethylene glycol

REGULATION OF OSMOLALITY
- the plasma osmolality is tightly regulated to maintain it between 285 and 295 mOsm/kg

MAINTENANCE WATER RATE

0 10 kg: 4 ml/kg/hr

10 20 kg: 40 ml/hr + 2 ml/kg/hr x (wt 10 kg)

>20 kg : 60 ml/hr +1 ml/kg/hr x (wt 20 kg)

Table 46 1:
TABLE 46 1. Body Weight Method for Calculating Maintenance Fluid Volume ` Body Weight Fluid per Day
0 10 kg 11 20kg > 20kg 100mL/kg 1,000mL + 50mL/kg for each kg > 10kg 1,500 mL + 20 mL/kg for each kg > 20kg*

* The maximum total fluid per day is normally 2, 400 mL

Box 46 -2:
BOX 46 2. Maintenance Water Rate
0 10kg: 4mL/kg/hr 10 20 kg: 40mL/hr + 2mL/kg/hr x (wt 10kg) >20 kg: 60 mL/hr + 1mL/kg/hr x (wt 20kg)*
* The maximum fluid rate is normally 100mL/hr.

FLUID MANAGEMENT OF DEHYDRATION

RESTORE INTRAVASCULAR VOLUME Normal Saline: 20 ml/kg over 20 minutes (repeat until intravascular volume restored) CALCULATE 24 HOUR WATER NEEDS Calculate maintenance water Calculate deficit water CALCULATE 24 HOUR ELECTROLYTE NEEDS Calculate maintenance sodium and potassium Calculate deficit sodium and potassium

FLUID MANAGEMENT OF DEHYDRATION

Select an appropriate fluid (based on total water and electrolyte needs)

- Administer half the calculated fluid during the 1st 8 hrs, 1st subtracting any boluses from this amount - Administer the remainder over the next 16 hrs.

Replace ongoing losses as they occur.

MAINTENANCE ELECTROLYTES
- Na, K and Cl are given in MF to replace losses from urine and stool - designed not to stress the bodys homeostatic mechanisms and to minimize the development of electrolyte imbalances - adequate Cl is provided if Na and K are given as Cl salts.

- Sodium = 2 3 mEq/kg/24 hrs; Potassium = 1 2 mEq/kg/24 hrs

GLUCOSE
- MF usually contain 5% dextrose which provides 17 cal per 100 ml and close to 20% of the daily caloric needs enough to prevent ketone production and minimize protein degration.

INTRAVENOUS SOLUTIONS

TABLE 46-2: TABLE 46 2. Composition of Intravenous Solutions

Fluid Normal saline (0.9% NaCl) Normal saline (0.45% NaCl) Normal saline (0.225% NaCl) Ringers lactate [Na+] 154 77 38.5 130 [ Cl- ] 154 77 38.5 109 [K+] [Ca2+] [Lactate-]

28

TABLE 46-3: TABLE 46 3. Adjustments in Maintenance Water

Source Skin Causes of Increased Water Needs Radiant warmer Fever Sweet Burns Tachypnea Tracheostomy Diarrhea Emesis Nasogastric suction Polyuria Surgical drain Third spacing Oliguria/anuria Hypothyroidism Causes of Decreased Water Needs Mist tent

Lungs

Humidified ventilator Mist tent

Gastrointestinal tract

Renal Miscellaneous

FACTORS MODIFYING FLUID REQUIREMENTS

______________________________________________________________________________

CONDITION
Extra Needed Fever Sustained hyperventilation or excessive muscular activity as in seizures, chills Hypermetabolic states severe thermal injury, salicylate intoxication, thyrotoxicosis burns on first day (4% increase per 1% area burnt), subsequent days Abnormal water and electrolyte losses as in diarrhea and vomiting Sweating Room temperature >31 C newborn under radiant warmer or phototherapy Full activity and oral feeds

ADJUSTMENT NEEDED
12% for each C above 37.5 C 25 50%

25 75% 2% increase per 1% area burnt volume per volume 10 25% 30% per C rise 25%

FACTORS MODIFYING FLUID REQUIREMENTS

_______________________________________________________________________

CONDITION Less Required Hypothermia Very high humidity Humidified inspired air Oliguria or anuria Sedated or paralyzed patient Edematous and antidiuretic state

ADJUSTMENT NEEDED 12% per each C below 37.5 C 30% 25% case-to-case basis 40% due to reduced energy expenditure

BOX 46 5
BOX 46 5. ADJUSTING FLUID THERAPY DIARRHEA
AVERAGE COMPOSITION OF DIARRHEA
Sodium: 55 mEq/L Potassium: 25 mEq/L Bicarbonate: 15 mEq/L

APPROACH TO REPLACEMENT OF ONGOING LOSSES

Solution: D5 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl Replace stool mL/mL every 1 6 hr

b.) LOSS OF GASTRIC FLUID (through emesis and NG suction)

BOX 46 6. Adjusting Fluid Therapy for Emesis or

Nasogastric Losses

AVERAGE COMPOSITION OF DIARRHEA

Sodium: Potassium: Chloride: 60 mEq/L 10 mEq/L 90 mEq/L

APPROACH TO REPLACEMENT OF ONGOING LOSSES

Solution: D5 NS + 10 mEq/L KCl Replace output mL/mL every 1 6 hr

c.) URINE OUTPUT - the largest cause of water loss - renal failure and SIADH can lead to decreased urine output, i.e., decreased need - post-obstructive diuresis, polyuric phase of ATN, DM and DI are examples of increased urine output thus increase need
-

BOX 46 7. Adjusting Fluid Therapy for Altered Renal Output

OLIGURIA/ANURIA
Place the patient on insensible fluids (1/3 maintenance) Replace urine output mL/mL with NS

POLYURIA
Place the patient on insensible fluids (1/3 maintenance) Measure urine electrolytes Replace urine output mL/mL with a solution that is based on the measured urine electrolytes

DEFICIT THERAPY
- dehydration from diarrhea is common problem in children - the first step in caring for the child with dehydration is to assess the degree of dehydration

Mild dehydration (3 5%): normal or increased pulse, decreased urine

output, thirsty, normal physical examination

Moderate dehydration (7 10%): tachycardia, little or no urine output,

irritable/lethargic, sunken eyes and fontanel, decreased tears, dry mucous membranes, mild tenting of the skin, delayed capillary refill, cool and pale

Severe dehydration (10-15%): rapid and weak pulse, decreased blood

pressure, no urine output, very sunken eyes and fontanel, no tears, parched mucous membranes, tenting of the skin, very delayed capillary refill, cold and mottled

CALCULATION OF DEFICITS
BOX 47 2. Calculation of Deficit Water and Electrolytes WATER DEFICIT
Percent dehydration x weight

SODIUM DEFICIT
Water deficit x 80 mEq/L

POTASSIUM DEFICIT
Water deficit x 30 mEq/L

MAINTENANCE ELECTROLYTE REQUIREMENTS

a generous estimation for electrolyte maintenance therapy is 2.5mmol of Na+ and K+ per 100 calories expended (exceptions: sweating, vomiting and diarrhea, surgical drainage tubes, burns, diuretic therapy and renal electrolyte losing disorders). daily electrolyte requirements:

Na+ = 2.5 3.0 mmol/100 cal/day K+ = 2.0 2.5 mmol/100 cal/day Cl= 4.5 5.5 mmol/100 cal/day

HYPONATREMIC DEHYDRATION (Na <130 mEq/L)

- usually due to a combination of Na and water loss and water retention to compensate for the volume depletion. - Initial goal: correction of IV volume depletion with isotonic fluid (NSS or LR) - To calculate Na deficit: Na deficit = 0.6 x Wt. x (NaD NaA) - avoid increasing the Na by >12 mEq/24 hrs: given over the 1st 8 hrs and replace on-going losses

HYPERNATREMIC DEHYDRATION (Na <130 mEq/L)

- the most dangerous form of DHN - avoid decreasing the Na by >12 mEq/24 hrs - treatment: (1) Restore intravascular volume NS: 20 ml/kg over 20 min Repeat until IV volume is restored
(2) Determine the time for correction based on the initial Na concentration mEq/L: 24 hrs mEq/L: 48 hrs hrs mEq/L: 84 hrs

Na = 145 157
Na = 158 170 Na = 171 183 mEq/L: 72 Na = 184 196

HYPONATREMIC DEHYDRATION (Na <130 mEq/L)

(3) Administer fluid at a constant rate over the time for correction D5 NS or D5 NS (both with 20 mEq/L KCI unless contraindicated) at 1.25 1.5 x maintenance (4) Follow serum Na concentration and adjust fluid based on clinical status and serum Na concentration Signs of volume depletion: NS 20ml/kg Na decreases too rapidly: Increase Na of IV or decrease IVF rate Na decreases too slowly: Decrease Na of IV or increase IVF rate (5) Replace on going losses as they occur.

HYPOKALEMIA (K < 3.5 mEq/L)

- neuromuscular: most common clinical manifestation - cardiac: most dangerous complication - therapy:

(1) Mild hypokalemia in asymptomatic patients may not require specific therapy. If taking digitalis, give K supplements.

HYPOKALEMIA (K < 3.5 mEq/L)

(2) If K deficit is severe with symptoms, IV replacement is necessary: a) Via peripheral vein, not > 40 mmol/L b) Via central vein, 80 mmol/L with monitoring c) Rate: not >0.2 - 0.3mmol/kg/hr or 1mmol/kg/hr in life-threatening cardiac arrhythmias in the ICU. d) K repletion always started once patient has voided e) Computation: (DESIRED ACTUAL) x wt x 0.4 +

maintenance

HYPERKALEMIA (K > 5 mmol/L)

- complications: neuromuscular and cardiac - therapy: (1) 10% Ca gluconate 0.5 -1 ml/kg in 2 10 min IV with CR monitoring (2) NaHCO3 1 -2 mmol/kg BW in 10 -30 min IV (3) D50W 0.5 1 g/kg or 1 cc/kg BW + Regular Insulin 0.1 U/kg in 15 30 min IV (4) Salbutamol or other B2 agonists by nebulization (5) Na polystyrene sulfonate (Kayexalate) 1g/kg BW/dose PO or per rectum diluted with 2 4ml Sorbitol or D10W every 4 -6 hrs 0.9% NaCl 10 20 ml/kg in 45-60 min IV:

(Ca < 9.0 mg/dl beyond neonatal period) - manifestations: tetany, seizures, laryngospasm - therapy: (1) if patient is symptomatic: a) elemental Ca/ml) min with CR 10% Ca gluconate (9.2 mg 0.5ml 1.0ml/kg IV over 3 5

HYPOCALCEMIA

monitoring

b) Maintenance 10% Ca gluconate should

follow IV bolus once symptoms are relieved. elemental Ca/kg/hr added Dose: 100mg

to the IVF

(Ca < 9.0 mg/dl beyond neonatal period)

HYPOCALCEMIA

c) Oral Ca supplements (50 mg elemental Ca/kg/day) Dose: 0 3 YO 10 25ml 4 12 YO 30 45ml Ca lactate (13% Ca by weight) Ca gluconate (9% Ca by weight) Ca chloride (21% Ca by weight) In severe Ca deficiency, Ca may be given up to daily doses of 75ml.

(Ca < 9.0 mg/dl beyond neonatal period)

HYPOCALCEMIA

(d) When Mg deficiency is suspected or

confirmed, give Mg Dose: 0.25 mmol/kg or 0.125 ml/kg of 50% MgSO4 IM (1g contains 99 mg Mg or about 4 mmol)

(Ca < 9.0 mg/dl beyond neonatal period)

HYPOCALCEMIA

(2) If patient is asymptomatic, oral Ca supplements should be given and patients admitted for work up.
(3) In all cases, milk should be changed to a low phosphate milk.

HYPERCALCEMIA (Ca >11 mg/dl)

- manifestations: seizures, weakness, bradycardia - therapy: (1) For symptomatic patients, initial emergency treatment is the infusion of saline at a rate 2x maintenance ff by Furosemide 1-2 mg/kg bolus every 6 8 hrs (depends on normal kidney function).

HYPERCALCEMIA (Ca >11 mg/dl)

(2) In patients with no pre existing cardiac disease, the subsequent amount of saline may be given at 2 3x daily maintenance until serum Ca returns to normal or depends on the hydration status of the patient.

HYPERCALCEMIA (Ca >11 mg/dl)

(3) For vitamin D intoxication, infuse PO4 or SO4 salts ff by oral prednisone (1 -2 mg/kg/day). (4) In malignancy, mithramycin at 25 ug/kg IV may be given. (5) For oliguric ARF, PD or HD is indicated

Electrolyte and Acid Base Disorders

TABLE 45 3. Appropriate Compensation During Simple Acid Base Disorders

Disorder
Metabolic acidosis Metabolic alkaosis
Respiratory acidosis Acute Chronic Respiratory alkalosis Acute Chronic

Expected Compensation
Pco2 = 1.5 x [HCO3-] + 8 + 2 Pco2 increases by 7 mm Hg for each 10 mEq/L increase in the serum [HCO3-]
[HCO3-]increases by 1 for each 10 mm Hg increase in the Pco2 [HCO3-]increases by 3.5 for each 10 mm Hg increase in the Pco2 [HCO3-] falls by 2 for each 10 mm Hg decrease in the Pco2 [HCO3-] falls by 4 for each 10 mm Hg decrease in the Pco2

ARTERIAL BLOOD GASES

I. Normal values of ABG
1.) pH 7.35 7.45 2.) pCO2 35 45 3.) [HCO3] 22 28 4.) BE (-) 3 (+) 4 5.) pO2 85 100

II. Definition of different blood gas abnormalities

1.) Acidosis 2.) Alkalosis 3.) Respiratory acidosis 4.) Respiratory alkalosis 5.) Metabolic acidosis 6.) Metabolic alkalosis pH < 7.35 pH >7.45 pCO2 > 45 pCO2 < 35 [HCO3] < 24 with dec BE [HCO3] > 24 with inc BE

III. Metabolic acidosis low pH with low [HCO3] and BE

A. Types BE 1.) Uncompensated pH pCO2 [HCO3]

2.) Partly compensated 3.) Compensated 7.35-7.4 A. Types

IV. Metabolic alkalosis - high pH with high [HCO3] and BE

pH pCO2 [HCO3]

BE 1.) Uncompensated

2.) Partly compensated 3.) Compensated 7.4-7.45

V. Respiratory Acidosis high pCO2

A. Types BE 1.) Uncompensated pH pCO2 [HCO3]

7.35-7.4

N
2.) Compensated

VI. Respiratory Alkalosis low pCO2

A. Types BE 1.) Uncompensated 2.) Compensated pH pCO2 [HCO3]

7.4-7.45

URINALYSIS

- a valuable diagnostic aid for the evaluation of patients with renal disease. - collection: aseptic technique

INTERPRETATION
(1) COLOR
- normal urine is of amber in
color but may appear lighter ff intake of large volume of fluid

CONDITIONS ASSOCIATED WITH ABNORMAL URINE COLOR

COLOR
Red Blood Hemoglobin Myoglobin Porphyrins Indicator of dye such as phenolphthalein (Exlax) Beets Blackberries Rhubarb, anthraquinone laxatives, some diagnostic dye Other: acetophenetidin, acrolie, aminopyrine, anisindione, antipryine, rhubarb, benzene, BSP, cascara, chincophen, crysarobin, Congo Red, crayon pigment, danthron, ethoxazene, mercurochrome, phenazopyridine, deferoxamine, indanediones, phenidione, emodin, phenothiazines, PSP, phenytoin, senna
MDS Metro Lab, 2006

CAUSE

CONDITIONS ASSOCIATED WITH ABNORMAL URINE COLOR

COLOR
Brown
Bile, bilirubin Melanin All causes of black urine Pyridium

CAUSE

Orange

Pyridium, Serenium Anisindione, ganstrisin, azogantisin, ethoxazone, indaediones, mannose, phenothiazines, nitrofurantoin, pyridium, rifampin, rhubarb, carrots, senna

Blue (blue-green)

Methylene blue, other dyes and medications, Doans pills, Evans Blue, dithiazine, nitrofurantoin
Pseudomonas Methylene blue, other dyes

Green

Food Additives
MDS Metro Lab, 2006

CONDITIONS ASSOCIATED WITH ABNORMAL URINE COLOR

COLOR
Black

CAUSE
Homogentistic Acid (Alkaptonuria)
Melanin (Malignant melanoma) Porphyrin (acute intermittent porphyria) Myoglobin (Rhabdomyoysis)

Urobilinogen
Hemoglobin Aloin, cascara, chloroquine, cresol, furazolidone, gentistic Acid, iron salts, metronidazole, nitrobenzene, nitrofuratoin, phenols, rhubarb, suphamethoxazole, sulphonamides Indican, Metronidazole, cascara, iron-sorbitol-citric acid complex, methyldopa (converted to melanin), levodopa, methocarbamol, naphthol, phenols, pyrogallol

MDS Metro Lab, 2006

INTERPRETATION
(2) SPECIFIC GRAVITY
- renal concentrating ability

- a ratio between the weight of a defined volume of urine and that of the same volume of distilled water - range: 1.010 1.020 - high SG: concentrated urine - low SG: dilute urine

INTERPRETATION
(3) pH

- renal acidification mechanism - range: 5.0 8.0 - high urine pH with systemic metabolic acidosis: Renal Tubular Acidosis - high urine pH with normal acid-base status: vegetarian diet (4) PROTEIN - renal parenchymal disease

SEMIQUANTITATIVE ESTIMATION OF URINARY PROTEIN

DEGREE OF PROTEINURIA (-) Trace 1+ 2+ INTERPRETATION Negative 20 mg/dL 50mg/dL 200mg/dL

3+
4+

500mg/dL
1000mg/dL or more
Makker, 1992

INTERPRETATION
(5) GLUCOSE - Diabetes Mellitus or Fanconi Syndrome (6) CASTS

DIAGNOSTIC SIGNIFICANCE OF CASTS IN THE URINARY SEDIMENT

Formed Element Category
Hyaline casts

Detected N Urine
Occasional

Clinical significance
Dehydration, following exercise, fever, diuretic use, congestive failure, and nephrotic syndrome

Granular casts
Red cell casts Leukocyte casts Broad waxy casts

Occasional

Dehydration, glomerulonephritis, tubulointerstitial diseases, and acute transplant rejection.

Glomerulonephritis Acute pyelonephritis, acute interstitial nephritis, acute glomerulonephritis

None

None

Chronic renal disease possibly associated with tubular hypertrophy Severe proteinuria, nephrotic syndrome Acute tubular necrosis, acute allograft rejection, heavy metal poisoning

Fatty casts Tubular cell casts

None None

Makker, 1992

DIAGNOSTIC SIGNIFICANCE OF URINE CRYSTALS

Detected N Urine Yes Yes Yes Yes

Type of Crystal PHOSPHATES Ammonium Mg phosphate Calcium phosphate Amorphous phosphate URATES Uric acid

Clinical significance

Infection stones Hypercalciuria urolithiasis Little diagnostic significance Gout, Lesch-Nyhan syndrome, and other hyperuricemic states(Tumor Lysis Syndrome) Little diagnostic significance except in stone formers

Amorphous urates OTHERS

Yes

Ca oxalate

Yes, after a highoxalate diet

Yes

Ethylene glycol poisoning, methoxyflurane anesthetic, chronic bowel resection, hyperoxaluria and intake of large amount of vit. C
Cystinuria, homocystinuria

Cystine

Tyrosine

Yes

Tyrosinemia

Makker,1992

DIAGNOSTIC SIGNIFICANCE OF CELLS IN THE URINARY SEDIMENT

Formed Element Category Red Blood Cells Detected N Urine <5/hpf Clinical significance Dysmorphic RBCs seen in glomerular bleeding. Non dysmorphic RBCs in hypercalciuria, hyperuricemia, sickle cell trait, and non glomerular bleeding. Urinary tract infection, acute interstitial nephritis, acute glomerulonephritis. Large numbers are seen in tubular disorders, acute tubular necrosis, tubulointerstitial nephritis, and (sometimes) renal cystic diseases. Nephrotic syndrome of any etiology especially in minimal change nephrotic syndrome. These appears as maltese crosses under polarized light
Makker, 1992

Leukocytes Renal Tubular Epithelial Cells

<5/hpf Occasional

Oval Fat Bodies

No