PowerPoint 演示文稿

Fluid Therapy 

The first affiliated hospital 

SUN YAT-SEN university 

Prof. Wang Huishen 

王慧深

Last lesson Emphasis 

Etiology 

(in/ex/no) 

Diagnosis 

Predisposing 

(4) 

Pathogenesis 

(4+ex/b/v/no) 

Differential 

Diagnosis 

(p/d/n) 

Clinical 

manifestation 

Treatment

Diagnosis 

� Not difficult 

� According to clinical manifestation, 

laboratory tests and character of stool. 

Infectious 

Or 

Noninfectious 

Dehydration 

Degree 

and 

quality 

+ + 

Electrolyte disturbances 

And 

Disturbance of 

acid-base balance

Case example 

An 8 – month boy had diarrhea and vomited for 3 days, urine 

stream reduced, irritability. PE: Pulse rate 150/min, weight 

loss was 10%, blood pressure 65/40mmHg, skin color showed 

grey and skin turgor looked like tents. Mucous membranes 

were very dry; eye ball was sunken greatly, anterior fontanel 

depressed greatly. Abdomen distended, bowel sound 

diminished. 

Questions: 

1.What is the diagnosis? 

2.How to administer the fluid therapy?

Answer diagnosis 

� Acute diarrhea 

� severe dehydration 

� hypokalemia

features of body fluid balance in children 

----amount of body fluid 

The younger The larger proportion of body water 

Total body water 

(by body mass) 

Neonate……………... 80% 

Older children………..65% 

Adult…………………..60%


----distribution of body fluid 

Body 

fluid 

The younger 

Intracellular 

Extracellular 

Interstitial fluid 

Plasma 

Lymph fluid 

Secretory juice 

The larger proportion 

of extracellular water


----distribution of body fluid in different ages (by BW) 

P 

6% 

IF 

37% 

P IF 

5% 20% 

IC 

40% 

IC 

35% 

P 

5% 

IF 

25% 

Neonate 78% ~1y 70% 

P: plasma 

IF: interstitial 

fluid 

IC: 

intracellular 

IF 

P 10% 

5% ~ 

15% 

IC 

40% 

IC 

40%~45% 

2y~14y 65% Adult 55%~60%

features of body fluid balance 

in children 

----water requirement 

� Requiring more water 

� Regulating function poorly 

� Easy water metabolism disturbance

features of body fluid balance 

in children 

----water requirement 

� Due to grow quickly, need 0.5%~3% water for growth. 

� Insensible water loss : 2 times more than adult. 

� Fluid exchange of digestive tract quicker. 

� Water metabolism higher: infant 1/2 by total fluid 

adult 1/7 by total fluid. 

� Regulating function of water metabolism poorly: 

kidney, lung.

Composition of body fluid 

◆Similar with adult 

Extracellular: 

Na + , Cl - , Hco 3 - 

Intracellular: 

K + , Mg ++ , Hpo 4 = , protein 

◆Features of neonate (Several days after birth) : 

K + , Cl - , P, lactic acid 

Na + , Ca ++ , Hco 3 - 

Function of excluding H + 

�Particularly in preterm infant 

Acidosis

Acid-base balance and adjust 

----two concept 

�Acid-base balance 

Acidity and alkalinity 

�Anion-cation balance 

Anion and cation

Acid-base balance and adjust 

� Buffer system 

NaHCO 3 /H 2 CO 3 

Na 2 HPO 4 /NaH 2 PO 4 

� lung :exhale of store CO 2 (respiratory) 

Compensation of adjust has limit 

----body liquid 

Buffer system of plasma protein 

� kidney: exclude H + and store Na + (metabolic) 

Adjust HCO 3 - NaHCO 3 /H 2 CO 3 =20:1

Acid-base index 

Blood gas analysis(normal ) 

� PH:7.4 (7.35~7.45) 

� PaCO 2 :40 (34~45) mmHg 

� SB:24 (22~27) mmol/L 

� BE:-3 ~ +3 mmol/L 

� CO 2 CP:22 (18~27) mmol/L

Acid-base balance disorder 

� respiratory acidosis 

� respiratory alkalosis 

� metabolic acidosis 

� metabolic alkalosis 

Compensation & decompensation

Electrolyte disturbance 

Diarrhea complicated 

� hyponatremia & hypernatremia 

� hypokalemia 

� hypocalcemia 

� hypomagnesemia

Dehydration 

Water loss 

By weight 

Spirit 

Skin 

Mocous 

Anterior fontanel 

and eye ball 

Tear 

Urine output 

Peripheral 

circulation 

Severity clinical signs of dehydration 

mild moderate severe 

10% 

Extremely dispirited 

apathy, hypnody, 

coma 

Gray mottled 

Parched 

depressed greatly 

No 

No urine output 

Cool, weak 

pulse,shock

Dehydration 

Isotonic 

Na+ :130~150mmol/L 

P IF C 

Same proportion 

loss 

Acute diarrhea 

after 

vomiting greatly 

P IF 

Hypotonic 

C 

Electrolyte loss 

more 

P hypotonic, 

IF+C hypertonic 

Cell expansion 

Severe 

Easy to shock 

P: plasma, IF: interstitial fluid, C: cell 

Hypertonic 

Na+: < 130mmol/L Na+: > 150mmol/L 

P IF 

C 

Water loss 

more 

P hypertonic 

IF+C hypotonic 

Cell hydration 

Mild 

Thirsty

Metabolic acidosis--clinical manifestation 

Mild: breath frequency slightly 

Severe: occur: 

� Dispirited, dysphoria, drowsiness, coma 

� Hypernea (Kussmauls breathing),exhalation cool 

� Expiratory gas smells ketone 

� Cherry lips 

� Nausea, vomit

Clinical manifestation-3: electrolyte disorder 

Hypokalemia 

K + (potassium)

hypokalemia K+ (potassium)

hypocalcemia & hypomagnesemia 

� Ca 2+

Purpose 

To cure water and 

electrolyte disturbance 

Recover and maintain 

blood volume , osmotic pressure , 

Acidity , alkalinity and electrolyte 

Normal 

physiological function

Method 

oral intravenous 

�prevention dehydration: Rice soup add salt solute(1/3) 

�Mild dehydeation: ORS。 

�Mild/moderate dehydeation : ORS 

——mild: ORS: 50~80ml/kg 

——moderate: ORS:80~100ml/kg 

�Severe dehydration or vomiting and diarrhea 

—— intravenous

oral rehydration salts (ORS) 

� NaCl:3.5g 

� NaHCO 3 (Sodium citrate):2.5g (2.9g) 

� KCl:1.5g 

� GS:20g 

Na+ 90mmol/L,K+20mmol/L, 

Cl-80mmol/L,HCO3- 30mmol/L 

Add water to 1000ml 2 / 3 isotonic , 

Total osmotic pressure: 220mmol/L 

Can be diluted in Children

口服补液盐 Oral rehydration salt (ORS) 

WHO2002年推荐的低渗透压ORS配方 

成分含量 (克) 

NaCl 2.6 

枸橼酸钠 2.9 

KCl 1.5 

葡萄糖 13.5 

水 1000ml 

该配方中各种电解质浓度为:Na + 75mmol/L, K + 20 

mmol/L,C1 - 65 mmol/L,枸橼酸根 10mmol/L,葡萄糖75m 

mol/L。总渗透压为245 mOsm/L 

sodium citrate could instead by NaHCO3

Mechanisms of ORS 

Na + -- GS transport of Small intestine 

Na + –GS 

carrier 

enterocyte 

Brush border 

Na + 

GS 

transport 

promote 

Na + 

GS 

Na +、 H 2 O absorb↑ 

intracellular→intercellular→blood 

Na + (pump) →intercellular space(Cl - )→OP↑ →H 2 O into blood

Characteristics of ORS 

---Advantages 

� Osmotic pressure similar with plasma(2/3 2/3 tonicity) 

� Correct losses by proper concentration of Na + 、K + 、Cl - 

� Children easily accept the tastes 

� Correct metabolic acidosis by sodium citrate 

� Promote Na + and H 2 O absorption by 2% GS

Characteristics of ORS 

� Liquid tonicity higher (2 / 3) 

---disadvantages 

� Can not be used as the maintenance media 

� Na + concentration is relatively higher to neonates 

and infants (proper diluted) .

Simple preparation at home 

� ORS: 

� GNS: 

Rice soup 500ml+ salt 1.75g 

Fried rice noodles 25g + salt 1.75g 

+ water 500ml (Cooking 2-3min) 

White sugar 10g + salt 1.75g + water 500ml (boil)

Sever dehydration 

intravenous

Concentration of electrolyte and calculation 

� Osmotic pressure of plasma (OPP) 

OPP= (crystal + colloid) osmotic pressure 

Na + 142 

Cation: K + 5 

(mmol) Ca ++ 2.5 

Mg ++ 1.5 

151 mmol/L 

HCO 3 - 27 

Anion: Cl - 103 

(mmol) HPO 4 = 1 

SO 4 = 0.5 

Organo-anion 19.5 

151 mmol/L 

OPP range:280-320mOsm/L

Fluid isotonic 

Isotonic liquid: osmotic pressure similar with plasma 

Sodium isotonic: 

�Isotonic: 150mmol sodium in 1000ml 

�½ tonicity: 75mmol sodium in 1000ml 

�2/3 tonicity: 100mmol sodium in 1000ml 

�1/3 tonicity: 50mmol sodium in 1000ml 

Na:Cl=3:2 (in plasma)

Liquid solution commonly used 

nonelectrolyte solution 

glucose enter the body by 

oxidation change into water 

and CO2 for energy and 

water without tension 

electrolyte solution 

5%GS 

10%GS 

0.9%NaCl 

10%NaCl 

Ringer 

5% NaHCO3 

11.2% NaL 

10%KCl 

Mixture

Calculation 

�10%NaCl: 1ml=1.7mmol 

�5%NaHCO 3:1ml=0.6mmol 

�11.2%NaL: 1ml=1mmol 

�10%KCl: 1ml=1.34mmol

The element and simple dispensing 

in the commonly mixed solution 

Solution composition ratio dispensing (ml) 

NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl 

2:1 isotonic solution . 2 1 500 30 47 

1:1 solution (1/2 tonicity) 1 1 500 20 

2:3:1 solution (1/2tonicity)2 3 1 500 15 24 

4:3:2 solution (2/3tonicity)4 3 2 500 20 33 

1:2 solution (1/3 tonicity)1 2 500 15 

1:4 solution (1/5 tonicity) 1 4 500 9 

daily requirement 

(1/3tonic) 1 4 500 9 7.5

常用溶液成分 

溶液每100ml含 Na∶Cl 电解质渗透压 

血浆 (142:103)3 :2 300mmol/L 

①0.9%氯化钠 0.9g 1∶1 等张 

②5%或10%葡萄糖 5或10g 

③5%碳酸氢钠 5g 3.5张 

④1.4%碳酸氢钠 1.4g 等张 

⑤10%氯化钾 10g 8.9张

续表 

溶液每100ml含 Na∶Cl 电解质 

1∶1含钠液 ①50ml,②50ml 1∶1 1/2张 

1∶2含钠液 ①35ml,②65ml 1∶1 1/3张 

1∶4含钠液 ①20ml,②80ml 1∶1 1/5张 

2∶1含钠液 ①65ml,④35ml 3∶2 等张 

2∶3∶1含钠液 ①33ml,②50ml 

④17ml 3∶2 1/2张 

4∶3∶2含钠液 ①45ml,②33ml 3∶2 2/3张 

④22ml

Water supplement & correct acidosis 

� Accumulative losses 

---losses from onset to pre-treatment 

� ongoing losses 

---continuing losses during treatment 

� daily requirement 

---to maintain basically physiological function 

Amount , composition and time

To master three principles 

� The volum of rehydration 

Deficit fluid 

=(percentage of dehydration)×(body weight in Kg) 

� The type of fluid 

Isotonic dehydration——1/2 tonicity solution 

Hypotonic dehydration——2/3 tonicity solution 

Hypertonic dehydration——1/3 tonicity solution 

� The speed of liquid:four steps

four steps 

(for fluid and electrolyte deficits) 

� Step 1. Expanding volume: 

restoration of circulation –emergency, 

within 30 min to 1 hour 

20ml/kg, 2:1 (isotonic )sodium solution 

� Step 2. supplement lost body liquid: 

first 8~10 hours 

8~10ml/h 

half of total loss volume 

2:3:1 solution(1/2 tonicity)

four steps 

� Step 3. maintenance rehydration: 

- next 16 hours 

5ml/(kg.h) 

- another half loss 

physical demand : 60~80ml/kg 

4:1 solution(1/3~1/2 tonicity) 

� Step 4. repair of potassium deficit

Water supplement-1: accumulation losses 

Amount , composition and speed: 

--- according to the degree and quality of dehydration 

Accumulation 

losses 

amount 

mild: 50ml/kg 

moderate: 50~100ml/kg 

severe: 100~120ml/kg

Water supplement-1: accumulation losses 

Accumulation 

losses 

composition 

speed 

Dehydration : 

isotonic : 1/2 tonicity(1:1) 

hypotonic:2/3 tonicity(4:3:1) 

Hypertonic:1/3~1/5 tonicity 

(1/3 tonicity) 

Principle: fast slow 

severe:bolus of isotonic fluid 

2:1 tonicity: 20ml/kg(

Dehydration 

Water loss 

By weight 

Spirit 

Skin 

Mocous 

Anterior fontanel 

and eye ball 

Tear 

Urine output 

Peripheral 

circulation 

Severity clinical signs of dehydration 

mild moderate severe 

10% 

Extremely dispirited 

apathy, hypnody, 

coma 

Gray mottled 

Parched 

depressed greatly 

No 

No urine output 

Cool, weak 

pulse,shock

Water supplement-2: ongoing losses 

Ongoing 

losses 

amount 

composition 

speed 

10~40ml/kg.d 

1/2~1/3 tonicity(1:1) 

�12~16h after stage-1 

�In 24h, steady speed 

5ml/(kg·h)

Water supplement-3: 

daily requirement 

daily 

requirement 

amount 

composition 

speed 

60~80ml/kg.d 

(including oral) 

1/3~1/5 tonicity 

(Physical main medium) 

�In 24h, steady speed 

�Accompany with stage-2

The first day fluid infusion : 

Dehydration 

Fluid replacement=losses 

(Accumulation + ongoing + daily ) 

Accumulation ongoing daily total amount 

(ml/Kg) 

mild 50 10~30 60~80 90~120 

moderate 50~100 10~30 60~80 120~150 

Severe 100~120 10~30 60~80 150~180 

Accumulation: accumulation losses 

Ongoing: Ongoing losses 

daily: Physiological requirement

Correct acidosis 

� mild:correct etiological factor 

� Moderat & severe: 

Alkaline solution requirement (mmol) 

= 

(40 –CO 2 CP Vol%) 

2.2 

= (22 - CO 2 CP mmol/L) × 0.7 × kg 

= BE × 0.3 × kg 

×0.7 × kg 

�Usually use the dose halved first and 

than according to blood gas analyses

Correct acidosis 

Emergency : 

� Per-elevate 5mmol HCO 3 - 5mmol/L(10% CO2 -CP) 

� need alkaline solution: 3mmol/kg 

5%NaHco 3 5ml/kg or 1.4% NaHco 3 20ml/kg

Supplement potassium: 10%KCL 

� mild hypokalemia:200~300mg/(kg·d) 

2~3ml/(kg·d)oral 

� sever hypokalemia:300~450mg/(kg·d) 

3~4.5ml/kg.d 10% KCl ivdrip

Supplement potassium principle: 

Supplement after urine or urination 

before coming diagnoses 

Intravenous concentration6~8h/d(intravenous) 

Time:keep 4~6 day 

interdiction:directly intravenous, 

because heart stop!

Supplement Calcium and Magnesium 

Convulsion emerged : 

10% Calcium Gluconate 10ml+25% Glucose 10ml IV 

If convulsion hasn’t relieved 

after supplement calcium, 

——give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6h 

be careful (Calcium ): 

� HR

Principles of Therapy 

first fast then slow 

first thick then thin 

supplement potassium 

when having urine 

adjust any time 

and monitor

The second day fluid infusion : 

Ongoing losses and daily requirement 

daily requirement 60~80ml/kg (1/3~1/5 tonicity) 

Ongoing losses follow the how much of the lost 

in the any time ( 1/2~1/3 tonicity) 

12~24H equal the speed iv drip 

To continue the supplement potassium 

and correct acidosis

Notes 

� Neonate: to reduce the liquid and electrolytes 

properly. 

� Severe malnutrition:to reduce the water 

amount properly, with low speed, 2/3~1/2 

tonicity, supplement 10% GS and / or plasma

Fluid requirement at post operation 

or heart failure 

� operation day 2 ml/kg/h 

� the first day* 4 ml/kg/h 

——(the first 10kg) 4 ml/kg/h 

——(the second 10kg) 2 ml/kg/h 

*heart failure / breathing machine utilization: 3ml/kg/h 

put to open warm casing, the volume > 10%

heart failure or heart post operation 

� Control the solution by intravascular injection 

� Volume include : 

— maintenance fluid in vascular; 

— medicine and dilution; 

— rinse solution for the vascular tubule; 

— gastric tube or food-intake。

Fluid requirement at post operation 

� Include potassium glucose and sodium 

1/4~1/5 tonicity 

� 10% GS 500ml 

� 10%NaCl 10ml 

� 10% KCl 15ml 

� ( 9.5%GS、0.19%NaCl、0.29%KCl )

Answer question 2 

How to administer the fluid therapy? 

An 8 – month boy had diarrhea and vomited for 3 days, 

urine stream reduced, irritability. 

PE: Pulse rate 150/min, weight loss was 10%, blood 

pressure 65/40mmHg, skin color showed grey and skin 

turgor looked like tents. Mucous membranes were very 

dry; eye ball was sunken greatly, anterior fontanel 

depressed greatly. Abdomen extended, bowel sound 

diminished.

Step 1:Plan supplementary fluid. 

�First body weight is calculated by 

formula of growth and development section. 

——(6+8×0.25=8kg) 

——2:1 sodium :20ml×8=160ml 

——finished intravenously within 30min.

Step 2:Acute loss 

� be always isotonic dehydration, so we 

choose : 

——2:3:1 (2:glucose , 3: sodium, 1: 1.4% bicarbonate ) 

——that belong to 1/2 tonicity. 

——Repair of water and sodium deficits 

● first 8-10 hours 8-10 ml/(kg·h) 

● half of total loss volume 

(160×8)ml/2=640 ml.

Step 3.:4:1 sodium 

● be taken next 16 hours 

5 ml/(kg·h) 

● 80 ml/kg×8kg=640 ml 

(another half)

Step 4:Potassium supplement 

� 8kg×0.4g=3.2g/d. 

� That means about 10% potassium chloride solution 

32ml will be used by intravenous infusion. 

� Notice supplement potassium 

——when urine stream must be seen; 

——meanwhile, be aware of concentration(


� Percentage concentration: 5%GS、10%NaCl 

� Molar (mol, gram molecular weight) , mmol 

� Molarity (mol/L) 

calculation: 

mol/L= 

1 mol NaCl=23+35.5=58.5g 

Percentage concentration of solute(%)×10 

Molecular weight (atomic weight) 

0.9×10 

e.g. 0.9%NaCl= =0.154mol/L =154mmol/L 

58.5


� Osmotic pressure, osmol(OSM) 

Dissolve 1mmol solute into 100ml water: 1mOsm. 

1mmol 

100ml water 

1mOsm


� To non electrolyte 

1mmol 

GS 

� To electrolyte 

1mmol 

Nacl 

1mmol 

Cacl 2 

1mOsm 

2mOsm 

3mOsm

PowerPoint 演示文稿

Create successful ePaper yourself

Delete template?

Save as template?