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  • Fluid therapy is guided by knowledge of the composition, distribution, and movement of body water.
  • Fluid requirements are divided into three parts:
    • maintenance fluids
    • deficit replacement
    • replacement of ongoing losses
  • Correction of circulatory failure with isotonic crystalloid or appropriate colloid is the first step in fluid management.
  • Hypernatremia should generally be corrected gradually to avoid the complication of cerebral edema.
  • Aggressive treatment of hyponatremia may lead to the osmotic demyelination syndrome.
  • Therapy for hyperkalemia is aimed at halting intake, stabilizing cellular membranes, intracellular translocation, and enhancing elimination.
  • Hypokalemia should be corrected orally, if possible. Extreme caution should be exercised during intravenous replacement to avoid hyperkalemia.


The initial approach to acutely ill children includes an assessment of their fluid and electrolyte status. The ability to maintain homeostasis and correct disturbances requires knowledge of the composition of the fluid spaces of the body and their changes with age and disease. This chapter discusses the physiologic basis of fluid management, some of the common disturbances, and an approach to management.


Fluid Compartments


Total body water (TBW) is divided into the intracellular and extracellular compartments, with the extracellular compartment subdivided into intravascular and extravascular compartments. The relative size of these compartments varies with age (Fig. 80–1).1 TBW is approximately 79% of body weight at birth, decreasing to the adult proportion of 55% to 60% over the first year of life. This primarily relates to a drop in extracellular fluid (ECF). Postnatal diuresis, as well as growth in cellular tissue, is responsible for the majority of the change. Additionally, blood volume decreases from 80 mL/kg at birth toward the adult value of 60 mL/kg. By the time the child is 1 year of age, TBW comprises approximately 60% of body weight and is approaching the adult distribution of one-third in the extracellular compartments and two-thirds in the intracellular compartments. Body water exists as a complex solution of salts, organic acids, and proteins. The exact composition varies with body compartment (Fig. 80–2).2

Figure 80-1.
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Distribution of total body water based on body weight at various ages. Both total body water and extracelluar water decline significantly over the first year of life.

Figure 80-2.
Graphic Jump Location

Electrolyte composition of intracellular space vs. extracellular space.


Movement of Fluid


Cellular membranes form the barrier between the extracellular and intracellular spaces (Fig. 80–3). They are freely permeable to water, but impermeable to electrolytes and proteins, except by active transport. Although the specific osmoles differ in the two compartments, the osmolality is equal. Water distributes across this barrier by osmotic pressure. A rise in extracellular osmolality, as occurs with a sodium load, results in movement of water from the intracellular space to the ...

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