Article fluid & electrolytes

Fluid and Electrolytes: Parenteral

Fluid Therapy
Kenneth B. Roberts, MD*
Objectives After completing this article, readers should be able to:

1. Relate maintenance fluid and electrolyte needs to metabolic rate rather than to body
weight.
2. Recognize the differences in mild, moderate, and severe deficits among infants
compared with children or adults when expressed as percentage of body weight.
3. Describe the indication for a “bolus” and specify the amount and composition.
4. Specify a rehydration plan without the use of a calculator for an infant who has
moderate dehydration.
5. List the measures most valuable for monitoring the state of hydration.

Introduction
Parenteral fluid therapy is a basic component of the care of hospitalized infants and
children. Clinicians who care for inpatients must be able to assess the need for parenteral
fluid therapy and to specify the composition of fluid and rate of administration. Fluid and
electrolyte problems can be challenging but generally can be “tamed” by an organized
approach, application of a few principles of physiology, and careful monitoring of the
patient. It can be useful to consider separately the amount of fluid needed and the
electrolyte composition for maintenance needs, deficit, and ongoing losses (Table 1).
Because maintenance is not as directly related to weight as deficit or as directly measureable
as ongoing losses, it tends to cause the most confusion. It will, therefore, be discussed first
and in more detail than deficit or ongoing losses.

Maintenance: Fluid
The key to understanding maintenance fluid and electrolyte needs is recognizing that they
stem from basal metabolism (Fig 1). Metabolism creates two by-products, heat and solute,
that need to be eliminated to maintain homeostasis. Heat is dissipated largely by the
insensible evaporation of water from the skin surface. (Active “sensible” skin loss—
sweating—is added only when there is an additional heat burden and is not considered part
of maintenance.) Elimination of warmed water vapor from the upper respiratory tract
during exhalation also contributes to insensible fluid loss. Soluble waste by-products of
metabolism are excreted in the urine.
Metabolic rate is not related directly to weight and is expressed in units of energy (kcal
or joules). When compared with body weight, basal metabolic rate is high in the newborn
period and much lower in adulthood, and the transition is not linear (Fig 2). Because
metabolic rate per unit of body weight declines with increasing age, children generate less
heat and solute from basal metabolism than do infants and, therefore, need less fluid and
electrolytes per unit of body weight. Adolescents and adults generate less heat and solute
from basal metabolism than do children or infants and, therefore, need less fluid and
electrolytes per unit of body weight. Although the amount of fluid and electrolytes declines
per unit of body weight, it remains constant per kilocalories of basal metabolism.
Because it is difficult to remember basal metabolic rates for various ages and sizes during
childhood, several methods have been proposed to relate maintenance needs to body
weight, including the surface area method, the basal calorie method, and the Holliday-
Segar system. All three systems “work” when used by knowledgeable individuals, but each

*Department of Pediatrics, Moses Cone Health System, Greensboro, NC.

380 Pediatrics in Review Vol.22 No.11 November 2001

 fluid & electrolytes parenteral fluid therapy

Table 1. Approach to a Fluid and Electrolyte Problem tion in urine) each can be considered
as representing 50% of maintenance
Fluid Electrolytes needs. This simple principle is a great
(Amount of Water) (Composition) aid in the management of children
Maintenance Determined by a “system”: D50.2NS ⴙ 20 mEq/L who have anuric renal failure. Main-
Holliday-Segar formula, surface Kⴙ tenance fluid needs decrease by 50%
area, or basal calorie method because the only fluids needing to be
Deficit Determined by acute weight change Determined by tables replaced are insensible losses.
or clinical estimate (generally D50.45NS
ⴙ Are maintenance fluid and
ⴙ 20 mEq/L K )
Ongoing Losses Determined by measuring Determined by tables or electrolytes all that children at bed
measuring rest in the hospital need? All chil-
dren have maintenance needs, but
most hospitalized children have
also has its problems. The surface area method requires a more than maintenance needs. They may be febrile,
table to determine surface area and ideally knowledge of needing fluid to dissipate additional heat; they may be in
the patient’s height and weight, different proponents a catabolic state, producing additional solute to be ex-
advocate different estimates of fluid to be administered creted; or they may be sequestering fluid in a “third
per m2, and the system does not address deviations from space” as a result of inflammation or low intravascular
normal activity. The basal calorie method also requires a colloid pressure. In addition, nutrition includes and cre-
table, it involves the most calculations, and it is “drier” ates additional osmoles that need to be excreted, requir-
than the other methods. The Holliday-Segar system, as ing additional fluid.
generally applied, does not address deviations from nor- In the absence of disease, should intake and output be
mal activity, but it is used most frequently because of the equal, or should urine output always equal half of what
ease with which the formula can be remembered and is taken in? Intake and the output that is measured
applied (Table 2). (mainly urine) should not be equal because insensible
The Holliday-Segar formula estimates kilocalories losses contribute to losses but are not measured. The
that, for practical purposes, can be equated with milli- half-half rule applies when the child has only mainte-
liters of fluid. (For each 100 kcal expended, approxi- nance needs and the amount of fluid being provided
mately 50 mL of fluid is required to provide for skin, matches those needs. Normal kidneys have the ability to
respiratory tract, and basal stool losses, and 55 to 65 mL modulate the amount of water excreted, but insensible
of fluid is required for the kidneys to excrete an ultrafil- losses come “off the top.” Therefore, as demonstrated in
trate of plasma at 300 mOsm/L—a specific gravity of Table 3, if more fluid is provided than is needed for
1.010 —without having to concentrate the urine. The maintenance, urine will be dilute and exceed 50% of the
sum generally is rounded to 100 mL of fluid per 100 kcal intake; if less fluid is provided than is needed for mainte-
expended, permitting kilocalories and milliliters to be used nance, urine will be concentrated and be less than 50% of
interchangeably.) The two functions of maintenance fluid intake.
(heat dissipation through insensible losses and solute excre- Should maintenance fluids be administered evenly
each hour? The convention of in-
fusing maintenance fluids at a uni-
form hourly rate is convenient for
the individual making the calcula-
tion and for the staff monitoring
the infusion, but it is only a conven-
tion. Maintenance fluids certainly
are not ingested at an even rate
when consumed orally, and they do
not need to be provided evenly
when infused parenterally. Flexibil-
ity is encouraged when it is not
Figure 1. Maintenance fluid and electrolytes are required because of losses that stem convenient for fluids to be infusing
from basal metabolism. or when the intravenous access

Pediatrics in Review Vol.22 No.11 November 2001 381

fluid & electrolytes parenteral fluid therapy

Should the sodium concentra-

tion of maintenance fluids pro-
vided to adolescents and adults dif-
fer from that generally provided to
infants and children? The sodium
concentration need not differ.
Both the amount of electrolyte and
the amount of water for mainte-
nance needs are based on metabolic
rate, not on body weight. The ratio
of electrolyte to water is fixed, so
the composition of maintenance
fluids should remain constant:
D50.2NS ⫹ 20 mEq/L K⫹. Ado-
lescents and adults frequently are
Figure 2. Basal metabolic rate, estimated total expenditure with normal activity, and provided D50.45NS, based on a
caloric expenditure of the “average hospitalized patient.” presumed need for sodium of 3
mEq/kg, when the actual need is 3
mEq/100 kcal. The error of calcu-
needs to be used for a different purpose, such as the lating sodium based on weight results in a linearly in-
administration of a medication that needs to be infused creasing amount with increasing weight, when fluid
slowly (eg, vancomycin). Acceptance of the convention needs actually decrease with advancing weight (Fig 2).
to infuse maintenance fluids at an even rate can make This results in adults generally being provided more
rehydration calculations unnecessarily difficult. sodium than needed for maintenance support, as was
recognized nearly 50 years ago. To illustrate the differ-
Maintenance: Electrolytes ence, a teenager or adult weighing 70 kg would receive
Fluid is lost from the skin largely by evaporation, and that 2,500 mL/d of fluid, based on the Holliday-Segar for-
lost from the respiratory tract consists of water vapor. mula. At 3 mEq/100 kcal, the individual would receive
Hence, insensible loss contains virtually no electrolytes. 75 mEq/d of sodium (1.7 g), but at 3 mEq/kg, the
For clinical purposes, all electrolyte loss can be consid- individual would receive 210 mEq/d of sodium (nearly
ered to be urinary. This further informs the treatment of 5 g), which is much more than is required to meet
patients who have anuric renal failure. Because their maintenance needs.
sodium and potassium are “recycled,” no sodium or
potassium administration is required. (If the patient is Deficit: Fluid
oliguric rather than totally anuric, the amount of sodium A deficit is the amount of water (and electrolytes) lost
lost in the urine can be determined in the laboratory and before treatment is begun. For practical purposes, it is a
replaced as an “ongoing loss.”) one-time estimate, and additional abnormal losses are
considered in the category of ongo-
Holliday-Segar Formula for Determining
Table 2. ing losses. Acute weight change is
the most direct basis for determin-
Calories (and Fluid Volume) for “Average ing the amount of deficit fluid; a
Hospitalized Patient” at Maintenance loss of body weight greater than 1%
per day almost always must be fluid.
Weight (kg) kcal/d or mL/d kcal/h or mL/h However, weight change can be
0 to 10 kg 100/kg per day 4/kg per hour misleading. For example, retention
11 to 20 kg 1,000 ⴙ (50/kg per day)* 40 ⴙ (2/kg per hour)* of fluid in a “third space” may lead
>20 kg 1,500 ⴙ (20/kg per day)† 60 ⴙ (1/kg per hour)† to intravascular depletion without
*For each kg ⬎10. a corresponding drop in body
†
For each kg ⬎20. weight. Clinical estimates of dehy-
From Holliday MG, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics.
1957;19:823– 832 dration are useful when a preillness
weight is not available or the differ-

382 Pediatrics in Review Vol.22 No.11 November 2001

 fluid & electrolytes parenteral fluid therapy

Relationship of Intake and Urine Output in a

Table 3. hemodynamic instability; hyper-
natremia maintains circulatory suf-
10-kg Child Receiving Various Volumes of Fluid* ficiency at the expense of intracellu-
lar depletion.
At More Than Less Than
Maintenance Maintenance Maintenance The rapidity with which the def-
icit is replaced depends on the de-
Volume 1,000 mL 2,000 mL 750 mL gree of dehydration and on how
Insensible loss 500 mL 500 mL 500 mL
Fluid available for urine 500 mL 1,500 mL 250 mL long it has taken for dehydration to
develop. (Hippocrates: “Those
*Note that urine output is half of intake only if the maintenance amount is provided.
bodies which have been slowly
emaciated should be slowly recruit-
ed; and those which have been
ence between the current weight and the preillness quickly emaciated should be quickly recruited.”) Rapid
weight does not seem to reflect the child’s clinical con- “recruitment” not only restores intravascular volume and
dition accurately (Table 4). Dry mucous membranes in diminishes myocardial work, but it also promotes an
association with normal hemodynamic measurements improved sense of well-being that often literally “re-
indicate mild dehydration; early hemodynamic signs of cruits” the child to be able to drink and ends the need for
intravascular depletion (eg, tachycardia) define moderate parenteral fluid. If signs of hypovolemia are present (eg,
dehydration; and signs of more profound hypovolemia tachycardia, hypotension), a rapid infusion of fluid (“bo-
(eg, hypotension, poor perfusion) are considered evi- lus”) is indicated. The amount generally administered in
dence of severe dehydration. Mild, moderate, and severe a single bolus is 20 mL/kg for infants and children and
degrees of dehydration in infants correspond roughly to 10 mL/kg for teenagers.
a loss of 5% (50 mL/kg), 10% (100 mL/kg), and 15%
By convention, dehydration often is expressed as per-
(150 mL/kg) of body weight, respectively. In teenagers
cent of body weight, and bolus replacement is considered
and adults, however, the loss generally is only half as
in milliliters per kilogram of body weight. This mismatch
great. Some authors suggest an estimate of 3% (30 mL/
of units is unfortunate. Recognizing that 20 mL/kg is
kg), 5% (50 mL/kg), and 7% (70 mL/kg) for mild,
equivalent to 2% of body weight permits the clinician to
moderate, and severe dehydration, respectively; others
recommend 3% (30 mL/kg), 6% (60 mL/kg), and 9% set expectations for the impact of a bolus of fluid. For
(90 mL/kg). For children between the newborn period example, an infant who is estimated to have lost 10% of
and adolescence, intermediate values should be applied. body weight and is tachycardic can be expected to have a
Serum sodium concentration affects the clinical signs lower heart rate after a single 20 mL/kg bolus, but an
of dehydration. Hyponatremia causes an exaggeration of infant who is estimated to have lost 15% of body weight

Table 4. Clinical Assessment of Dehydration in Infants and Adolescents

Infant Adolescent Severity of
EWL mL/kg EWL mL/kg Dehydration Clinical Data Problems in Assessment
5% 50 3% 30 Mild ● Dry mucous ●
Oral mucosa may be dry in chronic mouth
membranes breathers
● Oliguria ● Frequency and amount of urination may be
difficult to assess during diarrhea, especially in
infant girls
10% 100 5% to 6% 50 to 60 Moderate ● Marked oliguria ● See oliguria above
ⴙ
● Poor skin turgor ● Affected by serum [Na ]
● Sunken fontanelle ● Infants only
ⴙ
● Tachycardia ● Affected by fever, [Na ], underlying disease
ⴙ
15% 150 7% to 9% 70 to 90 Severe ● Hypotension ● Both may be affected by [Na ], underlying disease
● Poor perfusion

EWL ⫽ estimated weight loss

[Na⫹] ⬎150 mEq/L gives falsely low estimate of severity; [Na⫹] ⬍130 mEq/L exaggerates clinical estimate of severity

Pediatrics in Review Vol.22 No.11 November 2001 383

fluid & electrolytes parenteral fluid therapy

will require more than one such Table 5. Two Methods of Rehydration*
bolus to regain a comparable de-
gree of hemodynamic stability. Combined Deficit/ Sequential Deficit/
Maintenance Maintenance
Deficit: Electrolytes First 8 hours ⁄ remaining deficit ⴙ 1⁄3 daily
1 2 Remaining deficit: 400 mL
Normal saline or Ringer lactate is after bolus maintenance ⴝ 367 mL
1⁄2 remaining deficit ⴙ 2⁄3 daily
used when a bolus of fluid is admin- Next 16 hours Daily maintenance: 500 mL
istered because the sodium concen- maintenance ⴝ 533 mL
Total 900 mL 900 mL
tration is comparable to serum, so
intravascular volume is bolstered *A 5-kg infant who has moderate dehydration (10%, 500 mL deficit) following a 20 mL/kg bolus (100
mL). Remaining deficit is 400 mL; maintenance is 500 mL/d.
without fluid shifts. The remainder
of the deficit rarely requires such a
high sodium concentration. In the
usual situation, in which the deficit has been incurred tent of normal saline or Ringer lactate, and radiant losses
because of excessive gastrointestinal losses or a short are sodium-free.
period of reduced intake or both, the total sodium loss is
approximately 80 to 100 mEq/L. Particularly when a Parenteral Rehydration Without a Calculator
bolus of normal saline or Ringer lactate has been pro- of a Moderately Dehydrated Infant
vided, the remaining deficit is approximated by half- An initial bolus of 20 mL/kg is provided to restore
normal saline (D50.45NS). normal hemodynamics; adequacy of the bolus can be
Only sodium needs are calculated. The amount and assessed by resolution of hypovolemia-induced tachycar-
rate of potassium administered is governed by safety, dia. After the bolus, there are options. A common ap-
and full replacement is not achieved acutely. Once proach is to provide 50% of the remainder of the deficit in
urine output is assured, and, therefore, it is considered the next 8 hours along with 8 hours worth of mainte-
safe to administer potassium, 20 mEq/L is added to nance fluid; the remainder of the deficit is administered
the replacement solutions. If hypokalemia is a concern, in the subsequent 16 hours, along with the usual hourly
the concentration of potassium in replacement fluids maintenance requirement. Such calculations “work,”
can be increased, but the rate of infusion must be but they are unnecessarily complex and may be so daunt-
considered as well. The limiting factor is the amount of ing as to discourage any calculations, particularly in the
potassium infused per unit time, which should not middle of the night.
exceed 1 mEq/kg per hour without appropriate mon- An easier alternative is to recognize that the bolus of
itoring. 20 mL/kg represents 2% of body weight. If the initial
deficit was estimated to be 10%, the remainder after the
bolus is 8%. This can be replaced conveniently over
Ongoing Losses: Fluid
8 hours at an hourly rate of 10 mL/kg (1% body weight
Ongoing losses represent the abnormal losses that occur
per hour), a number that is easy to calculate mentally.
after the one-time determination of a deficit. Examples
The day’s worth of maintenance fluid then is provided in
include continued diarrhea or vomiting, aspirates from a
16 hours. Administering 24 hours worth in 16 hours re-
nasogastric tube attached to suction, or the polyuria of an
quires a rate of 1.5 times the usual hourly maintenance rate
osmotic diuresis. These losses can be measured directly.
(24 ⫼ 16 ⫽ 1.5). By this method, calculations are simpli-
Other losses, such as abnormal internal collections with
fied, and the amount of fluid administered hourly is close to
an ileus, peritonitis, or edema and external radiant losses,
the same as the more complex way, with slightly more at an
are more difficult to estimate and require experience and
early point (Table 5). As noted previously, rapid “recruit-
careful monitoring of the patient.
ment” is desirable and often obviates the need to provide
the parenteral infusion longer than overnight.
Ongoing Losses: Electrolytes The bolus is normal saline or Ringer lactate; the
Tables are available to estimate the composition of on- remainder of the deficit is provided as D50.45NS ⫹
going losses according to the source of the loss. As a rule 20 mEq/L K⫹, and the maintenance fluid is D50.2NS ⫹
of thumb, gastrointestinal losses can be replaced with 20 mEq/L K⫹. In summary, the rehydration plan is for
half-normal saline, transudates reflect the composition of 20 mL/kg of normal saline for hour 1, 10 mL/kg of
the intravascular space and have the higher sodium con- D50.45NS ⫹ 20 mEq/L K⫹ for hours 2 to 9, 1.5 times

384 Pediatrics in Review Vol.22 No.11 November 2001

 fluid & electrolytes parenteral fluid therapy

Table 6. Signs and Tests to Monitor State of Hydration

Sign or Test Problem
1. Physical signs of dehydration on May be deceiving if [Naⴙ] is abnormal; may be influenced by fever (especially
physical examination pulse)
2. Body weight Can be fooled by “third spacing”
3. Urine volume Output also low in syndrome of inappropriate secretion of antidiuretic
hormone (SIADH), renal failure
4. Urine specific gravity (SG) Concentrating ability of infant kidney limited; SG also high in SIADH, renal
failure; SG low in pyelonephritis
5. Input and output, with direct measure Must estimate maintenance; cannot measure “third space” loss
of all losses
6. Urea nitrogen (BUN) Glomerular filtration rate severely reduced before BUN rises; elevated by blood
in gastrointestinal tract; infant measure normally lower than adult
measure; may mean renal disease
7. Hematocrit Useful serially but not as single value and not if patient is bleeding
8. Concurrent serum and urine Good for detecting SIADH problem
osmolalities
9. Serum electrolyte concentrations By themselves, reveal little about state of hydration
From Roberts K. Fluid and electrolyte disorders in infants and children. In: Beers M, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed.
Whitehouse Station, NJ: Merch & Co; 1999

the usual maintenance amount of D50.2NS ⫹ blood urea nitrogen concentration is increased, it is
20 mEq/L K⫹ for the next 16 hours, and usual mainte- comforting to see a return to normal, but generally blood
nance thereafter. tests have little to offer compared with the bedside
“tests” noted previously. In particular, electrolyte con-
Hypertonic Dehydration centrations do not reflect the state of hydration.
Hypertonic dehydration is an exception to the foregoing
approach. In hyperosmolar states, fluid is drawn into the Summary
intravascular space from the intracellular space, bolster- When planning to rehydrate a dehydrated child parenter-
ing the circulation. The rapid administration of fluid, as ally, it is useful to consider the fluid and electrolyte needs
recommended for isotonic states, can create fluid shifts separately for maintenance, deficit, and ongoing losses.
that result in cerebral edema and intracranial bleeding. For maintenance, both fluids and electrolytes are based
Finberg described a rehydration protocol that permits on metabolic rate. The composition, therefore, is fixed
fluid and electrolytes to be administered safely and has (D50.2NS ⫹ 20 mEq/L K⫹). Systems, such as the
been widely accepted. A bolus may or may not be needed Holliday-Segar formula, relate fluid needs to body
because the contribution of the intracellular space may weight.
have maintained an effective circulating volume. The In assessing the extent of dehydration clinically, the
calculated deficit fluid and electrolyte needs are added to rule of 5 to 10 to 15 (mild dehydration⫽5%, moderate
2 days (48 h) worth of maintenance fluid and electrolyte dehydration⫽10%, severe dehydration⫽15%) applies
requirements; the sum is divided by 48 and administered only to infants. For adolescents and adults, the rule
at a constant hourly rate for 48 hours. estimates are 3% to 5% to 7% or 3% to 6% to 9%.
Intermediate values should be used for school-age chil-
Monitoring the Effectiveness of Parenteral dren.
Fluid and Electrolyte Therapy A bolus of fluid that is similar to extracellular fluid
The best monitoring “tests” are the simple ones that all (ECF) is administered if signs of hypovolemia are
too frequently are overlooked, such as the resolution of present. The amount generally provided to infants and
signs of dehydration apparent on physical examination: small children is 20 mL/kg (2% of body weight); the
tachycardia and dry mucous membranes (Table 6). Serial volume for adolescents is 10 mL/kg (1% of body
weights provide valuable information, as long as there is weight). If an infant’s degree of dehydration is estimated
no “third-spacing.” Measurement of urine volume and to be 15%, a single 20-mL/kg bolus will improve circu-
specific gravity are also helpful. In situations in which the lation but not normalize the hemodynamics. For timely

Pediatrics in Review Vol.22 No.11 November 2001 385

fluid & electrolytes parenteral fluid therapy

restoration of cardiovascular sufficiency, one or more sures because they are the most helpful: physical exami-
additional boluses of 20 mL/kg will be required. nation (to see if the signs of dehydration have improved),
Isotonic dehydration estimated to be 10% of body weight, urine volume, and specific gravity.
weight can be corrected by 20 mL/kg per hour of
ECF-like fluid followed by 8 hours of D50.45NS ⫹
20 mEq/L K⫹ at 10 mL/kg per hour. Maintenance
Suggested Reading
fluids, D50.2NS ⫹ 20 mEq/L K⫹, subsequently are Finberg L. Hypernatremic (hypertonic) dehydration in infants.
provided, initially at 1.5 times the usual rate for 16 hours, N Engl J Med. 1973;289:196 –198
followed by the usual maintenance rate (although, by Holliday MA, Segar WE. The maintenance need for water in
then, parenteral therapy may not be needed). parenteral fluid therapy. Pediatrics. 1957;19:823– 832
Roberts K. Fluid and electrolyte disorders in infants and children.
Ongoing losses, if significant, should be measured and
In: Beers M, Berkow R, eds. The Merck Manual of Diagnosis and
replaced. When it is not possible to measure the losses, Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co; 1999
extra diligence must be applied in patient monitoring. Welt LG. Clinical Disorders of Hydration and Acid-base Equilib-
Monitoring should focus on readily available mea- rium. Boston, Mass: Little, Brown; 1955

386 Pediatrics in Review Vol.22 No.11 November 2001

 fluid & electrolytes parenteral fluid therapy

PIR Quiz
Quiz also available online at www.pedsinreview.org.

9. A 6-year-old girl is admitted for elective removal of a mesenteric cyst. Physical examination reveals a
well-hydrated child whose weight is 23 kg and height is 115 cm. She is afebrile and appears healthy.
Which of the following is the most appropriate parenteral maintenance fluid and electrolytes regimen for
her?
A. 5% Dextrose with 0.20% saline ⴙ 20 mEq/L KCl at 65 mL/h.
B. 5% Dextrose with 0.20% saline ⴙ 40 mEq/L KCl at 95 mL/h.
C. 5% Dextrose with 0.45% saline ⴙ 20 mEq/L KCl at 65 mL/h.
D. 5% Dextrose with 0.45% saline ⴙ 40 mEq/L KCl at 95 mL/h.
E. 5% Dextrose with 0.90% saline ⴙ 40 mEq/L KCl at 65 mL/h.

10. A 2-year-old child presents with a 24-hour history of 10 to 12 large, watery stools and vomiting.
Physical examination reveals sunken eyes, weight of 12.5 kg, temperature of 36.8°C (98.2°F), heart rate of
144 beats/min, respirations of 26 breaths/min, and blood pressure of 78/40 mm Hg. His extremities are
cool, and the capillary refill time is 3 seconds. Of the following, the most appropriate initial intravenous
bolus to be administered over the next hour is:
A. 125 mL Ringer lactate.
B. 250 mL 0.9% saline.
C. 250 mL 5% Dextrose.
D. 125 mL 5% Dextrose with Ringer lactate.
E. 250 mL 5% Dextrose with 045% saline.

11. A 6-month-old girl presents with vomiting and loose stools of 3 days’ duration. Physical examination
reveals an axillary temperature of 37.2°C (99°F), respiratory rate of 32 breaths/min, heart rate of
126 beats/min, and blood pressure of 98/68 mm Hg. The anterior fontanelle and eyes are sunken, the lips
and oral mucous membranes are dry, and the skin appears doughy. Results of laboratory studies include:
serum sodium, 168 mEq/L (168 mmol/L); potassium, 5.2 mEq/L (5.2 mmol/L); chloride, 136 mEq/mL
(136 mmol/L); and bicarbonate, 10 mEq/L (10 mmol/L). A true statement about this girl’s condition is
that:
A. A 20 mL/kg bolus of 5% dextrose should be administered over 1 h.
B. Extracellular fluid is depleted more than intracellular fluid.
C. Rehydration should occur over 48 h at a constant rate.
D. Total body potassium is increased.
E. Total body sodium is increased.

Pediatrics in Review Vol.22 No.11 November 2001 387