fluid an electrolyte management in children.pptx

Fluid and electrolytes management in pediatric patients

1. 1 Fluid and electrolyte management in paEdiatrics d R OLADELE, A.G DEPARTMENT OF PAEDIATRICS FETHI IDO-EKITI 7/12/2021

2. OUTLINE: Introduction Fluid and electrolyte physiology Disturbances of fluid and Electrolytes Fluid therapy Electrolyte therapy

3. INTRODUCTION Fluid and electrolyte therapy is an essential component of care of sick children Fluid and electrolyte requirements in health and sickness may change with growth in children. Many factors contribute to fluid and electrolyte disturbances of children

4. Understanding the pathophysiology of the disease process is important in fluid and electrolyte therapy. Fluid and electrolyte therapy is categorized into maintenance, deficit and replacement therapy In children the turnover of Total body water(TBW) is 15-20% in 24 hrs compared to 5% in adults. As a result, fluid losses in infants and young children constitute significant percentage reduction of extra cellular fluid volume.  

5. Body Composition Fluid 60% Solid 40 % Fat Protein Carbohydrate Minerals 5

6. Distribution of body fluids (by wEIGHt ) Fluid 60% of Body weight Intracellular Extracellular Interstitial Intra vascular(plasma) 6 Intracellular 40% (cytoplasm, nucleoplasm ) Interstitial 15% (lymph, CSF, synovial fluid, aqueous humor and vitreous body of eyes, between serous and visceral membranes, glomerular filtrate of kidneys. ) Plasma 5% There is continuous ongoing equilibrium between the intracellular and extracellular spaces.

7. Fluid content according to age Total body water (TBW) vary with age: Preterm = 80-85% Term = 75% Infant= 65% Older children & adult male= 60% Adult female=50% 7 TBW ↓ to 60% by 1st yr of life Female has less fluid content because of more fat cells

8. Age and TBW Age Body water(%) ECF (%) ICF(%) Term baby 75 35-44 33 4-6 months 60 23 37 12 months 60 26-30 37 Puberty 60 20 40 Adult 50-60 20 40

9. Composition of body fluid Water Electrolytes : Inorganic salts, Sodium(Na), Potassium(K), Calcium (Ca), Chloride(Cl), Phosphate(Po4), Bicarbonate(HCO3, Sulphate(SO4) Nonelectrolytes : Minerals -iron and zinc, Glucose, Lipids, Creatinine, Urea 9 Electrolytes are measured in mEq or mmol Circulating electrolytes are electrically charged When positively charge called cation : Na + , K + , Ca ++ When negatively charge called anions : Cl - , HCO3 - , SO4 -

10. Electrolytes composition of body fluids Normal Values(serum) Cation : Sodium (Na +) 135 – 145 mEq /L Potassium (K + ) 3.5 – 5.5 mEq /L Calcium ( Ca ++ ) 8.5 – 10.5 mg/ dL Ionized Calcium 4.5 – 5.5 mg/ dL Magnesium (Mg++) 1.5 – 2.5 mEq /L Anion: Bicarbonate (HCO - 3 ) 24 – 30 mEq /L Chloride ( Cl -- ) 95 – 105 mEq /L Phosphate (PO 4 --- ) 2.8 – 4.5 mg/ dL 10

11. Distribution of Cation and Anion in ECF & ICF (mEq/l) 11 INTRA CELLULAR FLUID CATION Mg 1.1 Ca + 2.5 K+ 4 HCO3 – 24 Prot – 14 Others 6 PO4 - 2 Na+ 13 Mg+ 17 Prot - 40 HCO3- 10 Cl- 3 ANION ANION CATION EXTRA CELLULAR FLUID Na + 140 K + 140 Cl - 104 Phos - 107

12. Concentration of Body fluid Units of solute concentration are osmolarity and osmolality Osmolarity: Number of osmoles of solute per liter (L) of solution. It is expressed as osmol/L e.g 1 mol/L NaCl solution has an osmolarity of 2 osmol/L Osmolality : Number of osmoles of solute per kilogram(kg) of solvent. It is expressed as osmol/kg Normal serum osmolality=280-298 mosmol/kg 12

13. Clinical relevance of osmolality Calculation: Serum osmolality ( mosmol /kg) = Effective osmolality: O smotic force that is mediating the shift of water between the ECF and the ICF = The osmotic gap ( osmolal gap): is the difference between the actual osmolality (measured by the laboratory) and the calculated osmolality A normal osmolal gap is < 10 mOsm /kg 13 2(Na + + K + ) mmol /l + Urea ( mmol /l)+ Glucose ( mmol /l) 2 x Na + ( mmol /l )+ Glucose ( mmol /l)

14. Regulation of Body Fluids Body fluid Homeostasis is maintained through Fluid intake Hormonal regulation Antidiuretic hormone(ADH) Renin-Angeotensin-Aldosterone Mechanism Natriuretic Peptides Fluid output 14

15. A. Fluid intake Intake is controlled by hypothalamic thirst center 15 ↑ plasma osmolality of 1–2% ↓ plasma volume 10%–15% Baroreceptor input, angiotensin II, and other stimuli Moistening of the mucosa of the mouth and throat Activation of stomach and intestinal stretch receptors −Ve

16. 1. Antidiuretic hormone(ADH) ADH: Secreted by the hypothalamus, and stored in the posterior pituitary gland ADH is released by, thirst, ↓ fluid volume, High serum osmolality Action reabsorb water from collecting duct of kidney inhibit sweat glands to ↓ perspiration to conserve water acts on arterioles , causes constriction thus ↑ Blood pressure. ADH is Inhibited by Excessive fluid volume Low osmolality of serum 16 B. Hormonal regulation

17. 2. Renin- Angiotensin-Aldosterone Mechanism 17 Low blood volume ↓Renal perfusion Renin from Kidney Angiotensinogen Angiotensin I Angiotensin II ACE Aldosterone from adrenal cortex Reabsorption of sodium and water Excretion of potassium

18. 3. Natriuretic Peptides Natriuretic Peptides Atrial Natriuretic Peptide(ANP ) from atria Brain Natriuretic Peptide(BNP) from ventricle Action Acts like a diuretic that causes sodium loss and inhibits the thirst mechanism Inhibit renin release Inhibit the secretion of ADH and aldosterone Vasodilatation 18

19. C. Regulation by fluid output 19 Daily fluid losses: Kidney(Urine): 55% Skin: 30% Lung: 10% GI (Stool): 2-5%

20. Fluid & Electrolyte therapy 20

21. Fluid therapy 21 Maintenance therapy : Replacement of daily physiologic losses of water and electrolytes under normal condition Deficit therapy : Replacement of abnormal loss

22. Maintenance and Replacement Therapy  Goals of Maintenance Fluids: Prevent dehydration   Prevent electrolyte disorders    Prevent ketoacidosis    Prevent protein degradation

23. Maintenance fluid requirement Water requirements are directly related to caloric energy expenditures For expenditure of 1 kcal/kg need 1 ml/kg of water Caloric expenditure varies with the age. Younger the age expends more calories. 23

24. Calculation of daily maintenance fluid Daily Basis * Wt 1-10 kg: 100 ml/kg Wt 11 to 20 kg: 50 ml/kg Wt >20 kg up to 80 kg:20 ml/kg Maximum 2400 ml/day. 24 *Holliday-Segar Method

25. Adjustments in Maintenance Water SOURCE CAUSES OF INCREASED WATER NEEDS CAUSES OF DECREASED WATER NEEDS Skin Radiant warmer Incubator (premature infant)   Phototherapy     Fever     Sweat     Burns   Lungs Tachypnea Humidified ventilator   Tracheostomy   Renal Polyuria Oliguria/anuria Miscellaneous Surgical drain Hypothyroidism   Third spacing  

26. Alterations of Maintenance Fluid Requirements Factor Altered Requirement Fever 12% per °C Hyperventilation 10–60 mL/100 kcal Sweating 10–25 mL/100 kcal Hyperthyroidism Variable: 25%–50% Gastrointestinal loss and renal disease Monitor and analyze output. Adjust therapy accordingly.

27. Maintenance fluid requirement Daily losses in normal condition: 100ml/100kcal Sensible losses 60%: Urine: 55% Stool: 5% Insensible losses 40%: Skin: 30% Lung: 10% Insensible loss increase: Fever-Increase by 10-12% per 1 C above 37.8 C. Tachypnea increase loss by 10-30%. Prematurity- insensible loss more than term. 27

28. Daily maintenance electrolyte requirement Sodium 2 - 3 mmol /100ml H 2 O /day Potassium 1 - 2 mmol /100ml H 2 O /day Chloride 2 - 3 mmol /100ml H 2 O /day 28

29. What types of IV fluid ? Types of IVF used: Normal saline (0.9% NaCl /L) = 154 mEq Na + /L One-half NS (0.45% NaCl /L) = 77 mEq Na + /L One-third NS (0.33% NaCl /L) = 57 mEq Na + /L One-quarter NS (0.25% NaCl /L) = 38 mEq Na + /L One fifth NS(0.18% Nacl ) = 30 mmol /l Ringer’s lactate= Na + 130 mmol /l, K + 4 mmol /l, Cl - ,109 mmol /l, bicarb 28 mmol /l , and Ca ++ 3 mg/dl ) 29

30. OBJECTIVES OF FLUID THERAPY Objectives of Fluid therapy Restoration of Normal Volume and Composition To normalize the intracellular and extracellular chemical environments in order to optimize cell functions

31. OBJECTIVES OF FLUID THERAPY IN CIRCULATORY SHOCK To rapidly restore effective circulating volume in shock states such as hypovolaemic or distributive shock Restore oxygen-carrying capacity in haemorrhagic shock states Correct metabolic imbalances secondary to volume depletion

32. DETERMINATION OF REQUIREMENTS Fluid requirements are categorized into 3: Maintenance fluid requirement Depends on metabolic rate Replaces usual body losses of fluids and electrolytes Replacement of deficits: Replaces abnormal losses of fluids and electrolytes as a result of illness and is calculated per kilogram of body weight Supplemental fluid therapy : Replaces ongoing losses of fluids and electrolytes Administered in addition to the maintenance and deficit fluid replacement therapies

33. MODES OF FLUID THERAPY Oral fluid therapy- fluids administered orally or through a nasogastric or other tubes for enteral [intestinal] absorption Parenteral fluid therapy: Intravenous Intraosseous Intraperitoneal Subcutaneous (human hyaluronidase facilitated)

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35. TYPES OF FLUIDS FOR ORAL THERAPY Fluids that contain salt ORS solution A salted drink A salted soup Fluids that do not contain salt: Plain water Water in which a cereal has been cooked[ e.g Rice water[unsalted] Garri water Soup[unsalted] Yoghurt-based drinks unsalted Green coconut water Weak tea[unsweetened] Unsweetened fresh fruit juice

36. Types of Oral Rehydration Solutions (ORS) - Salt sugar solution - Standard ORS - Low Osmolarity ORS Super ORS Super Super ORS - ReSoMal

37. Composition of ors solutions Composition Standard ORS ( mmol /l) Low osmolarity ORS ( mmol /l) Na + 90 75 K + 20 65 Cl - 80 20 Citrate 10 10 Glucose 111 111 Osmolality 311mosm/l 245mosm/l

38. TYPES OF DEHYDRATION Classification based on: Fluid volume depletion-Mild, Moderate and Severe dehydrations Plasma tonicity [ osmolality ]-Hypotonic, Isotonic and hypertonic dehydrations Sodium deficit: Hyponatraemic [10-15%], Isonatraemic [70%] and Hypernatraemic [10-15%] dehydrations

39. ISOTONIC DEHYDRATION Commonly caused by diarrhoea . Net losses of water and sodium are in the same proportion as normally found in the Extracellular fluid, Signs appear when losses exceed 5% body weight and worsen with increasing losses. Features Balanced deficit of water and sodium Serum sodium concentration is normal[130-150mmol Serum osmolality is normal [275-295 mOsmol /l] Hypovolaemia occurs as a result of substantial ;loss of ECF

40. HYPERTONIC DEHYDRATION Results from ingestion of fluids with high sodium or electrolyte content with poor intake of water or other hypo-osmolar fluids and poor absorption of the administered fluids. There is osmotic diarrhoea with loss of fluid from ECF Features: There is deficit of water and sodium, but the deficit of water is greater Serum sodium concentration is elevated[>150 mmol /l]; Serum osmolality is elevated[> 295mOsmol/l] Thirst is severe and out of proportion to the apparent degree of dehydration; the child is very irritable; Seizures may occur, especially when serum sodium concentration exceeds 165 mmol /l

41. HYPOTONIC DEHYDRATION Results from intake of water or fluids with low solute content e.g. Dextrose infusions. The water is absorbed while sodium loss continues Features There is deficit of water and sodium but the deficit of sodium is greater Serum sodium concentration is low-<130mmol/l Serum osmolality is low-<275 mOsmol /l The child is lethargic and infrequently may have seizures

42. MANAGEMENT History: usually suggests the etiology of dehydration. Initial assessment Fluid therapy: -Enteral -Parenteral: 42

43. Clinical features of dehydration 43 From Lissauer & Graham 2002

44. Signs & Symptoms MILD MODERATE SEVERE Weight Loss 3-5% 6-9% >10% General condition Well, alert Irritable Lethargic/floppy Thirst Thirsty Drinks eagerly Unable to drink Oral mucous Slightly dry Dry Parched Ant fontanel Normal Depressed+ Depressed ++ Eyes Normal Sunken + Sunken ++ Skin turgor Skin pinch retracts: Normal Normally Depress in >2 sec Tenting Takes>3 sec Urine output Normal Decrease No urine Pulse Normal Rapid Rapid & weak Respiration Normal Deep Deep & Rapid BP Normal Normal Decrease Capillary refill time Normal ± 2 Sec > 3 sec 44 CLINICAL ASSESSMENT OF SEVERITY OF DEHYDRATION

45. Parenteral therapy has three phases: Initial therapy is to expand the extracellular fluid volume rapidly and improve circulatory and renal function Subsequent therapy is to replace deficits while providing for maintenance water, electrolyte requirements and ongoing losses Final phase is returning the patient to normal composition and oral feedings with gradual correction of total body potassium

46. 46 MANAGEMENT OF DEHYDRATION Water deficit = Weight X % of dehydration In mild dehydration 5% deficit = 50 ml/kg (1kg=1000gm=1000 ml; 5%=(5/100)X1000 = 50ml/kg) In moderate dehydration 6-9% deficit = 60-90 ml/kg In severe dehydration 10% deficit = > 100 ml/kg

47. Oral rehydration therapy (ORT) ORT is divided into 2 phases: A . Rehydration phase: aims to restore the existing deficit fluid B. Maintenance phase: compensate for continued fluid loss Golden rule: “Give them as much as they will drink” 47

48. ORS REQUIREMENTS IN DIARRHOEA Mild Dehydration 30 – 50ml/kg of ORS over 4hrs* Moderate Dehydration 60 -90ml/kg of ORS over 4hrs* * Re-assess after 4 hrs, if dehydration persists, repeat above.

49. CONTRAINDICATIONS TO ORT ADMINISTRATION Purging at very high rate[>10-15ml/kg/hr] Persistent vomiting Severe Dehydration Inability or refusal to drink Glucose malabsorption Abdominal distension and ileus

50. MANAGEMENT OF DEHYDRATION Parenteral therapy Indications: Severe dehydration Persistent vomiting Inability to take orally Intestinal surgery Paralytic Ileus 50

51. Initial Therapy This is part of deficit replacement given to expand the ECF rapidly. Normal saline is the fluid of choice or Ringers lactate It is given at dose of 20 – 30 ml/kg over 1hour for an infant For older children, it is given over 30 minutes A Second dose can be given, and occasionally a third dose until patient is stabilized This therapy applies to isonatremiic , hyponatremic or hypernatremic dehydrations Potassium containing fluid is not given in initial therapy except ringers lactate which contains only 4 mEq /L In situation of severe anaemia , whole blood can be given at 20 ml/kg Colloids can be used to re-expand the plasma volume if crystalloids did not achieve good result.  

52. Subsequent Therapy This involves the replacement of the remaining deficit. Provision of maintenance fluid and electrolyte Replacement of ongoing losses

53. Principles of administration of subsequent Therapy There are two methods: Correction of remaining deficit and maintenance together. . In this situation, the fluid of choice is 5% dextrose in 0.45% saline . .

54. Calculate the remaining deficit replacement after the initial therapy has been given Calculate the maintenance for 24 hours Give this remaining deficit plus 1/3 of maintenance over 8hrs. Maintenance of potassium at 20mEq/L should be added The remaining part of maintenance therapy is given over 16hrs Ongoing losses is quantified during these period and replaced accordingly

55. B: Another method is to correct deficit completely before commencement of maintenance For infants, this is done over 6hrs, and for older children 3 hours IV Normal saline 20 – 30 ml/kg over 1 hour. The remainder of 70 – 80 ml is given over 5 hours For older children, IV N/saline 20 – 30 ml/kg over 30 minutes, the rest is given over 2½ hours. For moderate dehydration, 75 ml/kg is given orally for 4hours. After this deficit correction, the maintenance is calculated and administered over 24 hours. On-going losses are recorded at interval of 2hours and added to maintenance.  

56. MONITORING FLUID THERAPY Proper regulation of the quantity of fluids: The drops per minutes should be checked regularly and the fluid levels recorded hourly Examine the patient frequently, more frequently when rapid fluid administration is being carried out, otherwise, do it hourly; assess for signs of dehydration Weigh the child daily Monitor fluid input and output including urine (newborn and infant: 1-2ml/kg/hour, Toddler: 1.5ml/kg/hr, older child: 1ml/kg/hr, adult: 0.5ml/kg/hr) and other outputs closely Laboratory parameters-Electrolytes, Urea and creatinine , Hb /PCV, Urinalysis

57. Water deficit= Weight X % of dehydration In mild dehydration deficit= 50 ml/kg (1kg=1000gm=1000 ml; 5%= (5/100)x1000 = 50ml/kg) In moderate dehydration deficit = 60-90 ml/kg In severe dehydration deficit = > 100 ml/kg Electrolyte deficit Na & Cl deficit=water deficit X 8 mmol /100ml K deficit= water deficit X 3 mmol /100 ml 57 Fluid & electrolyte calculation

58. Shock therapy: 10 × 20=200 ml of normal saline should be given over 20- 30 min as shock therapy Serum sodium was 138 mmol /l Subsequent therapy: Deficit fluid=10 × 100=1000 ml Fluid given during shock therapy=200 ml Remaining fluid deficit= 1000-200=800 ml Maintenance fluid for 24 hour=10 × 100=1000 ml Total fluid for 24 hour = 800 ml+1000ml= 1800 ml 58 Example : 2yr old Child, weight is 10 kg, arrived in EPU with severe dehydration.

59. Choice of fluid: Na requirement: Deficit=8 mmol /100ml=0.8 × 800= 64 mmol Maintenance requirement= 3 mmol /100ml= 10 × 3=30 mmol Total = 64+30=94 mmol /day Potassium 30+10=40 mmol /day One half NS in D5W + 20 mmol of KCL/l will be appropriate solution 59 Parenteral therapy(cont ..)

60. 2. Hypernatremic dehydration : Serum Na+ > 160mEq/l Initial phase of therapy is same Deficit therapy should be spread over 36-84 hours according to the result of serum Na: Serum Na 145-157 mEq /l- over 24 hr Serum Na 158-170 mEq /l- over 48 hr Serum Na 171-183 mEq /l over 72 hr Serum Na 184-196 mEq /l over 84 hr Goal is not to decrease serum sodium >10 mEq /L over 24hr 60 Parenteral therapy(cont..) Subsequent therapy

61. One yr. old wt 10 kg with severe dehydration in shock Shock therapy: 20 × 10=200 ml N S to be given over 30 min E/U/Cr result shows S. Na 170 mmol /l. Subsequent therapy: Deficit=10 × 100=1000 ml Fluid given during initial phase= 200 ml Remaining deficit 1000-200=800 ml Maintenance requirement for 48 hr=(10 × 100) × 2=2000 ml Total fluid 2000+800=2800ml to be given over 48 hr ½ NS D5W+ KCL should be used 61 Parenteral therapy(cont..) Example:

62. Electrolyte Imbalances Hyponatremia/ hypernatremia Hypokalemia/ Hyperkalemia Hypocalcemia/ Hypercalcemia 62

63. HYPERNATREMIA Na+ Concentration ˃145 mEq /L There is excessive loss of body water in comparison to loss of Na+ Can also be caused by excess administration of Na+ to the body system  

64. CAUSES OF HYPERNATREMIA (a) Excess Na gain: - Hypertonic infant formula - Hypertonic ORS - Excessive use of NaHCO 3 in resuscitation - Hypertonic enemas - Zealous infusion of hypertonic saline - Intentional salt poisoning(munchausen syndrome by proxy) - Intravenous hypertonic saline - Hyperaldosteronism  

65. (b) Primary water Deficit - Diabetics insipidus - DKA - Diarrhoeas - Increased insensible loss - Reduced water intake - Inadequate breast feeding infants - Adipsia Water and Sodium deficit - diarrhoea , DM, postobstructive diuresis . -osmotic carthartics eg lactulose , osmotic diuretics,

66. Clinical Features Sign of dehydration are less pronounced because intravascular volume is fairly maintained as fluid sift from cells into ECF. Doughy’ feeling of the skin rather than tenting is observed in testing for skin turgor Increased Muscle tone Hyper- reflexia Irritability out of proportion to degree of dehydration High-pitched cry Lethargy Intracranial haemorrhage Seizures Coma

67. Treatment Treatment could be challenging for symptomatic hypernatraemia Avoid rapid correction of Na+ levels as rapid decline can cause cerebral oedema Recommended rate of decline is 10-12 mEq /L in 24 hours Fluid and Na+ deficit should be corrected over 48 – 72 hours Severe level exceeding 180 mEq /L needs dialysis For non-symptomatic hypernatraemia , treat the aetiologic factor promptly For symptomatic hypernatraemia , (a) Calculate body water deficit Water deficit = [(observed Na ÷ 145) -1] x 0.6 x weight (kg) For a 10kg child with Na+ of 160 mEq /L Water deficit = [(160 ÷ 145 mEq /l)-1] x 0.6 x 10kg = 0.62L

68. (b) Calculate the volume of actual fluid to be replaced. This is determined by Na+ concentration in IVF to be used. Usually 0.45% saline in 5% dextrose water is preferred.   Replacement fluid = 0.62L x [1 ÷ 1-(75÷154mEq/L)] 0.62L x [1÷1-0.5] 0.62L x 2 = 1.24 L This amount of 0.45% saline in 5% Dextrose is given over 48-72 hours. Once child starts making urine, 40 mEq /L of K is added to the fluid to aid water movement into cells. For hypernatraemia due to NaCl poisoning or Na overload , 5% dextrose water is used plus diuretics

69. Monitor Na Plasma level 4hourly Monitor other electrolytes and blood sugar Hyponatraemia Greater loss of Na+ than water Serum Na+ less than 130 mE.q /L

70. Causes Renal losses - prematurity - ATN in recovery phase - Diuretics (thaizide and loop diuretics) - Renal salt wasting - mineralocorticoid deficiency - osmotic diuresis - Renal tubular acidosis

71. Extra renal causes - Diarrhoea and vomiting - Burns - Nasogastric drainage - cystic fibrosis Water excess as in compulsive water drinking SIADH Infusion of hypotonic IV fluid Psychogenic polydipsia Tap water enemas   (d) Na+ and water retention - Nephrotic syndrome - Cirrhosis - Cardiac failure - Acute and Chronic renal failure  

72. Clinical Features: Nausea, anorexia, vomiting and malaise in mild reduction Lethargy, confusion Decreased level of consciousness Headaches Seizure and coma in severe reduction Decreased reflexes, muscles weakness and cramps

73. TREATMENT OF HYPONATRAEMIA - Calculate Na+ deficit using the formula below: Na+ deficit = 135 – observed Na+ level x 0.6 x weight The value of 0.6 is a constant for cation which is the distribution in TBW The calculated deficit is given over 24 – 48 hours period Symptomatic hyponatraemia which manifests with seizure is corrected using 3% saline at 12ml/kg given at 1ml/min. Replacement fluid in hyponatraemic dehydration is calculated as isonatraemic dehydration.

74. HYPERKALAEMIA - Plasma K level ≥ 5.5 mEq/L Causes - Increased K+ intake - Acute or Chronic renal failure - Adrenal insufficiency - Use of K+ sparing diuretics - Acute tissue breakdown from trauma, surgery, burns - Tumour lysis syndrome - Digitalis overdose - Transfusion of haemolysed blood  

75. Effects of ECG ST – segment depression PR interval peaked T wave Flattening of P wave  Widening of QRS complex Ventricular fibrillation Effects in other systems include: Paraesthesias Fasciculations of the muscles Weakness Ascending paralysis Signs of cardiac toxicity usually precedes these effects.  

76. TREATMENT OF HYPERKALAMIA - It is a medical emergency - Promptly discontinue all K+-containing IV fluids and drugs Three Principles of therapy 1. Stabilize cardiac membrane - Give IV calcium gluconate 10% at 0.5 ml/kg over 5-10 minutes with ECG monitoring. - This dose may be repeated as necessary

77. 2. Enhance cellular uptake of K+ a. IV Sodium bicarbonate 1-3mg/kg diluted and given slowly b. IV Regular insulin and glucose - IV Glucose load is 0.5 g/kg / hr - Insulin 0.05 IU/Kg / hr c. Give salbutamol at 0.5 mg/kg IV or Nebulized salbutamol at 2.5 mg if <25kg; or 5mg if ˃25 kg 3. Enhance Elimination - Na+ polystyrene sulfonate (kayexalate) orally/rectally at a dose of 1g/kg/24hrs 6hourly - IV frusemide - Emergency haemodialysis if severe hyperkalemia of ˃ 7.0 mEq /L

78. HYPOKALAEMIA Potassium level of less than 3.5 mEq/L Cause, - Decreased intake - Diuretics [ thaizide and loop diurectics causes kaliuresis] - Renal tubular acidosis - Acid – base disturbances - DKA - Barter Syndrome - Cushing,s syndrome - Primary aldosteronisism - Mg deficiency -

79. - Chronic diarrhea - Persistent diarrhea - Chronic catharsis - Frequent enemas - Protracted vomiting - Enterocutaneous fistulas Effects: (a) Neuromuscular effects: - orthostatic hypotension - tetany Areflexia due to decreased muscular excitability Muscle weakness of the limbs, the trunk and respiratory muscles.

80. GUT: - Paralytic ileus due to decreased gut mortility - Gastric dilatation Kidney - nephrosclerosis due to tubular vacuolation - Interstitial fibrosis - Polyurea - Polydipsia - Systemic alkalosis   Polyurea and polydipsia results from inability of kidney to concentrate urine. Heart - Prolonged QT interval - flattened T waves

81. T wave inversion and prominent U waves in hypokalaemia

82. Treatment of Hypokalaemia - Treatment of the aetiology before attempt to treat hypokalaemia - Asymptomatic or mild hypokalaemia may resolve with treatment of aetiology or with oral potassium supplements - Symptomatic hypokalaemia to be corrected with intravenous potassium - Calculate deficit K+ Deficit = 4 mEq/L – observed K+ x 0.6 x weight - Add maintenance at 2mEq/Kg - Add both deficit and maintenance in IVF for 24 hours  

83. Hypocalcemia Corrected Serum calcium < 8.5 mg/dl(<2.1 mmol/L) Ionized calcium level < 4.5 mg/dl(1 mmol/l) ↓ of 1 gm/dl of serum albumin, there is decrease of 0.8mg/dl (0.2 mmol/l) of total serum calcium Corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 (4.0 - serum albumin [g/dL]), where 4.0 represents the average albumin level gm/dl Cause inadequate intake, nutritional ricket malabsorption, pancreatitis, Hypoparathyroidism (Congenital or aquired ), loop diuretics, low magnesium levels 85

84. Signs & Symptoms Neuromuscular Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany Fractures Diarrhea ECG changes 86

85. Management Calcium gluconate IV for acute symptomatic cases Oral or IV calcium replacement Vit D replacement in case of Ricket Cardiac monitoring 87

86. Hypercalcemia Causes- Malignancy(bone secondaries) ↑ parathyroidism , granulomatous dis, vit D or A intoxication, thiazide. Total Ca> 15mg/dl or symptomatic is considered an emergency Identify and treat cause Saline hydration Frusemide 1-2 mg/kg/d 4hrly Calcitonin -4unit/kg –inhibits bone resorption Steroid especially if ↑Ca due to tumor, vitamin D toxicity or granulomatous disease- decreases gut Ca absorption

87. Hypercalcemia contd. Mithramycin – in hyperparathyroidism or malignancy with spread to bone. - 15-25mcg/kg / day IV over 3-4days. Reduces bone resorption Dialysis with Ca free dialysate Last resort- bind Ca with chelators or bisphosphonates

88. CONCLUSION Disorders of fluid and electrolytes constitute major morbidity and mortality in children. Understanding the disease processes and the accompanying fluid and electrolyte derangement are important in management. Prompt management is most often life saving. In some cases of end-organ damage it could be very challenging A good laboratory backing is important for successful therapy

89. THANKS FOR LISTENING!

90. REFERENCES Kliegman , Robert, Larry. Nelson Textbook of Paediatrics : Fluid and electrolyte disorders. Edition 21. Philadelphia, PA: Elsevier, 2020. McMillan, Feigin . Oski’s Paediatrics principles and practice: Fluid and electrolyte physiology and therapy. Edition 4. Lippincott Williams & Wilkins, 2006. WHO. (2005). The treatment of diarrhoea : a manual for physicians and other senior health workers, 4 th rev. ln : https://apps.who.int/iris/handle/10665/43209. Dr Onyema , 2021,lecture slides on f luid and electrolyte therapy in children. 92

91. REFERENCES Recombinant human hyaluronidase -enabled subcutaneous pediatric rehydration. Coburn H Allen et al. Pediatrics. 2009 Nov. ln : https://pubmed.ncbi.nlm.nih.gov/19805455/ Accessed 26/11/21 Subcutaneous rehydration: updating a traditional technique. Pediatric emergency care. 2011; 27(3): 230-6(ISSN: 1535-1815). Spandorfer PR. ln : https://www.medscape.com/medline/abstract/21378529?src=mbl_msp_android&ref=share . Accessed 26/11/21 93