fluid and electrolyte in pediatrics.pptx

Fluid and Electrolyte management in pediatrics

1. Fluid and Electrolyte in Pediatrics Presenter -Dr Henok M( Pediatric resident )

2. Outline Introduction Regulation of osmolality and Volume Fluid management Electrolyte abnormalities

3. Only 41.96 % of respondents had adequate knowledge of IV fluid therapy Showed that 56.3% of respondents had a satisfactory practice of IV fluid therapy in children. 

4. Introduction

5. Osmolality Plasma osmolality, normally 285-295 mOsm /kg. The plasma osmolality can also be estimated by a calculation based on the following formula: Osmolality = 2 × [Na] + [glucose] /18+ [BUN] /2.8 Effective osmolality determines the osmotic force that is mediating the shift of water between the ECF and the ICF. Effective osmolality = 2 × [Na] + [glucose] /18

6. Osmolality Regulation of Osmolality Modification of water intake and excretion maintains normal plasma osmolality. Osmoreceptors in the hypothalamus sense plasma osmolality. Regulation of Volume adequate body sodium is necessary for maintenance of intravascular volume The kidney determines sodium balance

7. Osmolality Volume overload occurs when Na + intake exceeds output. Kidney failure Neonatal period Primary hyperaldosteronism or Renal artery stenosis Acute glomerulonephritis HF, liver failure, nephrotic syndrome, and other causes of hypoalbuminemia

8. Osmolality continue .. Volume depletion usually occurs when Na+ losses exceed intake . Urinary Na+ wasting Iatrogenic renal Na + wasting CAH Inadequate intake of Na+ is uncommon Isolated disorders of water balance can affect volume status and Na+ balance

9. Fluid management Maintenance intravenous (IV): fluids are used in a child who cannot be fed enterally. Replacement fluids if they have continued excessive losses, as may occur with drainage from a nasogastric (NG) tube or with high urine output. Deficit replacement . If dehydration is present, the patient also needs to receive

10. Maintenance Fluid(MF) Maintenance fluids are composed of a solution of water, glucose, Na + , and K + . It approximately 20% caloric needs of the patient. Goals of MF Prevent dehydration Prevent electrolyte disorders Prevent ketoacidosis Prevent protein degradation

11. Maintenance Fluid amount   Holliday-Segar  Body wt Fluid per day 0-10kg 100ml/kg 11-20kg 1000ml + 50ml/kg > 20kg 1500ml + 20ml/kg Hourly Maintenance Water Rate For Wt. 0-10kg: 4mL/kg/ hr For Wt. 10-20kg: 40mL/ hr + 2mL/kg/ hr × (wt. - 10kg) For wt. >20kg: 60mL/ hr + 1mL/kg/ hr × (wt. - 20kg) 1500 ml /m2 /24 hours

12. Selection Of Maintenance Fluid type Surgical patients typically receive isotonic fluids during surgery. Children with meningitis are fluid restricted unless intravascular volume depletion is present . In resp. distress patient esp. due to obstructive air way disease it is better to use solutions with lesser Cl -. In MV patients 2/3 of normal maintenance. IHPS and DKA

13. Replacement Fluids

14. Replacement Fluid for Emesis or Nasogastric Losses AVERAGE COMPOSITION OF GASTRIC FLUID Sodium: 60mEq/L Potassium: 10mEq/L Chloride: 90mEq/l APPROACH TO REPLACEMENT OF ONGOING LOSSES Solution: normal saline + 10mEq/L KCl Replace output mL/mL every 1-6hr

15. Replacement Fluids Surgical drains can produce measurable fluid output. Replacement of third space fluid is empirical. Protein losses from chest tube drainage can be significant, occasionally necessitating that 5% albumin be used as a replacement solution.

16. Deficit Therapy First step is to assess the degree of dehydration. The degree of dehydration is underestimated in hypernatremic dehydration . Fluid deficit= DHN% x weight % DHN = (pre-illness wt kg – illness wt kg) / pre illness wt X 100%

17. Positive fluid balance Affect oxygenation Longer duration of ventilation Longer hospital stay I ncrease mortality

18. Case scenario Hx : A 2-yr-old/Male presented to ER C/C: with a 2-day hx of watery loose stools. He has poor feeding had passed urine once since morning . P/E: has sunken eye and had a weak cry. p BP at 5th centile Pulses were very feeble, cooled extremity ,capillary refill time >3 s and wt 2 days back 12 kg and currently 11.5kg

19. Electrolyte abnormlity

20. About 45% of patients developed electrolyte abnormalities Hyponatremia 23.1% hypernatremia 16% Hypokalemia 22.1 % hypokalemia 11% Hypernatremia contributed for significant mortality Eight times increased mortality was noted in hyperkalemia patient

21. Case scenario Hx “ A3 month old has diarrhea for 4 days. P/E: BP :80/40, PR : 150, doughy skin and sunken eyes. creatinine 1.0, BUN 60, Na :170, K: 6.0, Cl : 132, and bicarbonate 15 . Fluid therapy is instituted and 12 hours later the patient has a generalized seizure. The most likely explanation for these findings

22. Hypernatremia Hypernatremia is a [Na+] >145 mEq /L , Classified into Mild: Na 146 - 150 mmol / L Moderate : Na 150 - 169 mmol / L Severe : Na ≥ 170 mmol / L

23. Etiology and Pathophysiology There are three basic mechanisms of hypernatremia Excessive Sodium Water Deficit Water and Sodium Deficits Increased GI, Cutaneous and Renal loss

24. Clinical manifestation Dehydrated and show the typical clinical signs and symptoms.. Some infants have a high-pitched cry and hyperpnoea. Brain hemorrhage ( subarachnoid, subdural, and parenchymal ) Osmotic demyelination syndrome (ODS) Thrombotic complications

25. Diagnosis .

26. Treatment Issues that need to be addressed when treating pediatric hypernatremia are: volume status magnitude of the water deficit rate of correction Replacement therapy underlying cause of hypernatremia and specific interventions

27. Treatment water deficit in L = 0.6 × Wt. in kg × ([Current plasma Na/140] – 1 ) water deficit in mL = (4 mL/kg) × (Wt. in kg) × (Desired change in plasma Na ) R ate of correction should   not  exceed a decline of Na greater than 0.5 meq/L/ hr (i.e., 10 to 12 meq/L per day)

28. Treatment C hronic hypernatremia should not be corrected rapidly . An infusion of 3% saline can acutely increase the serum [Na+], reversing the cerebral edema. Acute, severe hypernatremia, usually secondary to sodium administration, can be corrected more rapidly with D5W . The fluid of choice is 0.9% NS

29. Case scenario Hx “ A6 month old has diarrhea for 4 days. P/E : weight 10kg BP :80/40, PR : 150, doughy skin and sunken eyes. creatinine 1.0, BUN 60, Na :170, K: 6.0, Cl : 132, and bicarbonate 15.

30. Case scenario Hx : A 10 yr old/male has Dx with AGE and has been anuric for 12hr P/E : concious BP 80/50, HR 120, capillary refill > 3 seconds and lab Na 30, K 5.0, Cl :100, BUN 100,Cr 10, bicarbonate 12 and HGB 12. The most appropriate parenteral fluid regimen ?

31. Hyponatremia Is a serum sodium level <135 mEq /L. Hyponatremia exists when the ratio of water to Na+ is increased Severity Mild -130 and 134 meq/L Moderate -120 to 129 meq/L Severe <120 meq/l

32. Hyponatermia cause Pseudohyponatremia Hyperosmolality Hypovolemic Hyponatremia Extra renal Losses Renal Losses Euvolemic Hyponatremia

33. Hyponatermia Clincal Manifestation Brain cell swelling is responsible for most of the symptoms Neurologic symptoms : anorexia, nausea, emesis, malaise, lethargy, confusion, agitation, headache, seizures, coma, and decreased reflexes. Muscle cramps and weakness; rhabdomyolysis can occur with water intoxication.

34. Diagnosis History and physical examination Basic laboratory testing Blood glucose BUN and creatinine  Plasma/serum potassium Urine dipstick Serum and Urine osmolality  

35. Treatment Principle Duration of hyponatremia – Acute versus chronic Severity of hyponatremia Determining and treating the underlying cause in a timely manner, Readjustment of therapy

36. Treatment of hyponatermia A patient with severe symptom no matter the etiology should be given a bolus of hypertonic saline. hypovolemic hyponatremia -treat dehydration to restore the intravascular volume with isotonic saline. load of 0.9% NaCl , 20 ml/Kg in 10-30 minutes; repeat if necessary Replace the Na deficit in 24 hours with solutions with Na supply of 75 mEq / L or 100 mEq / L if Na < 120 mmol / L. -

37. hypervolemic hyponatremia - cornerstone of therapy is water and Na+ restriction. Water restriction. Negative water balance Administration of diuretics Administration of albumin if hypoproteinemia isovolumic hyponatremia Negative water balance (50-80% basal needs) without restriction of Na or 300 - 400 ml / m 2/24 hours plus the volume of diuresis or restrict the fluids

38. Symptomatic hyponatremia with Na <125 mmol / L : Rapid correction until reaching Na>120 mEq / L. Set a correction rate of 0.5-1 mEq / L / h (maximum 12 mEq per day ). Bolus of 3% hypertonic NaCl : 3-5 ml / kg in 20-30 minutes . Repeat if there is no improvement . Measure plasma sodium concentrations , at least once every hour until symptoms subside. Calculate deficit using the formula: Na deficit = 0.6 x Wt. x (Desired Na --- Current Na)

39. Case scenario eg 5 month old 10 kg child with serum Na of 114meq/l How do you manage the patient if it is acute What if it is chronic onset

40. Case scenario An 8-year-old with AKI. Electrolytes reveal a potassium of 7.3 and an EKG demonstrates peaked T-waves. What is the most appropriate next step?

41. HYPERKALEMIA Hyperkalemia—because of the potential for lethal arrhythmias—is one of the most alarming electrolyte abnormalities. Severity Mild: (K 5.5-6.5 mEq / l) Moderate (K 6.5-7 mEq / l) Severe (K> 7 mEq / l)

42. cause of Hyperkalemia Three basic mechanisms cause hyperkalemia including increased intake, cellular shifts, and decreased excretion; spurious lab values are also commonly seen

43. C/M of hyperkalemia The most important effects of hyperkalemia result from the role of K+ in membrane polarization. Asymptomatic Paresthesias , fasciculation, weakness, and even an ascending paralysis, but cardiac toxicity usually precedes these clinical symptoms ECG changes

44. Diagnosis of hyperkalemia Elevated plasma or serum potassium level . Blood glucose, CBC creatinine, BUN, and assessment of the acid-base status. The treatment of hyperkalemia has two basic goals: to stabilize the heart and to remove K+ from the body

45. Treatment Stop all sources of additional K+ (oral, IV). If the [K+] is >6.5 meq/L , an ECG should be obtained to help assess the urgency of the situation .

46. Hyperkalemia mangment cont .. Initial Emergent Therapy Calcium infusion  Calcium gluconate  ( 10% solution) is given at a dose of 0.5 mL/kg ( max dose 20 mL [2 g]) by IV infusion. Insulin and g lucose therapy regular insulin (0.1 units/kg , maximum dose of 10 units ) Inhaled beta-adrenergic agonists Sodium bicarbonate

47. Hyperkalemia cont .. Nonemergent Therapy adjunctive therapy for patients with severe hyperkalemia asymptomatic children with acute hyperkalemia  Treatment of reversible causes Hypovolemia Congenital adrenal hyperplasia Medications Metabolic acidosis

48. Hyperkalemia cont .. Therapies removing potassium from the body Diuretics Enteral cation exchange resins (Polystyrene sulfonates  ) Dialysis Chronic Hyperkalemia a low-potassium diet, use of loop diuretic therapy, correction of metabolic acidosis with carbonate therapy, and avoidance of drugs that increase potassium level.

49. Case scenario A DKA patients to the emergency room in diabetic ketoacidosis . She has tachycardia and hyporeflexia on physical examination, U waves on ECG, and serum potassium of 2.5mEq/L. How would you treat the hypokalemia?

50. Hypokalemia Hypokalemia is common in children, with most cases related to gastroenteritis. Severe hypokalemia – < 2.5 mEq /L Moderate hypokalemia – between 2.5 and 3 mEq /L Mild hypokalemia – between 3 and 3.5 mEq /L

51. Hypokalemia causes There are four basic mechanisms of hypokalemia. Spurious hyperkalemia Transcellular shifts Decreased intake Extra renal losses Renal losses

52. hypokalmeia Clinical Manifestations The heart and skeletal muscle are especially vulnerable to hypokalemia. ECG changes include a flattened T wave, a depressed ST segment, and the appearance of a U wave . Ventricular fibrillation and torsade's de pointes may occur.

53. Hypokalemia C/m continued In skeletal muscle include muscle weakness and cramps. Paralysis is a possible complication slows GI motility Hypokalemia impairs bladder function polyuria and polydipsia by impairing urinary concentrating ability Chronic hypokalemia may cause kidney damage, including interstitial nephritis and renal cysts.

54. Treatment Factors that influence the treatment the K+ level, clinical symptoms, kidney function, the presence of transcellular shifts of K+, ongoing losses, and the patient’s ability to tolerate oral K+. Potassium supplementation In symptomatic patients rapid supplementation should be provided.  0.5 to 1 meq/kg of body weight per hour The goal is to raise the potassium level by 0.3 to 0.5 meq/L .

55. In asymptomatic patients with potassium levels less than 3 mEq /L, replacement of potassium stores is generally needed . Oral therapy starting dose is 1-2 meq/kg/day , potassium-sparing diuretics Correction of concurrent hypomagnesaemia

56. Hypocalcaemia Ca corrected = Ca measured + [8.0 (4.0 – albumin measured mg/dl)] Causes I nadequate calcium intake, malabsorption, hormonal imbalance or dysfunction or chelation by anions. Signs and symptoms of hypocalcaemia are most commonly the manifestations of altered function of calcium-dependent excitable tissues.

57. Treatment Severe symptomatic and/or acute hypocalcemia   — 10% calcium gluconate boluses 1 ml / kg(max. 20 ml) diluted  in 50 mL of 5% dextrose or NS, over 10-20 minutes. it should be followed by a slow infusion of calcium in patients with persistent hypocalcemia . Mildly symptomatic or chronic hypocalcemia - oral 50-75mg/kg/day

58. Hypercalcemia Total calcium > 10.5 mg / dl (2.62 mmol / l or 5.25 meq / l ); ica > 5.2 mg/dL ( 1.31mmol / L or 2.62 meq / L) Etiology : vitamin D and Vitamin A poisoning, malignant processes, tumorlysis , immobilization, hyperparathyroidism , hyperthyroidism, chronic renal insufficiency, thiazides or iatrogenic.

59. Clinical manifestation Symptom usually appear from Tca >12 mg/dL D igestive (anorexia, vomiting, constipation); C ardiovascular (short QT, arrhythmias, hypertension ); R enal (polyuria, polydipsia, nephrolithiasis, or renal failure) Neuromuscular (weakness, hypertonia, seizures, coma );

60. Treatment Treatment is dependent on its severity. Mild and moderate -no specific therapy is warranted and efforts should focus on identifying the underlying condition . Severe or symptomatic NS (Administer a load of 10 ml / kg NS and bolus of lasix (1 mg/kg ) and then 1.5-2x maintenance to maintain diuresis of 2.5 to 4 ml /kg/h Other measures

61. References Nelson text book of pediatrics 22 nd edition Up-to-date Roger’s textbook of pediatrics intensive care 5 th edition Fleisher & Ludwig's Textbook Of Pediatrics Emergency Medicine 7 th Edition SPHMMC Pediatrics and child health pulmonary and critical care unit Guideline for common critical conditions 2020