Post on 17-Oct-2015
description
MANAGEMENT OF ELECTROLYTE IMBALANCE IN CHILDREN WITH ACUTE DIARRHEA
IBG Suparyatha
Objectives
1) Most common electrolyte imbalance in children with acute diarrhea
2) Recognize these imbalances
3) Apply appropriate management principles
Objectives
1) Most common electrolyte imbalance in children with acute diarrhea
2) Recognize these imbalances
3) Apply appropriate management principles
ACUTE DIARRHEAMayor complication : dehidration, electrolyte imbalance, and renal failure
Electrolyte imbalance : Ukarapol N, et al. (2002) 69,8%Shah GS, et al. (2006) 79%
ACUTE DIARRHEA
Electrolyte imbalanceUkarapol N, et al. Shah GS, et al.Hyponatremia17%56%Hypernatremia9,4%10,4%Hypokalemia22,6%46%Hiperkalemia3,4%5,2%
Objectives
1) Most common electrolyte imbalance in children with acute diarrhea
2) Recognize these electrolyte imbalances
3) Apply appropriate management principles
Signs and SymptomsIrritabilitypoor feedingnausea and vomiting lethargy seizures and eventually coma and death
Treatment of HyponatremiaACUTE CORRECTION
urgent treatment ~ neurological changes or seizures
The goal : to 120-125 mEq/L or until seizures stop
Hypertonic saline solution, 3% NaCl, ideally a central venous line but acceptable during emergency via peripheral IV or IO, over 15-20 minutes
1.2 ml/kg of 3% NaCl raise the level by 1 mEq/L
Treatment of HyponatremiaSLOWER CORRECTION
acute correction completed or not neurological changes
More slowly at approximately 12 mEq/L per day(0.5 to 1 mEq/L every hour)
FORMULA : 0.6 x (Wt in kg) x (target Na+-measured Na+)= Total mEq of Na+required to raise sodium level to target.
Case Study
A 2 month-old child (5 kg) present with seizures and sunken eyes and fontanelle . Mother reports two days of diarrhea and is found to have a sodium level of 114 mEq/L.
First step : acute correctionYou decide to give 3% saline to correct to 120 mEq/L.
Amount of NaCl = 0.6 x 5 kg x (120-114)= 18 mEq of Na+
3% NaCl = 0.5mEq/L or approx 36 mL of 3% NaCl solution or
(1.2 mL/kg) of 3% NaCl raises the serum sodium apporx 1 mEq/L
1.2 mLx5kg x (120-114) = 36 mL of 3% NaCl solution
Second step: slower correction
To raise the serum sodium level an additional 12 mEq/L from the 120 mEq/L
0.6x5kgx(132-120) = 36 mEq/L additional sodium needed over the remainder of the 24 hours
additionally, the calculated deficit is added to this and administered over 12-24 hours
Treatment of hyponatremia
A good fluid ~ D5% 1/2NS or normal saline, with or without (potassium 20 mEq/L)
Fluid rates : first 8 hours deficit + 1/3 maint. (44 ml/hr) next 16 hours deficit + 2/3 maint (32 ml/hr)
Water (ml)Na (mEq)deficit37552Na neeed36maintenance50015TOTAL875103
Defined as a serum sodium level >145 mEq/L
In acute diarrhea :Excessive water lossInadequate free water intakeIncreased sodium intake through ORS
Hypernatremia dehidrationHYPERNATREMIA
Signs and SymptomsIrritability, high-pitched cry, lethargy, seizures, fever, renal failure, and rhabdomyolysis. In infants, these symptoms mimic those of infections and sepsis
Treatment of HypernatremiaEssential to correct ~ slowlyMost recommendations no more than 0.5 mEq/L/hr or 12 mEq/L/day
To calculate :Free water deficit = (Wt in kg x 0.6) x 1 (desired Na+/actual Na+) (1000mL/L)OR4 ml/kg of free water ~ drop sodium by 1 mEq/L
Case Study
A 10 month-old child (8 kg) present with profuse diarrhea and moderate dehidration and is found to have a sodium level of 157 mEq/L.
treatment of hypernatremiaFree water deficit = (8x0.6) x 1 (145/157) x (1000 mL/L) 365 mL = 4.8 x 0.076 (1000 mL/L)
Quick Calculation :4mL x 8kg x 12mEq/L = 384 mL of free water
Maintenance fluid amounts for an 8-kg child are (100mL/kg x 8) = 800 mL/24hrs
1 L of normal saline = 500 mL of free water1 L of normal saline = 750 mL of free water
1 L of D5 NS will provite 400 mL of free water and is a good starting point
treatment of hypernatremia
Na deficit ~ 600-365/1000 x 140 = 47 mEq
D5 NS is a good starting point
Water (ml)Na (mEq)Free water deficit365-Na deficit-47maintenance80024TOTAL116571
Signs and symptomsfatigue and paresthesias (ECG) changes : flattened T wave,ST depressions, U waves and ventricular dysrhythmias
Treatment of hypokalemiaOral or IV supplementation urgency of sympptoms
Oral :Asymptomatic hypokalemia (no ECG changes) or mild hypokalemiaAbility to tolerateIncrease diet intake1-3 mEq/kg/day in three or four divided dosesSafest
TREATMENT OF HYPOKALEMIAA conservative protocol for IV replacement :
3.0-3.5 mEq/L 0,25 mEq/kg of IV KCl over 1 hour
2.5-3.0 mEq/L 0.5 mEq/kg of IV KCl over 2 hours
less than 2.5 mEq/L 0.75/L of IV KCl over 3 hours.
A potassium level should be checked halfway through this infusion.
====>>>> SYMPTOMATIC HYPOKALEMIA
TREATMENT OF HYPOKALEMIAIV replacement :
No more than 0.5 mEq/kg/hr of KCI in a single IV with a max dose of 10 mEq over 1 hr.
Via a central venous line
If peripheral: do not exceed 40-50 mEq/L potassium
HYPERKALEMIAPotassium levels >5.5 mEq/L
In acute diarrhea :Metabolic acidosisExogenous potassium
Signs and SymptomsTo inadequate cardiac output ~> arrhythmias. Cardiac (ECG changes) :
Skeletal muscles and nerve: weakness and paresthesias
Treatment of HyperkalemiaHyperkalemia requires urgent intervention and th
Place a cardiorespiratory monitor Recheck to confirm the hyperkalemiaDiscontinue any exogenous potasssium Administer one or more of drugs therapiesEmergency Hemodialysis
Administer one or more of the drug therapies :Calcium gluconate, 100 mg/kg over 3 min (1mL/kg of 10% solution) IVSodium bicarbonate, 1-2 mEq/kg given IV over 10-15 min
Insulin, 0.1 U/kg/hr, mixed with Dextrose solution 0.5 g/kg/hr
An exchange resin, such as sodium polystyrene resin (Kayexalate), administered 1g/kg rectally
SummaryHyponatremia, Hypernatremia, Hypokalemia, and Hyperkalemia are common in children with acute diarrhea
Acute correction must be considered carefully for symptomatic electrolyte imbalance
Strict attention to detail is important in providing safe and effective therapy
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