Fluid -Electrolyte Imbalance 2012-Ined.ppt

8/14/2019 Fluid -Electrolyte Imbalance 2012-Ined.ppt

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Fluid and Electrolyte Imbalance

Wan Nedra


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Introduction to the Principles of Fluid and

Electrolyte Therapy

Important to understand the underlying physiologic principles

of a therapy commonly employed in pediatrics

Understanding basic principles essential for the understanding

of the management of more complex disorders such as:

Cholera

Dengue

Pyloric stenosis

Hyperosmotic non-ketotic coma


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Crystalloid and Colloid

Crystalloid: Water and electrolyte solution

Does not remain within the intravascular space but rather

distributes to the entire extracellular space

Only impacts on the intracellular space if it causes a change in

extracellular osmolarity E.g.: 0.9% NaCl, D5 0.3% NaCl

Colloid: Contains large particles which tend to remain within the blood

vessels

Colloid preferentially expands the intravascular space because the

particles exert oncotic force which retains water within theintravascular space

E.g.: 5% albumin, blood, dextran solution


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Isotonic Saline Solution

Isotonic saline solution: Solution such as 0.9% NaCl or Ringerslactate with a Na concentration similar to that of plasma water

Crystalloid distributes throughout the extracellular space

Infusion of crystalloid will cause a fluid shift into or out of the

intracellular space only if it creates an osmotic gradientbetween the extracellular and intracellular space

Isotonic saline does not change the osmolarity of theextracellular space

Therefore: Isotonic saline solution remains within and

expands the extracellular space and has minimal effect onthe intracellular space


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Composition of Fluids

1. D5W (5 g sugar/100 ml): 252 mOsm/L

2. D10W (10 g sugar/100 ml): 505 mOsm/L

3. NS (0.9% NaCl) 154 mEq Na/L: 308 mOsm/L

4. 1/2 NS (0.45% NaCl): 77 mEq Na/L: 154 mOsm/L5. D5 1/4 NS (34 mEq Na/L): 329 mOsm/L

6. 3% NaCl 513 mEq Na/L: 1027 mOsm/L

7. 10% NaCl 1.7 mEq/cc

8. 20% NaCl 3.4 mEq/cc9. 8.4% NaHCO3 (1 meq/cc Na & HCO3): 2000 mOsm/L


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IV fluids

Lactated Ringers0-10 gram glucose/100ccNa 130 meq/LNaHCO3 28 meq/L as lactateK 4 meq/L

273 mOsm/L Amino acid 8.5 %8.5 gm protein/100 cc880 mOsm/L

Albumin 25% (salt poor)

25 gm protein/100 cc

Na 100-160 meq/L300 mOsm/L

Intralipid

2.25gm lipid/100cc 284 mOsm/L


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Requirements of FLUID

Increased requirement :

Fever

Vomiting

Renal failure Burn

Shock

Tachypnea

Gastroenteritis Diabetes (Insipidus, mellitus -

DKA)

Cystic fibrosis

Decreased requirement

CHF

Postoperatively

Oliguric ( RF )


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Maintenance Fluid and Electrolyte Requirements

Maintenance: The replacement of normal ongoing losses

Normally serum Na concentration is approximately 140 meq/land serum K concentration is approximately 4 meq/l

Maintenance solution replaces normal losses

Maintenance solution does not have an electrolyteconcentration equal to serum because the electrolytecomposition of urine and stool is not equal to that of serum

Maintenance fluids commonly provided as a 5% dextrose solution

Dextrose provides some energy and prevents hypoglycemia

Spares protein

Cannot meet patients nutritional requirements with 5% (or

10%) dextrose


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Maintenance Requirements are a Function of

Caloric Requirements

0-10 kg: 100 kcal/kg

10-20 kg: 50 kcal/kg

> 20kg: 20 kcal/kg

Examples:

8 kg: 8 kg X 100 kcal/kg = 800 kcal.

12 kg: 10 kg X 100 kcal/kg + 2 kg X 50 kcal/kg = 1000 kcal +100 kcal = 1100 kcal

20 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg = 1000 kcal

+ 500 kcal = 1500 kcal 25 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg + 5 kg X 20

kcal/kg = 1000 kcal + 500 kcal + 100 kcal = 1600 kcal


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Water and Electrolyte Requirements are

Determined by Caloric Requirements

Requirements per 100 kcal:

100 ml water (provided as a 5% dextrose solution)

2-4 meq Na

2 meq K

2 meq Cl

Plasma: Anion is a balance of Cl and base (bicarbonate)

Maintenance solution: Can provide some anion as Cl andsome as base (lactate, citrate, phosphate) or can provide

all of it as Cl But: Providing large volumes of fluid (e.g., in DKA or

hypovolemic shock) with all of the anion as Cl will promotea hyperchloremic metabolic acidosis


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Standard Maintenance Solution

D5W with 20-40 meq/l Na Cl and 20 meq/l KCl (or KAcetate orKPhosphate) will work well as a maintenance solution in mostpediatric patients

Can use D5 0.2% (or D5 0.3%) NaCl with 20 meq/l KCl (or

KAcetate or KPhosphate) as maintenance solution Recent article advocated routine use of isotonic saline solution

for pediatric maintenance solution

Some disease states: Another solution might be appropriate

E.g.: Sickle cell anemia patients may have a relatively high Na

requirement due to high urinary Na losses

0.9% NaCl (without dextrose) in head trauma patients

K should be used with caution or omitted in patients with renalinsufficiency


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Water and Electrolyte Requirements Based on

Weight

Water:

0-10 kg: 100 ml/kg

10-20 kg: 1000 mlplus50 ml/kg

> 20 kg: 1500 mlplus20 ml/kg

Electrolytes:

Na: 2-3 meq/kg

K: 1-2 meq/kg

Water requirement is the same as with the caloric-based

system

Electrolyte requirement is greater than with caloric-basedsystem: Electrolyte requirement is a direct linear function ofweight


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Fluids and Electrolytes Principles Total body water(TBW) = Intracellular fluid (ICF) +

Extracellular fluid (ECF)

ECF) = Intravascular fluid (in vessels : plasma, lymph -IVF) + Interstitial fluid (between cells - IF)

ECF ( intravascular, interstitial &trancelluler)Fluid % in child body ( 75%-80%)

Goals:

Maintain appropriate ECF volume,

Maintain appropriate ECF and ICF osmolality and ionicconcentrations


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Things to consider:Normal changes in TBW, ECF

All babies are born with an excess of TBW,

mainly ECF, which needs to be removed

Adults are 60% water (20% ECF, 40% ICF) Term neonates are 75% water (40% ECF, 35% ICF) :

lose 5-10 % of weight in first week

Preterm neonates have more water (24 wks: 85%,

60% ECF, 25% ICF): lose 5-15% of weight in first

week


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Diagnostic Evaluation

1. Anamnesis, Physical, Lab assessment

2. Type of dehydration


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Physical Assessment of FE status

Skin/Mucosa: Altered skin turgor, sunken AF, drymucosa, edema etc are not sensitive indicators inbabies

Cardiovascular: Tachycardiatoo much (ECF excess in CHF) or

too little ECF (hypovolemia)

Delayed capillary refilllow cardiac output

Hepatomegaly can occur with ECF excess

BP changes very late

Urine output


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Lab Assessment of FE status

Serum electrolytes and plasma osmolarity

Urine electrolytes, specific gravity (not very useful if

the baby is on diuretics - lasix etc), FENa Blood urea, serum creatinine (values in the first few

days reflect moms values, not babys)

Acid Base (low pH and bicarb may indicate poor

perfusion)


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Type of Dehydration

1. Isotonic

(affect ECF ,Na = 135meq /l)

2. Hypotonic( loss in ECF 2 correct ICF, Na = less than

135meq/l )

3. Hypertonic( sever loss in ICF ,Na = more than 150meq/l


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Physical Signsof Dehydration

Signs & sympt. MILD Moderate Severe

General Thirsty, allert,

restless

Thirsty, irritable,

or drowsy

Drowsylimp,

skin cold / sweaty

Radial pulse Normal rate Rapid, weak Rapid, feeble

Respiration Normal Deep Deep & rapid

Anterior font. Normal Sunken Very sunkenSkin turgor Pinch retracts

immediately

Retracts slowly Poor

Eyes Normal Sunken Grossly sunken

Tears Present Absent Absent

Mucous memb. Moist Dry Very dry

Urine flow Normal Dark &decreased

Oliguria / anuria


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Pediatric Fluid Therapy Principles

I. Assess water deficit by:

1. weight:

weight loss (Kg) = water loss (L)

OR

2. Estimation of water deficit by physicalexam:

Mild moderate severeInfants < 5 % 5 - 10 % >10 %

Older children < 3 % 3 - 6 % > 6 %


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Pediatric Fluid Therapy Principles

II. Maintenance H2O needs:

Weight in Kg H2O fluid needs

1-10 100cc /kg /day

11-20 1000+50cc/kg/day

> 20 1500 + 20cc/kg/dayAdd 12 % for every

0C

Therapeutic management of fluid loss

Oral rehydration therapy

Parenteral fluid therapy

Meet ongoing daily loss

Replace previous deficit

Replace ongoing abnormal losses


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Correction of Dehydration

1. Estimate Fluid Deficit (% :- Mild, Moderate, Severe).

2. Moderate to severe dehydration:

IV push 10-20cc / Kg Normal saline, May repeat.

Half deficit over 8hours, and half over 16hours.

3. Find Type of Dehydration

(Isonatremic, Hyponatremic, Hypernatremic).

4. Give daily Maintenance.

5. Give Deficit as follows:

Half volume over 8 hours, half volume over 16 hours

(Exception: in Hypernatremic Dehydration, replace deficitover 48 hours).


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Disturbance of F&E balance

1. Na 2. K 3. Ca

( Na is the primary osmatic farce )

Serum Osmolality

Defined as the number of particles per liter.May be approximated by:

2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8

Normal range: 275-295 mOsm/L300-500 cc/M2/day

Less in patients on the ventillator


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When administrating I.V fluid

Monitors the response of the fluids.

Considering the fluid volume.

Content of fluid. Patient clinical status.


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1. Isotonic fluids:

-Have a total osmolality close to that of extra cellular fluids

(ECF) and don't cause RBCs to shrink or swell.

- 3 L of isotonic solutions are needed to replace 1 L of

blood, so pt should be carefully monitored for signs offluid overload.

Examplesof Isotonic fluids:

D5W: has a serum osmolality of 252 mosm/L.

D5W s mainly used supply water and to correct an increasedserum osmolality


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NORMAL SALINE SOLUTION

NS (0.9% Sodium chloride with TO of 308

NS osmolality is contributed by electrolytes- So the solution remains within ECF.

- NS is used to treat ECF deficit.

- Ringer's solutions: Contains Ca, K and NaCl


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2. Hypotonic Fluids

- The purpose of hypotonic fluids is to replacecellular fluids, because it is hypotonic ascompared with plasma.

- It also used to provide free water for excretionof body wastes.

- It may used to treat hypernatramia (hypotonic

Na solutions).Examples of hypotonic solutions: 0.45% Nacl

Half-strength saline.

Complications of excessive use of


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Complications of excessive use of

hypotonic solutions include:

Intravascular fluid depletion.

Decreased blood pressure.

Cellular edema. Cell damage


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3.Hypertonic Solutions

Hypertonic solutions exert an osmoticpressure greater than that of ECF

Examples

* High concentrations of dextrose such as 50%dextrose in water are used to help meetcaloric requirements.

These hypertonic solutions must beadministered into control veins so that theycan be diluted by rapid blood flow.


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Saline solutions are also available in osmolar

pressures greater than that of ECF and cause

cells to shrink.

If administered rapidly or in large quantities,

they may cause an extra cellular volume

excess and cause circulatory overload and

dehydration.


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*Management and Nsg Care for certain fluid

and electrolyte balance disturbances

1-Water depletion

- Provide replacement of fluid.

-Determine and correct cause of waterdepletion.

- Measure intake and output.

- Monitor V/S


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2- Water Excess:

- Limit fluid intake.

- Administer diuretics.

- Monitor V/S

- Determine and treat cause.

- Analyze laboratory electrolyte measurementfrequently


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3- Hyponatremia

- Determine and treat cause

- Administer I.V fluids with appropriate saline

concentration 4- Hypernatramia:


Administer fluids as prescribed.

- Measure intake and output.

- Monitor lab. Data.


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5- Hypokalemia:


- Monitor V/S and ECG.

- Administer supplemental K.

- Assess for adequate renal output before

administration.

IV: administered slowly.

Oral: after high K fluids and foods.


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6- Hyperkalemia- Determine and treat cause.

- Monitor V/S and ECG - Administer I.V fluids if prescribed.

- Monitor serum potassium levels.

7- Hypocalcaemia:- Determine and treat cause.

- Administer calcium supp. as prescribed and administered slowly.

- Monitor serum calcium levels.

- Monitor serum protein level

8- Hypocalcaemia:


- Monitor serum Ca levels.


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SODIUM

Na+ are very important for regulating blood and interstitial fluid

pressures as

well as nerve and muscle cell conduction of electrical currents.

Aldosterone causes

retention of Na+.

a. HYPONATREMIA:- Vomiting, diarrhea, sweating, and burns cause Na+ loss. Dehydration,

tachycardiaand shock (see above) can result. Intake of plain water worsens thecondition.

Pedialyte is a better fluid to drink. Explain this.b. HYPERNATREMIA

Severe water deprivation, salt retention or excessive sodium intakecauses this.Increased Na+ draws water outside of cells, resulting in tissue

dehydration.Thirst fati ue and coma result.


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CHLORIDE

Cl- anion is necessary for the making of HCl,

hyper polarization of neurons,

regulating proper acid levels, and balancing

osmotic pressures between compartments.


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CHLORIDE

a. HYPOCHLOREMIA

Excessive vomiting causes chloride loss,

resulting in blood and tissue alkalosis, and a

depressed respiration rate.

b. HYPERCLOREMIA

Dehydration or chloride gain can result in

renal failure or acidosis (increases in

Cl- are accompanied by increases in H+).


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POTASSIUM

K+ is important in the intracellular fluid. Aldosterone

causes excretion of K+.

a. HYPOKALEMIA

Caused by diarrhea, exhaustion phase of stress, excessivealdosterone secretions

in adrenal cortical hyperplasia and some diuretics. K+

loss from cells contributes to tissue

dehydration and acidosis. Flattened T waves,bradycardia, muscle spasms, a lengthened

P-R, and mental confusion can also result.


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POTASSIUM

b. HYPERKALEMIA

Caused by eating large amounts of "light salt"(KCl), kidney failure, and

decreased aldosterone secretions in Addison'sDisease; resulting in elevatedT waves and fibrillation of the heart. Themovement of K+ into cells accompanies

tissue alkalosis.


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CALCIUM

Calcium Ca++ cations are needed for bone,

muscle contraction, and synaptic

transmission.


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CALCIUM

a. HYPOCALCEMIA

Excessive calcitonin, inadequate PTH,

decreased Vita. D, or reduced Ca++

intake results in muscle cramps, and

convulsions.

b. HYPERCALCEMIA

Increased PTH, Vita. D or calcium intake can

cause kidney stones, bone spurs,

and lethargy.


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Child vs. Adult in medication administration

1. Water %

2. Body service area

3. Type of food

4. Stomach acidity

(infant much less than adult )

5. Enzyme chains not maturity

6. Rate of break down of drug ( growth&development rate )

TPN replacement for chronic case

Child Ad l i di i


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7. % of protein binding & fat distributions

8. Drug half life

9. Excretion

10. Gastric empty time

11. Eating habits

12. Exercise pattern13.sexual development

Child vs. Adult in medication

administration (2)


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Steps to give medication

1. Identification the child

2. Oral medication ( infantpreschool school

age)

3. Teach the child how to swallowing ( liqide

need hr ,Tablet (1/2-1hr)

* Safe storage of medication

* Determination of the correct dosage

Fluid -Electrolyte Imbalance 2012-Ined.ppt

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