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

HYPONATREMIASerum sodium level

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

HYPOKALEMIADefined as a potassium level

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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