Electrolyte imbalance in children Dr. WAN NEDRA Sp.A Bagian Ilmu Kesehatan Anak FK YARSI2008

*ined/h20/elk/ab1Introduction In developed countries, 50% of pediatric hospitalization is due to acute diarrhea (WHO)Electrolyte abnormalities are common in children with diarrheaIt may remain unrecognized and result in mortality and morbidityThe common electrolyte disturbance: hyponatremia (56%) hypokalemia (46%) mixed electrolyte disturbance: 37%

The pathogenesis of hyponatremia in diarrhea is due to a combination sodium and water loss and water retention to compensate the volume depletion

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*ined/h20/elk/ab1CASE 1A 4 year old male presents to the emergency department with a history of vomiting and diarrhea. He has had 10 episodes of vomiting & 8 episodes of diarrhea with some mucusy material in the first few episodes. The diarrhea is now watery and the last few episodes have been red in color.

His parents gave him a sports drink, and then they tried clear Pedialyte. Despite this, he continues to have vomiting and diarrhea. He feels weak and tired and he looks slightly pale at times. He has only urinated twice in the last 15 hours.

Exam: T 38.2 , P 110, R45, BP 90/65, Weight 18 kg. He is alert and cooperative, but not very active. He is not toxic or irritable. His eyes are not sunken. His oral mucosa is moist but he just vomited. His neck is supple. Hear and lung exams are normal except for tachycardia. His abdomen is soft and non-tender. Bowel sounds are normoactive.

His overall color is slightly pale, his capillary refill time is 2 seconds over his chest, and his skin turgor feels somewhat diminished.

He is clinically assessed to be 5% dehydrated by clinical criteria.

Oral versus IV rehydration They now have emesis on their furniture and carpet and he has splattered some diarrhea, so they would like the IV for him. An IV is started and a chemistry panel is drawn at the same time.

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*ined/h20/elk/ab1Normal saline is infused at 360 cc/hour for two hours (total of 720 cc).

It is pointed out that 360 cc is only 20 cc/kg which replaces only 2% of the body's weight (i.e., it corrects 2% dehydration), it doesn't include maintenance fluids, and 360 cc is the same volume as a soft drink can.

He is also given ondansetron (Zofran) for nausea relief.

His chemistry panel shows Na 135, K3.4, Cl 99, bicarb 15. During the first hour of the IV fluid infusion, he says that he feels much better. He is on a regular diet and continues to improve. Because he has improved, no antibiotic treatment is started. However, vigorous hand washing and hygiene regarding dishes/utensils for all family members is recommended.

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*ined/h20/elk/ab1Kebutuhan Maintenance Mineral/kg bb/24 jam

MineralDosisSodium (Na)2-3 mEqPotasium (K)1-2 mEqChlorida (Cl)3-5 mEqCalcium (Ca)50-200 mgMagnesium (Mg)0.4-0.8 mEqPhosphate (P)15-50 mg

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*ined/h20/elk/ab1Sodium SerumLaboratory finding:IsonatremiaHiponatremiaHipernatremia

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*ined/h20/elk/ab1Isonatremia

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*ined/h20/elk/ab1Isonatremia-Isotonisitas IsoosmolalitasIsonatremia Sodium serum 135-145 mEq/LIsotonikOsmotic gradient (-)Tekanan osmotik: normalPerpindahan air: tidak ada

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*ined/h20/elk/ab1Isonatremia-IsotonisitasHiperosmolalitasIsonatremia Sodium serum 135-145 mEq/LIsotonikOsmotic gradient (-)Tekanan osmotik: normalPerpindahan air: tidak ada

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*ined/h20/elk/ab1Isonatremia-HipertonisitasHiperosmolalitasIsonatremia Sodium serum 135-145 mEq/LHipertonisitasOsmotic gradient (+)Tekanan osmotik: tinggiPerpindahan air: ICF ECF dehidrasi sel

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*ined/h20/elk/ab1Hiponatremia

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*ined/h20/elk/ab1Hiponatremia-Hipotonisitas HipoosmolalitasHiponatremiaSodium serum < 130 mEq/LHipotonikOsmotic gradient (+)Tekanan osmotik: rendah Perpindahan air: ECF ICF edema sel

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*ined/h20/elk/ab1Hiponatremia-HipertonisitasHiponatremiaSodium serum < 130 mEq/LHipertonikOsmotic gradient (+)Tekanan osmotik: tinggi Perpindahan air: ICF ECF dehidrasi sel

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*ined/h20/elk/ab1Hipernatremia

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*ined/h20/elk/ab1Hypernatremia Less common than hyponatremiaRelative water deficit in relation to sodium in the plasmaUsually iatrogenic

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*ined/h20/elk/ab1HipernatremiaHipernatremiaSodium serum 150 mEq/L HipertonikOsmotic gradient (+)Tekanan osmotik: tinggi Perpindahan air: ICF ECF dehidrasi sel

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*ined/h20/elk/ab1Isonatremia-Isotonisitas IsoosmolalitasHipovolume (Dehidrasi isonatremia)

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*ined/h20/elk/ab1TerapiDehidrasi IsonatremikHitung defisit : Air dan NaHitung maintenanceAir dan NaAsumsi : Isonatremik - isotonik ~ NaCl 0.9% (NaCl 0.9% = 154 mEq Na/L H2O)

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*ined/h20/elk/ab1TerapiDehidrasi Isonatremik Contoh Dehidrasi 10%: (BB : 5 kg 4.5 kg)

Defisit air : 500 ml Defisit Na : 500 ml x 154 mEq/L = 77 mEqMaintenance air: 5 (kg) x 100 mL/kg = 500 mlMaintenance Na : 5 (kg) x 3 mEq/kg = 15 mEq

Total H2O / 24 hr = 500 + 500 = 1000 mlTotal Na /24 hr = 77 + 15 = 92 mEq

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*ined/h20/elk/ab1Dehidrasi hiponatremikSodium and water losses Gastrointenstinal losses: Vomiting Diarrhea Urinary losses Salt water nephropathy Adrenal insufficiency Diuretic

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*ined/h20/elk/ab1TerapiDehidrasi Hiponatremik

Hitung jumlah natrium : Hiponatremia Isonatremia

Selanjutnya :

Sesuai : Dehidrasi Isonatremia

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*ined/h20/elk/ab1Contoh Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 125 mE/LJumlah Na: hiponatremia isonatremiaNa = (NaD-NaA) x TBW mEqNa = (135-125) x 0.6 x 4.5= 27mEq Defisit air = 500 ml Defisit Na = 500 ml x 154 mEq/L= 77 mEq Maintenance air= 5 (kg) x 100 ml/kg = 500 ml Maintenance Na= 5 kgx3 mEq/kg Na = 15 mEq Total air/24 jam = 500 + 500 = 1000 ml Total Na/24 jam = 27+77+15 = 119 mEq Terapi Dehidrasi Hiponatremik

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*ined/h20/elk/ab1HyernatremiaHypovolemic Water loss in excess of sodium lossSodium lost (hypotonic solution)KidneyGI tractSkinRespiratory tract

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*ined/h20/elk/ab1TerapiDehidrasi - HipernatremiaDehidrasi hipernatremikHitung jumlah air Hipernatremia isonatremia

Selanjutnya Sesuai : IsonatremiaIsotonik-Hipovolemia

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*ined/h20/elk/ab1Terapi Dehidrasi - Hipernatremia ContohDehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L Jumlah air hipernatremiaisonatremia = X

(X+TBW) x NaD = TBW x NaAX = (NaA/NaD) x TBW- (TBW) mlX = (170/145) x (0.6x4.5)(0.6x4.5) = 465 ml

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*ined/h20/elk/ab1Terapi Dehidrasi - Hipernatremia ContohDehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L Defisit air= 500 mlDefisit Na = 500-465 = 35 mL (NaCl 0.9%) = 35ml x 154 mEq/L = 5 mEq

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*ined/h20/elk/ab1Terapi Dehidrasi - Hipernatremia Maintenance Air 5 (kg) x 100 ml/kg = 500 mlMaintenance Na 5 (kg) x 3 mEq/kg = 15 mEql

Jumlah Air/24 jam=500 + 500 ml = 1000 mlJumlah Na/24 jam=5 + 15 mEq = 20 mEq

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*ined/h20/elk/ab1Terapi Dehidrasi - Hipernatremia Hati-hati: Dehidrasi sel edema sel (otak)

Koreksi dalam 48 jam

Air= 2 x maintenance + 1 x defisit = (2x500) + (1 x 500) =1500 mlNa = 2 x maintenance + 1 x defisit = (2x15)+(1x5) = 35 mEq

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*ined/h20/elk/ab1TerapiDehidrasi Hiponatremik Initial resuscitationIsotonic saline as for isotonic dehydration

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*ined/h20/elk/ab1HipernatremiaDiabetes Insipidus Polyuria and polydipsiaDeficient production of vasopressin or ADHCalled pituitary DI or central DI. Polyuria without hypernatremia is not DI

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*ined/h20/elk/ab1Hipernatremia Diabetes Insipidus EtiologyHead trauma Cranial surgeryspecifically post-pituitary surgery Infectiousmeningitis, encephalitis

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*ined/h20/elk/ab1Hipernatremia-HipervolemikTherapy DiuresisReplacing urinary losses with water

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*ined/h20/elk/ab1Potasium

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*ined/h20/elk/ab1Potassium balance Internal Balance1. AcidosisK+ moves from the intracellular to the extracellular compartment in exchange for H+2. Insulin Stimulates K+ uptake by muscle and hepatic cells. 3. Aldosterone Makes cells more receptive to the uptake of K+ and increases renal excretion of K+

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*ined/h20/elk/ab1Potassium balance Internal Balance4. Epinephrine Combined alpha and beta receptor stimulation releases K+ from the liver Beta-receptor stimulation enhaces K+ uptake by muscle and liver The end result is a decrease in serum K+ 5.Propranolol impairs cellular uptake of K+.

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*ined/h20/elk/ab1Potassium balance B. External Balance - Renal Potassium ExcretionAn acute or chronic increase in K+ intake leads to increased secretion in the distal convoluted tubule. 2. A sodium load will increase flow past the distal tubule and cause K+ wasting. The converse is true too. 3. A mineralcorticoid deficiency leads to K+ retention and Na+ wasting, just as excess leads to opposite changes.

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*ined/h20/elk/ab1Potassium balance External Balance - GI Potassium ExcretionFecal excretion of K+ normally is smallDiarrhea disorders, K+ loss increases significantly.

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*ined/h20/elk/ab1Potassium disordersHypokalemia The serum potassium is only a fair reflection of total body potassium. Work up: Urinary K+ and Cl Arterial pH and HCO3 History and PE Current medications Causes: Many

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*ined/h20/elk/ab1Potassium disordersHypokalemia Treatment Repletion of K+ Removal of the cause of hypokalemia. Emergency situationIn the presence of arrhythmiasK+ can be replaced intravenously by a solution containing 40 to 60 meq/lInfused at a rate of no more than 40 meq/hourAny magnesium deficiency must be corrected in order to correct the hypokalemia.

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*ined/h20/elk/ab1Potassium disordersHyperkalemia Potassium is released from cellsAt times of stress, injury, acidosisThe kidney is able to regulate potassium wellHyperkalemia is rarely a problem. In the presence of renal failure Hyperkalemia becomes a common problem.

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*ined/h20/elk/ab1Potassium disordersHyperkalemia It is generally treated if There is an abrupt rise from normal to > 6.5 meq/liter Any level is associated with EKG changesClinical featuresInvolve neuromuscular abnormalities, GI complaints of nausea, vomiting, colic, and diarrhea. Cardiac abnormalitiesConduction defects, dysrhythmias.

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*ined/h20/elk/ab1Potassium disordersHyperkalemia Hyponatremia and acidosis Potentiate the adverse effects of hyperkalemia on the heart. Peaked T waves Flattening of P waves Prolonged PR interval Widening of the QRS Sine Wave pattern V Fib/cardiac arrest.

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*ined/h20/elk/ab1Potassium disordersHyperkalemia Treatment Restrict Exogenous K+ Calcium gluconate - 10 to 30 ml of 10% solution over 3 to 5 minutes NaHCO3 - 50 to 100 ml of 7.5% solution Hyperventilation will also create an alkalosis and drive K+ into cells Avoid hypoventilation,

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*ined/h20/elk/ab1Potassium disordersHyperkalemia Treatment Glucose insulin500 ml of 10% dextrose plus 10 units regular insulin or 50 - 100 gm with 10 -20 units regular insulin Lasix, ethacrynic acid, or bumex Oral or rectal sodium or calcium polystyrene with sorbitol Peritoneal dialysis or hemodialysis Transvenous pacemaker

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