Electrolyte imbalance in children

Dr. WAN NEDRA Sp.A Bagian Ilmu Kesehatan Anak FK YARSI 2008

Introduction
In developed countries, 50% of pediatric hospitalization is due to acute diarrhea (WHO) Electrolyte abnormalities are common in children with diarrhea It may remain unrecognized and result in mortality and morbidity The 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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CASE 1
A 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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Normal 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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Kebutuhan Maintenance Mineral/kg bb/24 jam

Mineral
Sodium (Na) Potasium (K) Chlorida (Cl) Calcium (Ca) Magnesium (Mg) Phosphate (P) 7/30/2013

Dosis
2-3 mEq 1-2 mEq 3-5 mEq 50-200 mg 0.4-0.8 mEq 15-50 mg

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Sodium Serum
Laboratory finding:

Isonatremia Hiponatremia Hipernatremia

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Isonatremia
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Isonatremia-Isotonisitas Isoosmolalitas

Isonatremia
Sodium serum 135-145 mEq/L

Isotonik

Osmotic gradient (-) Tekanan osmotik : normal Perpindahan air: tidak ada
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Isonatremia-Isotonisitas Hiperosmolalitas

Isonatremia
Sodium serum 135-145 mEq/L

Isotonik

Osmotic gradient (-) Tekanan osmotik : normal Perpindahan air : tidak ada
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Isonatremia-Hipertonisitas Hiperosmolalitas

Isonatremia
Sodium serum 135-145 mEq/L

Hipertonisitas

Osmotic gradient (+) Tekanan osmotik : tinggi Perpindahan air: ICF ECF dehidrasi sel
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Hiponatremia

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Hiponatremia-Hipotonisitas Hipoosmolalitas
Hiponatremia Sodium serum < 130 mEq/L Hipotonik Osmotic gradient (+)
Tekanan osmotik : rendah Perpindahan air

edema sel
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: ECF ICF
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Hiponatremia-Hipertonisitas
Hiponatremia Sodium serum < 130 mEq/L Hipertonik Osmotic gradient (+) Tekanan osmotik : tinggi Perpindahan air : ICF ECF dehidrasi sel
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Hipernatremia

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Hypernatremia
Less common than hyponatremia Relative water deficit in relation to

sodium in the plasma Usually iatrogenic

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Hipernatremia
Hipernatremia Sodium serum 150 mEq/L Hipertonik Osmotic gradient (+)
Tekanan osmotik : tinggi

Perpindahan air

dehidrasi sel
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: ICF ECF
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Isonatremia-Isotonisitas Isoosmolalitas

Hipovolume (Dehidrasi isonatremia)

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Terapi Dehidrasi Isonatremik

Hitung defisit :

Hitung maintenance

Air dan Na

Asumsi :

Air dan Na

Isonatremik - isotonik ~ NaCl 0.9% (NaCl 0.9% = 154 mEq Na/L H2O)
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Terapi Dehidrasi Isonatremik

Contoh Dehidrasi 10%: (BB : 5 kg 4.5 kg) 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 (kg) x 3 mEq/kg = 15 mEq Total H2O / 24 hr = 500 + 500 = 1000 ml Total Na /24 hr = 77 + 15 = 92 mEq

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Dehidrasi hiponatremik
Sodium and water losses
Gastrointenstinal losses: Urinary losses
Vomiting Diarrhea

Salt water nephropathy Adrenal insufficiency Diuretic

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Terapi Dehidrasi Hiponatremik

Hitung jumlah natrium : Hiponatremia Isonatremia Selanjutnya :
Sesuai : Dehidrasi Isonatremia

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Terapi Dehidrasi Hiponatremik

Contoh Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 125 mE/L Jumlah Na: hiponatremia isonatremia Na = (NaD-NaA) x TBW mEq Na = (135-125) x 0.6 x 5 = 30 mEq 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 = 30+77+15 =122 mEq
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Hyernatremia Hypovolemic
Water loss in excess of sodium loss Sodium lost (hypotonic solution)

Kidney GI tract Skin Respiratory tract

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Terapi Dehidrasi - Hipernatremia

Dehidrasi hipernatremik
Hitung jumlah air

Hipernatremia isonatremia
Selanjutnya Sesuai : IsonatremiaIsotonik-Hipovolemia
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Terapi Dehidrasi - Hipernatremia

Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L

Contoh

Jumlah air hipernatremiaisonatremia = X (X+TBW) x NaD = TBW x NaA X = (NaA/NaD) x TBW- (TBW) ml
X = (170/145) x (0.6x4.5)(0.6x4.5) = 465 ml
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Terapi Dehidrasi - Hipernatremia

Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L

Contoh

Defisit air = 500 ml Defisit Na = 500-465 = 35 mL (NaCl 0.9%) = 35ml x 154 mEq/L = 5 mEq

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Terapi Dehidrasi - Hipernatremia

Maintenance Air Maintenance Na
5 (kg) x 100 ml/kg 5 (kg) x 3 mEq/kg = 500 ml = 15 mEql

Jumlah Air/24 jam = 500 + 500 ml = 1000 ml Jumlah Na/24 jam = 5 + 15 mEq = 20 mEq
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Terapi Dehidrasi - Hipernatremia

Hati-hati: Dehidrasi
sel edema sel (otak)

Koreksi dalam 48 jam Air = 2 x maintenance + = (2x500) + (1 x 500) Na = 2 x maintenance + = (2x15)+(1x5)

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1 x defisit =1500 ml 1 x defisit = 35 mEq

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Terapi Dehidrasi Hiponatremik

Initial resuscitation Isotonic saline as for isotonic

dehydration

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Hipernatremia
Diabetes Insipidus
Polyuria and polydipsia Deficient production of vasopressin or

ADH Called pituitary DI or central DI. Polyuria without hypernatremia is not DI

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Hipernatremia
Diabetes Insipidus
Etiology

Head trauma Cranial surgery

Infectious
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specifically post-pituitary surgery meningitis, encephalitis

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Hipernatremia-Hipervolemik
Therapy Diuresis Replacing urinary losses with water

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Potasium
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Potassium balance
Internal Balance 1. Acidosis K+ 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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Potassium balance
Internal Balance 4. 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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Potassium balance
B. External Balance - Renal Potassium Excretion 1. An 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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Potassium balance
External Balance - GI Potassium Excretion Fecal excretion of K+ normally is small Diarrhea disorders, K+ loss increases significantly.

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Potassium disorders Hypokalemia

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
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Causes: Many

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Potassium disorders Hypokalemia

Treatment Repletion of K+ Removal of the cause of hypokalemia. Emergency situation
K+ can be replaced intravenously by a solution containing 40 to 60 meq/l Infused at a rate of no more than 40 meq/hour Any magnesium deficiency must be corrected in order to correct the hypokalemia. 7/30/2013 ined/h20/elk/ab 1

In the presence of arrhythmias

Potassium disorders Hyperkalemia

Potassium is released from cells At times of stress, injury, acidosis The kidney is able to regulate potassium well Hyperkalemia is rarely a problem. In the presence of renal failure Hyperkalemia becomes a common problem.

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Potassium disorders Hyperkalemia

It is generally treated if There is an abrupt rise from normal to > 6.5 meq/liter Any level is associated with EKG changes Clinical features Involve neuromuscular abnormalities, GI complaints of nausea, vomiting, colic, and diarrhea. Cardiac abnormalities Conduction defects, dysrhythmias.
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Potassium disorders Hyperkalemia

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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 Treatment

Potassium disorders Hyperkalemia

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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Potassium disorders Hyperkalemia

Treatment Glucose insulin
500 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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