Electrolyte Emergencies for Pediatric Residents

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  • Infants maintain a state of positive K balance for growth: 1st 3 months is 1.2mmol/day, 3-12mo is 0.8mmol/day, >1yr is 0.4mmol/day.Discuss routes in (diet and/or IVF or TPN) AND Routes out (poo or pee).
  • TALK ABOUT THINGS THAT CAUSE K to be FALSELY ELEVATED.Spurious hi K can be from hemolysis, spherocytosis.K also moves out of white cells and platelets after clotting has occurred, so the lab value is usually 0.1-0.5mmol/L higher than true plasma value (which is why a blood gas usually differs from the BMP value). This is rarely significant in most patients, but can be as high as 9mmol/L in patients with marked leukocytosis or thrombocytosis.
  • The gradient of potassium across the cell membrane is the major determinant of the resting membrane potential, which is the basis for the action potential that is essential for neuronal and muscular function. As the extracellular potassium levels increase in AKI, the gradient and membrane potential are affected, resulting in the clinical signs of muscle weakness and cardiac arrhythmias
  • For either case, STOP THE K GOING IN! (IVF/TPN/enteral)
  • Hypokalemia can cause: CV: arrhythmias (usu PAC, PVCs), sinus brady, AV block, others; increased SVR Neuromusc: wekaness, cramps, smooth muscle dysfunction (intestinal & urinary) Renal: dec urinary concentrating ability, dec Na excretion, incr renal ammonium production Endo/Metab: negative nitrogen balance (poor growth), glucose intolerance, decreased aldo release and increased renin release
  • It’s not usually a sodium deficit, but rather too much water.
  • What happens with hypernatremia: water moves out of cells to establish osmotic equilibrium, and brain cells shrink. Progressive lethargy, even coma. Intracranial bleeding can occur, and is more common in children. The dehydrated, shrunken brain “hangs” by the meninges in the skull which can tear the delicate bridging veins.
  • Electrolyte Emergencies for Pediatric Residents

    1. 1. Electrolyte Emergencies for Pediatric Residents<br />July 2010<br />Jennifer Vick, MD<br />
    2. 2. Cases 1 & 2: Serum K of 7.0<br />12 yo boy involved in MVC, 3 hours ago<br />Leg was pinned between front passenger seat and door<br />Foley inserted, with urine seen here:<br />11 do baby presented to ED with fever but was overall well-appearing<br />Sepsis work-up initiated<br />
    3. 3. Potassium Balance<br />DIET or IVF/TPN<br />98% intracellular<br />Distribution maintained by Na/K ATPase<br />Daily balance<br />Adults: net zero<br />Kids require + K balance<br /> for growth (infants>toddlers>kids)<br />CELL 140 mmol/L<br />BLOOD 3.5-5.0 mmol/L<br />SWEAT & STOOL <br />(5-10%)<br />URINE (90-95%)<br />
    4. 4. Most Common Etiologies of True Emergent Hyperkalemia<br />Increased K load<br />Acute Renal Failure<br />↑ed Tissue Catabolism<br />Tumor Lysis Syndrome<br />Rhabdomyolysis<br />Severe hemolysis<br />Immediately post cardiac surgery<br />Nonoliguric hyper-kalemia of the premature infant<br />
    5. 5. EKG Changes<br />
    6. 6. Management of Hyperkalemia<br />No EKG Changes, Have Time <br />No Time—Gotta Treat<br /><ul><li>IV Calcium to stabilize the myocardium
    7. 7. 10% Calcium gluconate</li></ul> 0.5-1.0ml/kg<br /><ul><li>IV Insulin (and glucose) which drives K into cells
    8. 8. Glucose 0.5-1.0g/kg
    9. 9. Insulin 0.1 unit/kg
    10. 10. Albuterol neb (if easily accessible)
    11. 11. <25kg give 2.5mg
    12. 12. >25kg give 5mg
    13. 13. IV NaHCO3 causes H+ to move out of cells, and K+ to move in
    14. 14. 1-2mEq/kg</li></ul>Decrease dietary (or IVF) K<br />Review medications<br />Increase Renal excretion (if possible)<br />Loop diuretic (lasix)<br />Increase GI excretion<br />Kayexalate (1gram/kg po or rectal)<br />Dialysis if appropriate (ESKD, TLS, etc)<br />
    15. 15. HYPO kalemia<br /><ul><li>RARELY an emergency
    16. 16. Muscle weakness and cramps are most common symptoms
    17. 17. Symptom severity is proportional to degree
    18. 18. EKG:
    19. 19. Depressed ST segment, decreased T wave amp, increase U wave amp
    20. 20. Consider 5 groups of causes:
    21. 21. Spurious, redistribution, true depletion (usu GI), renal losses, expanded “effective” circulating volume (with HTN, due to mineralocorticoids)
    22. 22. Correction can almost always be done enterally</li></li></ul><li>Potassium Preparations: PO is PREFERRED ROUTE OF REPLACEMENT!<br /><ul><li>Potassium Chloride (KCl)
    23. 23. Preferred for pts with metabolic acidosis due to diuretics or vomiting
    24. 24. Can be given IV if deemed necessary:
    25. 25. (3.0 – Measured K) x body weight in kg x 0.04 gives you the value of KCL to give in mmol
    26. 26. If IV required, but not urgent, rate of infused K should not exceed 0.5-1.0mmol/kg/hr
    27. 27. Potassium Citrate or Potassium Bicarbonate
    28. 28. Most often used for patients with RTA (low K and acidosis)
    29. 29. Potassium Phosphate
    30. 30. Can be used in recovery from DKA, in patients at risk of refeeding syndrome and in TPN</li></li></ul><li>Disorders of Water Metabolism<br />
    31. 31. Cases 3 & 4: Serum Na 110<br />18 mo boy with known diagnosis of Bartter’s syndrome, appearing ill after GI illness<br />Initial labs:<br />110/0.9/76/32/16/0.3<br />3yo girl got dehydrated during a GI illness<br />Received 20cc/kg NS, then admitted overnight for IVF. <br />Initial lab studies (3pm):<br />144/5/110/16/28/0.6<br />Called to bedside at 3am when she is not rousing<br />
    32. 32. Hyponatremia<br />Most common electrolyte abnormality in hospitalized children<br />
    33. 33. SIADH<br />VERY common in hospitalized kids<br />Sosm & Uosm for diagnosis<br />Fluid restriction is primary treatment<br />Often resolves with child’s recovery<br />
    34. 34.
    35. 35. Management of Hyponatremia<br /><ul><li>Treat the underlying cause if possible
    36. 36. Pain, nausea, inadequate solute intake, infection, etc.
    37. 37. Fluid restriction if SIADH is suspected etiology
    38. 38. Remember that SIADH is not a Na problem—it’s a WATER problem.
    39. 39. 3% saline (0.5mEq/ml) if severely symptomatic to get patient’s serum Na to 125
    40. 40. Rule of thumb is to correct no more than 10-12mEq/L in a 24 hour period
    41. 41. Calculate Na deficit: 0.6 x wt (kg) x (Desired Na – Measured Na)</li></li></ul><li>Management of Hyponatremia: Some Cautions<br /><ul><li>Don’t be fooled by hyperglycemia.
    42. 42. The osmotic load of elevated serum blood glucose pulls water out of the cells, diluting the concentration of Na (as well as K). An osmotic diuresis causes total body loss of Na & K.
    43. 43. Differentiate by serum osmolality.
    44. 44. Final Na (mEq/L)=meas Na + 0.16 [glucose(mg/dL) – 100]
    45. 45. Regardless of your calculations, you need to check the serum Na frequently to prevent overcorrection.
    46. 46. Why? Central pontinemyelinolysis</li></li></ul><li>Cases 5 & 6: Serum Na 150<br />13yo girl with severe CP and developmental delay in a group home<br />Has recently not been feeling well, and has had decreased interest in taking po<br />16yo boy with recent diagnosis of ALL, who developed a hemorrhagic stroke as a complication of dialysis needed for TLS<br />Water intake and UOP each exceed 10L per day<br />
    47. 47. Hypernatremia<br />Breaks down to either 1) Loss of water, or 2) Failure to adequately replace water loss<br />Moritz M, Ayus JC. Disorders of Water Metabolism in Children: Hyponatremia and Hypernatremia. Pediatrics in Review Vol 23, No 11, Nov 2002.<br />
    48. 48. Management of Hypernatremia<br />If ECFV depletion: bolus with NS <br />Subsequent IVF should slowly correct fluid loss<br />Can calculate water deficit and/or monitor serum Na closely<br />H20 deficit: TBW x (Measured Na – Desired Na)/ Desired Na. TBW is 0.6 x wt in kg<br />Possible complication of rapid correction: CEREBRAL EDEMA<br />Generally correct 0.5-1.0mEq/L per hour, and complete correction over 36-72 hours<br />
    49. 49. Cases 7 & 8: Serum Ca 5.5<br />16yo girl with ESKD with a several year history of non-compliance<br />Presented to ED complaining of leg cramping over past several days that has worsened, and now hand cramping<br />21 mo boy with FTT, weakness<br />Cries when his mom changes his diaper<br />X-ray of hips/legs showed severe osteopenia and fractures in various states of healing<br />
    50. 50. Hypocalcemia<br />
    51. 51. Management of Hypocalcemia<br /><ul><li>Measure serum total (low is <9), and ionized forms (low <4); full set of chemistries; albumin, Phos, Mg, PTH, alkphos. +/- Vit D
    52. 52. Can see prolonged QTc on EKG
    53. 53. For severe symptoms (usually seizures):
    54. 54. Give 10-20mg/kg elemental Calcium
    55. 55. IV 10% Calcium gluconate: 1ml=9mg=0.45mEq
    56. 56. IV 10% Calcium chloride: 1ml=27mg=1.36mEq
    57. 57. IV Calcium can cause tissue necrosis if extravasates
    58. 58. If Magnesium is low, correct that too</li></li></ul><li>Hyperphosphatemia<br /><ul><li>Advanced chronic kidney disease
    59. 59. Decreased renal excretion
    60. 60. Minimize dietary phosphate
    61. 61. Phosphate binders
    62. 62. Tumor lysis syndrome
    63. 63. Cell lysis, intracellular phosphate released into serum
    64. 64. Can require hemodialysis
    65. 65. Rasburicase
    66. 66. If normal renal function, saline diuresis helps</li></li></ul><li>

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