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Fluid Electrolyte By Monica N Fluid Electrolyte By Monica N Presentation Transcript

  • Fluid and electrolyte imbalance MONIKA NANDA 20/2/2009
  • Things to consider:
    • Normal changes in TBW, ECF
    • Changes in salt and water balance
    • Normal changes in renal function
    • Insensible water losses
  • Body fluid composition in the fetus and newborn
    • Total Body Water = ICF + ECF (Intravascular+Interstitial)
    • As gestational age increases, TBW and ECF decrease while ICF increases
    • At birth, TBW = 75% of body weight in term infants and about 80% in premature infants
    • ECF decreases from 70% to 45%
    • At 32 wks gestation, TBW = 83% and ECF 53%
  • HOW WET ARE THE NEWBORN  TBW - 0.7 L/kg in Newborn 0.6 L/kg at 1yr. Age    ECF 40% - Newborn 20% - Older Children
  • Perinatal changes
    • During the first week to 10 days of life, reduction in body weight is due to the reduction in the ECF
    • Term infants- wt loss = 5%-10% within 3-5 days of birth
    • LBW infants lose about 10-15% of body weight during the first 5 days of life
      • Can lead to imbalances in sodium and water homeostasis
  • Sodium balance in the newborn
    • Renal sodium losses are inversely proportional to gestational age
    • Term infants have Fractional excretion of sodium = 1% with transient increases on day 2 and
    • At 28 weeks- Fractional excretion of Sodium = 5% to 6%
    • Preterm infants <35wks display negative sodium balance and hyponatremia during first 2-3 wks of life
  • Sodium balance in the newborn
    • Preterm infants may need 4-5mEq/kg of sodium per day to offset high renal losses
    • Increased urinary sodium losses
      • hypoxia
      • respiratory distress
      • hyperbilirubinemia
      • ATN
      • polycythemia
      • diuretics.
  • Sodium balance in the newborn
    • Pharmacologic agents like dopamine, increase urinary sodium losses
    • Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys
  • Water balance in the newborn
    • Primarily controlled by ADH which enables water to be reabsorbed by the distal nephron collecting duct
    • Stimulation of ADH occurs when blood volume is diminished or when serum osmolality increases above 285mOsm/kg
    • Intravascular volume has a greater influence on ADH secretion than serum osmolality
  • Renal concentration and diluting capacity
    • Adults can concentrate urine up to 1500mOsm/kg of plasma water and dilute as low as 50mOsm/kg of plasma water
    • Concentrating capacity is 800 mOsm/kg in term infants and 600 mOsm/kg in preterm
    • Diluting capacity is 50 mOsm/kg in term and 70 mOsm/kg in preterm
    • Newborns have reduction in GFR and decreased activity of transporters in the early distal tubule
  • Factors affecting insensible water losses in the neonate
    • Level of maturity
    • Elevated body temperature increases loss by 10%
    • Radiant warmer - increased by 50% compared to thermo-neutral with high humidity
    • Phototherapy increases losses by 50%
    • High ambient or inspired humidity - reduced by 30%
    • Double walled isolette or plastic shield reduces losses by 10-30%
  • WHO REQUIRE FLUID  Infant < 30 wks. & <1250 gm.    Sick Term Newborns - Severe birth asphyxia - Apnoea - RDS - Sepsis - Seizure
  • HOW MUCH FLUID TO BE GIVEN <1 kg 1-1.5 kg. >1.5 kg. 1 st day 100 ml/kg. 80 ml/kg. 60 ml/kg. 7 th day 190/ml/kg 170 ml/kg 150 ml/kg.  increase 15 ml/kg/day upto 6 th day  Add  20 ml/kg/day for Phototherapy & Warmer.
  • Fluid requirements in the first month of life
    • Birth weight Water requirements
    • D 1-2 D3-7 D8-30
    • <750 100-200 150-200 120-180
    • 750-1000 80-150 100-150 120-180
    • 1000-1500 60-100 80-150 120-180
    • >1500 60-80 100-150 120-180
  • WHAT FLUID 1 st 48 hrs. <1 kg - 5% Dextrose 1-1.5 kg. - 10% Dextrose >1.5 kg. - 10% Dextrose After that  ISO – P  Na + - 20 mEq / lit K + - 20 mEq / lit Cl - 25 mEq / lit D - 5% OR 25ml 25% D + 75ml ISO – P  Na + - 22.7 mEq / lit K + - 18 mEq / lit Cl - 22 mEq / lit D - 10%
  • LESS FLUID Birth asphyxia Meningitis Pneumothorax IVH PDA CLD 2/3 of Maintenance  
  • Nursing requirements of FLUID
    • Increased requirement :
    • Fever
    • Vomiting
    • Renal failure
    • Burn
    • Shock
    • Tachypnea
    • Gastroenteritis
    • Cystic fibrosis
  • EXTRA FLUID  NEC & other condition with loss in 3 rd space  May require upto 200ml / kg – repeated 10ml / kg RL/NS bolus.  ELBW / VLBW neonates – Due to high IWL.
  • KEY POINTS TO REMEMBER IN FLUID THERAPY Term – 1% Per day  Allow a wt. Loss Preterm – 2% Per day  1 st 48 hrs – no electrolyte required
  • Pediatric Fluid Therapy Principles
    • Maintenance H 2 O needs:
    • Weight in Kg H 2 O fluid needs
    • 1-10 100cc /kg /day
    • 11-20 1000+50cc/kg/day
    • > 20 1500 + 20cc/kg/day
    • Add 12 % for every 0 C
  • Premature 1.25 kg. day 1 give fluid direction  10% Dextrose  100 ml / day  25 ml 6 hourly  10% Dextrose 4 ml / hr = 4drops / min
  • A 3 kgs., term sick newborn on 4 th day under radiant warmer & phototherapy, calculate fluid requirement  ISO – P  315 ml + 60 ml + 60 ml = 435 ml  108 ml / 6 hrs.  18 ml / hr. = 18 drops / min.
  • Na + & K + Daily Needs
    • Na+ = 2-3 meq / kg / day
    • K+ = 1-2 meq / kg / day
    • Notice:
    • Daily fluid maintenance in pediatrics:
    • 0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc
  • ELECTROLYTE REQUIREMENT
    • SODIUM :
    • Add - from day 2 - 3
    • In VLBW add when lost 6% wt.
    • Require - Term & LBW  2 - 3 mEq / kg / day
    • ELBW  3 - 5 mEq / kg / day
  • ELECTROLYTE REQUIREMENT….
    • POTASIUM :
    • Add - from day 3
    • can wait till serum K+ < 4 in small
    • prematures
    • Require - 2 - 3 mEq / kg / day
  • ELECTROLYTE REQUIREMENT.... C. CALCIUM :  Give to IDM Preterm Birth asphyxia <1500 gm.  Add from day 1.  36-72 mEq / kg / day or 4- 8 ml / kg / day of 10% Cal. gluconate  
  • Commercial electrolyte and dextrose stock sol. 25 ml ampoule 50 w/v 50 G/100 ml 50% Dextrose 10 ml ampoule and 25 ml ampoule 25 w/v 25 G/100 ml 25% Dextrose 1 ml = 0.5 mEq of Na 10 ml ampoule 50 ml bottle 3% Sodium Chloride If 25% Mg 4.15 mOsm/dL 2 ml ampoule 50% and 25% Magnesium sulphate 1 ml = 9.3 mg of Cal. 10 ml ampoule 10% w/v Calcium gluconate 1 ml = 2 mEq of K 10 ml ampoule 15% w/v Potassium Chloride 1 ml = 1 mEq of HCO 3 + 1 mEq of Na 10 ml ampoule 7.5% Soda bicarb solution Equivalents Available from Concentration Solution
  • Composition of commercial i.v. fluid available 368 22 20 25 50 Isolyte P Ped. Maint. 347 34 34 50 D5 0.2% NaCl 381 57 57 50 D5 0.33% NaCl 415 77 77 50 D5 ½ NS 585 154 154 50 5% DNS Dextrose, electrolyte solution 556 100 10% 278 50 5% Electrolyte free solution 154 77 77 ½ NS ½ isotonic 270 2 29 111 5 131 RL 308 154 154 NS Isotonic G/L mOsm/L Ca Lactat Cl K Na Dextr.
  • GOALS OF FLUID ELECTROLYTE THERAPY  Urine output 1 – 3 ml/kg/hr.  Allow a weight loss 1 – 2% / day in 1 st wk. (weigh the splint before putting i/v line)  Absence of Edema / Dehydration / Hepatomegaly  Urine Sp. gravity 1005 - 1015  Euglycaemia - 75 – 100 mg / dl  Normonatremia - 135 - 145 mEq / lit  Normokalemia - 4 – 5 mEq / lit  
  • Monitoring fluid and electrolyte balance
    • Oral mucosal integrity
    • Heart rate and blood pressure
    • Capillary refill
    • Sunken anterior
    • fontanelle
  • MONITORING FLUID ELECTROLYTE THERAPY Check Daily - Definitely  Wt. - loss > 3% - dehydration <1% over dehydration  Urine output <1 ml / kg / hr – dehydration or SIADH (Hourly) >4 ml / kg / hr. – overhydration / dieresis Napkin weight technique Collect in syringe from cotton    Urine specific gravity >1015 fluid deficit (each sample if possible) <1005 fluid overload  Blood Glucose  Clinical Signs
  • Pediatric Fluid Therapy Principles
    • Assess water deficit by:
    • 1. weight:
    • weight loss (Kg) = water loss (L)
    • OR
    • 2. Estimation of water deficit by physical exam:
    • Mild moderate severe
    • Infants < 5 % 5 - 10 % > 10 %
    • Older children < 3 % 3 - 6 % > 6 %
  • Physical Signs of Dehydration
  • Correction of Dehydration
    • Moderate to severe dehydration:
    • IV push
    • 10-20 cc / Kg Normal saline
    • (5 % albumin)
    • May repeat.
    • Half deficit over 8 hours, and half over 16 hours.
    • If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed).
  •  
  • CALCULATION-
    • DEFICIT- % dehydration x wt.(kg)x 10
    • TOTAL FLUID- maintainence + deficit
    • %deydration =  %weight loss
      • Wt loss = 15 – 13.5 = 1.5kg %Wt loss = 1.5/15 x 100 = 10%
  • CALCULATION-
  • 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
  • Estimated water nd elec. Deficit in dehydration 4-10 2-5 2-5 120-180 hypertonic 20-28 10-14 10-14 50-100 hypotonic 16-20 8-10 8-10 100-150 isotonic Cl /hco3(meq/kg) K(meq/kg) Na(meq/kg.) Water(ml/kg)
  • HYPONATREMIA  Serum Na + <130 mEq / lit  Neurological Signs or Na + <120 mEq / lit  treat promptly  What to give : 3% Nacl  0.5 mEq Na+ / ml  2 – 3 ml /kg initial dose  use 3% Nacl to raise Na + upto 125 mEq / lit    NaHco 3 7.5% solution  0.9 mEq Na + / ml (if 3% Nacl not available)
  • hypoNa Manifestations
    • Water excess => rapid weight gain
    • Na+ loss => neurological symptoms
        • irritability, seizures, < LOC
        • Muscle cramps
        • Anorexia/ Nausea/Vomiting (subtle signs )
    • Treat
    • water excess
    • Fluid restriction (I&O)
    • Treat sodium loss
    • Oral or IV sodium
  • HYPONATREMIA…….  How to calculate deficit  Na + deficit (mEq) = (desired Na + - obs Na + ) x wt x 0.6  Add next 2 days daily requirement 2-3 mEq / kg / day    correct in 48 hrs.    Thumb rule - correct 1/3 rd 8hr 1/3 rd 16 hr 1/3 rd 24 - 48 hr.  
    • Male baby of 7 days wt. 1.5 kgs., serum Na+ obs. 122 mEq. / lt.
    • How to correct the hyponatremia ?
    •  Deficit of Na+ = (135 – 122) x 1.5 x 0.6 = 11.7 mEq.
    •  Maintenance Na+ = 3 x 1.5 x 2 ( correction made in 48 hrs .)
    • = 9 mEq.
    •  Total requirements = 11.7 +9 = 20.7 mEq. = 21 mEq.
    •  Fluid requirements for 48 hrs. = 1.5 x 150 x 2 = 450 ml.
    •  21 mEq Na+ in 450 ml. fluid = 50 mEq. Na+ in 1 lit.
    •  Fluid required = 450 ml. N/3 Solution.
  • HYPERNATREMIA  Serum Na> 150 mEq / lit  Excess free water loss than Na + (mc in ELBW infants)  Do not treat with Na + free water  Fluid therapy -- 2/3 maintenance with N 2 / N 5 sol. + 5% D. -- correct Na + over 24 – 48 hrs. Do not drop >1 mEq / kg / hour. -- May require 3% NaCl if over correction leads to CNS signs.  
  • POTASSIUM 2 meq/kg/day The total body potassium deficit cannot be calculated from the serum potassium. l g of KCl contains 13.4 mEq K and 13.4 mEq Cl. 1ml KCl = 2 Meq The MAXIMUM safe rate of K infusion IV = 0.3 mEq/kg/hour (beware of K concentrations over 4 g/litre in IV fluid). Eg: For an 8 kg child with hypokalaemia, with IV fluid at 25 ml/hour: 8 x 0.3 = 2.4 mEq K MAXIMUM in 25 ml 2.4 mEq in 25 ml = 2.4 x 1000/25 or 96 mEq/l. 96 mEq K = 96/13.4 or 7g KCl per litre.= 48ml = max 4 ampules per pint To be safe, add only half this amount (3.5 g) to each litre.
  • K+ DISORDERS
    • HYPOKALEMIA
    • Nasogastric D
    • Ileostomy D
    • Renal tubular defects
    • Chronic DU use
    • HYPERKALEMIA
    • Trauma
    • Hypothermia
    • IVH
    • Renal failure
    • Medication error
  • HYPOKALEMIA (<3meq/L)
    • A Newborn 3kgs on 2 nd day developed abdominal distension, NG tube inserted, on 3 rd day Serum K + observed was 2.1 mEq / lit. How to correct.
    • K + deficit = (Req K + - obs K + ) x body wt.
    • 3
    • = (3.5 - 2.1) x 3
    • 3
    • = 1.4 mEq
    • Treat by increasing the intake by 1-2 mEq/kg
      • If severe, 0.5-1mEq/kg is infused IV over 1 hour with EKG monitoring
  • HYPOKALEMIA …    Max K + i/v without ECG - monitoring – 40 mEq / lit = 2ml 1.5ml KCL / 100ml of Fluid.    Max K + i/v with ECG – monitoring – 60 - 80 mEq / lit    Signs of hypokalenia in newborn – ileus Obtundation  QT / ST depression
  •  
  • HYPERKALEMIA  Serum K + > 6 mEq / lit   How to manage 1. Check Sampling error and Recheck Value 2. Remove all sources of K + 3. Upto 7mEq / lit  Kayexelate 1gm / kg at 0.5gm / ml of NS given as enema (upto 1- 3 cm)  minimum retention time = 30 min.
    • HYPERKALEMIA….
    • K+ > 7 mEq / lit - Ca – gluconate 1- 2ml / kg over 0.5/ 1hr.
    • - NaHCo 3 1 – 2ml / kg slowly
    • - 2ml / kg of 10% D + 0.05 units / kg regular insulin followed by – infusion
    • - Kayexelate
    • - Salbutamol Nebulisation 4mcg / kg
    • 5. If above measure fails 
    • Peritoneal dialysis
    •  Exchange transfusion
    • ECG  Tall - T /  PR /  QRS
  • CALCIUM DISORDERS-
    • HYPOCALCEMIA-
      • Renal insufficiency
      • Hepatobiliary ds.
      • Malabsorption
      • Rapid infusion of citrate buffered blood
      • Inappr. Diuretic use
      • phototherapy
  • HYPOCALCAEMIA   Serum calcium <7.0 mg / dl ionised cal <4.0 mg / dl (1mmol/L) Seizure Treatment of Hypocalcaemic Crisis apnoea Tetany 1 – 2ml Ca-glu. / kg + 5 - 10% D 10ml over 10 min.  No response in 10min  REPEAT DOSE  Maintenance Cal  8ml / kg / day x 48 hrs.  Switch to oral therapy
  • HYPOCALCAEMIA … Refractory hypocalcaemia  think hypomagnesaemia(0.8 mg/dl)  0.2ml of 50% mgso 4 2 doses 12hr. Apart i/v or deep im Caution in Ca ++ therapy  Rapid i/v infusion - dysrythmia / bradycardia  Extravasation of Ca ++ Solution  S/C necrosis & Calcification
  • HYPERCALCEMIA
    • CAUSES-
      • Hyperparthyroidism
      • Hyperthyroidism
      • Hypervitaminosis A
      • Thiazide DU
    • Total S ca >11mg/dl
    • Ionized ca level>5mg/dl
    • Hypotonia, lethargy,constipation
    • Rx- volume expansion with isotonic saline sol.
    • frusemide
    • Common fluid problems
    • Oliguria : UOP< 1cc/kg/hr. Prerenal, Renal, or Postrenal causes. Most normal term babies pee by 24-48 hrs. Don’t wait that long in sick l’il babies! Check Baby, urine, FBP. Try fluid challenge, then lasix. Get USG if no response
    Common fluid problems
    • Dehydration: Wt loss, oliguria + , urine sp. gravity >1.012. Correct deficits, then maintenance + ongoing losses
    • Fluid overload: Wt gain, often hyponatremia. Fluid+ sodium restriction
  • Thank U