Fluid Electrolyte By Monica N

8,476 views

Published on

0 Comments
16 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
8,476
On SlideShare
0
From Embeds
0
Number of Embeds
1,457
Actions
Shares
0
Downloads
0
Comments
0
Likes
16
Embeds 0
No embeds

No notes for slide

Fluid Electrolyte By Monica N

  1. 1. Fluid and electrolyte imbalance MONIKA NANDA 20/2/2009
  2. 2. Things to consider: <ul><li>Normal changes in TBW, ECF </li></ul><ul><li>Changes in salt and water balance </li></ul><ul><li>Normal changes in renal function </li></ul><ul><li>Insensible water losses </li></ul>
  3. 3. Body fluid composition in the fetus and newborn <ul><li>Total Body Water = ICF + ECF (Intravascular+Interstitial) </li></ul><ul><li>As gestational age increases, TBW and ECF decrease while ICF increases </li></ul><ul><li>At birth, TBW = 75% of body weight in term infants and about 80% in premature infants </li></ul><ul><li>ECF decreases from 70% to 45% </li></ul><ul><li>At 32 wks gestation, TBW = 83% and ECF 53% </li></ul>
  4. 4. 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
  5. 5. Perinatal changes <ul><li>During the first week to 10 days of life, reduction in body weight is due to the reduction in the ECF </li></ul><ul><li>Term infants- wt loss = 5%-10% within 3-5 days of birth </li></ul><ul><li>LBW infants lose about 10-15% of body weight during the first 5 days of life </li></ul><ul><ul><li>Can lead to imbalances in sodium and water homeostasis </li></ul></ul>
  6. 6. Sodium balance in the newborn <ul><li>Renal sodium losses are inversely proportional to gestational age </li></ul><ul><li>Term infants have Fractional excretion of sodium = 1% with transient increases on day 2 and </li></ul><ul><li>At 28 weeks- Fractional excretion of Sodium = 5% to 6% </li></ul><ul><li>Preterm infants <35wks display negative sodium balance and hyponatremia during first 2-3 wks of life </li></ul>
  7. 7. Sodium balance in the newborn <ul><li>Preterm infants may need 4-5mEq/kg of sodium per day to offset high renal losses </li></ul><ul><li>Increased urinary sodium losses </li></ul><ul><ul><li>hypoxia </li></ul></ul><ul><ul><li>respiratory distress </li></ul></ul><ul><ul><li>hyperbilirubinemia </li></ul></ul><ul><ul><li>ATN </li></ul></ul><ul><ul><li>polycythemia </li></ul></ul><ul><ul><li>diuretics. </li></ul></ul>
  8. 8. Sodium balance in the newborn <ul><li>Pharmacologic agents like dopamine, increase urinary sodium losses </li></ul><ul><li>Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys </li></ul>
  9. 9. Water balance in the newborn <ul><li>Primarily controlled by ADH which enables water to be reabsorbed by the distal nephron collecting duct </li></ul><ul><li>Stimulation of ADH occurs when blood volume is diminished or when serum osmolality increases above 285mOsm/kg </li></ul><ul><li>Intravascular volume has a greater influence on ADH secretion than serum osmolality </li></ul>
  10. 10. Renal concentration and diluting capacity <ul><li>Adults can concentrate urine up to 1500mOsm/kg of plasma water and dilute as low as 50mOsm/kg of plasma water </li></ul><ul><li>Concentrating capacity is 800 mOsm/kg in term infants and 600 mOsm/kg in preterm </li></ul><ul><li>Diluting capacity is 50 mOsm/kg in term and 70 mOsm/kg in preterm </li></ul><ul><li>Newborns have reduction in GFR and decreased activity of transporters in the early distal tubule </li></ul>
  11. 11. Factors affecting insensible water losses in the neonate <ul><li>Level of maturity </li></ul><ul><li>Elevated body temperature increases loss by 10% </li></ul><ul><li>Radiant warmer - increased by 50% compared to thermo-neutral with high humidity </li></ul><ul><li>Phototherapy increases losses by 50% </li></ul><ul><li>High ambient or inspired humidity - reduced by 30% </li></ul><ul><li>Double walled isolette or plastic shield reduces losses by 10-30% </li></ul>
  12. 12. WHO REQUIRE FLUID  Infant < 30 wks. & <1250 gm.    Sick Term Newborns - Severe birth asphyxia - Apnoea - RDS - Sepsis - Seizure
  13. 13. 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.
  14. 14. Fluid requirements in the first month of life <ul><li>Birth weight Water requirements </li></ul><ul><li>D 1-2 D3-7 D8-30 </li></ul><ul><li><750 100-200 150-200 120-180 </li></ul><ul><li>750-1000 80-150 100-150 120-180 </li></ul><ul><li>1000-1500 60-100 80-150 120-180 </li></ul><ul><li>>1500 60-80 100-150 120-180 </li></ul>
  15. 15. 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%
  16. 16. LESS FLUID Birth asphyxia Meningitis Pneumothorax IVH PDA CLD 2/3 of Maintenance  
  17. 17. Nursing requirements of FLUID <ul><li>Increased requirement : </li></ul><ul><li>Fever </li></ul><ul><li>Vomiting </li></ul><ul><li>Renal failure </li></ul><ul><li>Burn </li></ul><ul><li>Shock </li></ul><ul><li>Tachypnea </li></ul><ul><li>Gastroenteritis </li></ul><ul><li>Cystic fibrosis </li></ul>
  18. 18. 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.
  19. 19. 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
  20. 20. Pediatric Fluid Therapy Principles <ul><li>Maintenance H 2 O needs: </li></ul><ul><li>Weight in Kg H 2 O fluid needs </li></ul><ul><li>1-10 100cc /kg /day </li></ul><ul><li>11-20 1000+50cc/kg/day </li></ul><ul><li>> 20 1500 + 20cc/kg/day </li></ul><ul><li>Add 12 % for every 0 C </li></ul>
  21. 21. 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
  22. 22. 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.
  23. 23. Na + & K + Daily Needs <ul><li>Na+ = 2-3 meq / kg / day </li></ul><ul><li>K+ = 1-2 meq / kg / day </li></ul><ul><li>Notice: </li></ul><ul><li>Daily fluid maintenance in pediatrics: </li></ul><ul><li>0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc </li></ul>
  24. 24. ELECTROLYTE REQUIREMENT <ul><li>SODIUM : </li></ul><ul><li>Add - from day 2 - 3 </li></ul><ul><li>In VLBW add when lost 6% wt. </li></ul><ul><li>Require - Term & LBW  2 - 3 mEq / kg / day </li></ul><ul><li>ELBW  3 - 5 mEq / kg / day </li></ul>
  25. 25. ELECTROLYTE REQUIREMENT…. <ul><li>POTASIUM : </li></ul><ul><li>Add - from day 3 </li></ul><ul><li>can wait till serum K+ < 4 in small </li></ul><ul><li>prematures </li></ul><ul><li>Require - 2 - 3 mEq / kg / day </li></ul>
  26. 26. 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  
  27. 27. 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
  28. 28. 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.
  29. 29. 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  
  30. 30. Monitoring fluid and electrolyte balance <ul><li>Oral mucosal integrity </li></ul><ul><li>Heart rate and blood pressure </li></ul><ul><li>Capillary refill </li></ul><ul><li>Sunken anterior </li></ul><ul><li>fontanelle </li></ul>
  31. 31. 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
  32. 32. Pediatric Fluid Therapy Principles <ul><li>Assess water deficit by: </li></ul><ul><li>1. weight: </li></ul><ul><li>weight loss (Kg) = water loss (L) </li></ul><ul><li>OR </li></ul><ul><li>2. Estimation of water deficit by physical exam: </li></ul><ul><li>Mild moderate severe </li></ul><ul><li>Infants < 5 % 5 - 10 % > 10 % </li></ul><ul><li>Older children < 3 % 3 - 6 % > 6 % </li></ul>
  33. 33. Physical Signs of Dehydration
  34. 34. Correction of Dehydration <ul><li>Moderate to severe dehydration: </li></ul><ul><li>IV push </li></ul><ul><li>10-20 cc / Kg Normal saline </li></ul><ul><li>(5 % albumin) </li></ul><ul><li>May repeat. </li></ul><ul><li>Half deficit over 8 hours, and half over 16 hours. </li></ul><ul><li>If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed). </li></ul>
  35. 36. CALCULATION- <ul><li>DEFICIT- % dehydration x wt.(kg)x 10 </li></ul><ul><li>TOTAL FLUID- maintainence + deficit </li></ul><ul><li>%deydration =  %weight loss </li></ul><ul><ul><li>Wt loss = 15 – 13.5 = 1.5kg %Wt loss = 1.5/15 x 100 = 10% </li></ul></ul>
  36. 37. CALCULATION-
  37. 38. Type of Dehydration <ul><li>1. Isotonic </li></ul><ul><li>(affect ECF ,Na = 135meq /l) </li></ul><ul><li>2. Hypotonic </li></ul><ul><li>( loss in ECF 2 correct ICF, Na = less than 135meq/l ) </li></ul><ul><li>3. Hypertonic </li></ul><ul><li>( sever loss in ICF ,Na = more than 150meq/l </li></ul>
  38. 39. 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)
  39. 40. 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)
  40. 41. hypoNa Manifestations <ul><li>Water excess => rapid weight gain </li></ul><ul><li>Na+ loss => neurological symptoms </li></ul><ul><ul><ul><li>irritability, seizures, < LOC </li></ul></ul></ul><ul><ul><ul><li>Muscle cramps </li></ul></ul></ul><ul><ul><ul><li>Anorexia/ Nausea/Vomiting (subtle signs ) </li></ul></ul></ul><ul><li>Treat </li></ul><ul><li>water excess </li></ul><ul><li>Fluid restriction (I&O) </li></ul><ul><li>Treat sodium loss </li></ul><ul><li>Oral or IV sodium </li></ul>
  41. 42. 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.  
  42. 43. <ul><li>Male baby of 7 days wt. 1.5 kgs., serum Na+ obs. 122 mEq. / lt. </li></ul><ul><li>How to correct the hyponatremia ? </li></ul><ul><li> Deficit of Na+ = (135 – 122) x 1.5 x 0.6 = 11.7 mEq. </li></ul><ul><li> Maintenance Na+ = 3 x 1.5 x 2 ( correction made in 48 hrs .) </li></ul><ul><li> = 9 mEq. </li></ul><ul><li> Total requirements = 11.7 +9 = 20.7 mEq. = 21 mEq. </li></ul><ul><li> Fluid requirements for 48 hrs. = 1.5 x 150 x 2 = 450 ml. </li></ul><ul><li> 21 mEq Na+ in 450 ml. fluid = 50 mEq. Na+ in 1 lit. </li></ul><ul><li> Fluid required = 450 ml. N/3 Solution. </li></ul>
  43. 44. 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.  
  44. 45. 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.
  45. 46. K+ DISORDERS <ul><li>HYPOKALEMIA </li></ul><ul><li>Nasogastric D </li></ul><ul><li>Ileostomy D </li></ul><ul><li>Renal tubular defects </li></ul><ul><li>Chronic DU use </li></ul><ul><li>HYPERKALEMIA </li></ul><ul><li>Trauma </li></ul><ul><li>Hypothermia </li></ul><ul><li>IVH </li></ul><ul><li>Renal failure </li></ul><ul><li>Medication error </li></ul>
  46. 47. HYPOKALEMIA (<3meq/L) <ul><li>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. </li></ul><ul><li>K + deficit = (Req K + - obs K + ) x body wt. </li></ul><ul><li> 3 </li></ul><ul><li> = (3.5 - 2.1) x 3 </li></ul><ul><li> 3 </li></ul><ul><li> = 1.4 mEq </li></ul><ul><li> Treat by increasing the intake by 1-2 mEq/kg </li></ul><ul><ul><li>If severe, 0.5-1mEq/kg is infused IV over 1 hour with EKG monitoring </li></ul></ul>
  47. 48. 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
  48. 50. 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.
  49. 51. <ul><li>HYPERKALEMIA…. </li></ul><ul><li>K+ > 7 mEq / lit - Ca – gluconate 1- 2ml / kg over 0.5/ 1hr. </li></ul><ul><li>- NaHCo 3 1 – 2ml / kg slowly </li></ul><ul><li>- 2ml / kg of 10% D + 0.05 units / kg regular insulin followed by – infusion </li></ul><ul><li>- Kayexelate </li></ul><ul><li>- Salbutamol Nebulisation 4mcg / kg </li></ul><ul><li>5. If above measure fails  </li></ul><ul><li>Peritoneal dialysis </li></ul><ul><li> Exchange transfusion </li></ul><ul><li>ECG  Tall - T /  PR /  QRS </li></ul>
  50. 52. CALCIUM DISORDERS- <ul><li>HYPOCALCEMIA- </li></ul><ul><ul><li>Renal insufficiency </li></ul></ul><ul><ul><li>Hepatobiliary ds. </li></ul></ul><ul><ul><li>Malabsorption </li></ul></ul><ul><ul><li>Rapid infusion of citrate buffered blood </li></ul></ul><ul><ul><li>Inappr. Diuretic use </li></ul></ul><ul><ul><li>phototherapy </li></ul></ul>
  51. 53. 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
  52. 54. 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
  53. 55. HYPERCALCEMIA <ul><li>CAUSES- </li></ul><ul><ul><li>Hyperparthyroidism </li></ul></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><li>Hypervitaminosis A </li></ul></ul><ul><ul><li>Thiazide DU </li></ul></ul><ul><li>Total S ca >11mg/dl </li></ul><ul><li>Ionized ca level>5mg/dl </li></ul><ul><li>Hypotonia, lethargy,constipation </li></ul><ul><li>Rx- volume expansion with isotonic saline sol. </li></ul><ul><li>frusemide </li></ul>
  54. 56. <ul><li>Common fluid problems </li></ul><ul><li>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 </li></ul>Common fluid problems
  55. 57. <ul><li>Dehydration: Wt loss, oliguria + , urine sp. gravity >1.012. Correct deficits, then maintenance + ongoing losses </li></ul><ul><li>Fluid overload: Wt gain, often hyponatremia. Fluid+ sodium restriction </li></ul>
  56. 58. Thank U

×