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8/14/2019 Fluid -Electrolyte Imbalance 2012-Ined.ppt
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Fluid and Electrolyte Imbalance
Wan Nedra
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Introduction to the Principles of Fluid and
Electrolyte Therapy
Important to understand the underlying physiologic principles
of a therapy commonly employed in pediatrics
Understanding basic principles essential for the understanding
of the management of more complex disorders such as:
Cholera
Dengue
Pyloric stenosis
Hyperosmotic non-ketotic coma
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Crystalloid and Colloid
Crystalloid: Water and electrolyte solution
Does not remain within the intravascular space but rather
distributes to the entire extracellular space
Only impacts on the intracellular space if it causes a change in
extracellular osmolarity E.g.: 0.9% NaCl, D5 0.3% NaCl
Colloid: Contains large particles which tend to remain within the blood
vessels
Colloid preferentially expands the intravascular space because the
particles exert oncotic force which retains water within theintravascular space
E.g.: 5% albumin, blood, dextran solution
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Isotonic Saline Solution
Isotonic saline solution: Solution such as 0.9% NaCl or Ringerslactate with a Na concentration similar to that of plasma water
Crystalloid distributes throughout the extracellular space
Infusion of crystalloid will cause a fluid shift into or out of the
intracellular space only if it creates an osmotic gradientbetween the extracellular and intracellular space
Isotonic saline does not change the osmolarity of theextracellular space
Therefore: Isotonic saline solution remains within and
expands the extracellular space and has minimal effect onthe intracellular space
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Composition of Fluids
1. D5W (5 g sugar/100 ml): 252 mOsm/L
2. D10W (10 g sugar/100 ml): 505 mOsm/L
3. NS (0.9% NaCl) 154 mEq Na/L: 308 mOsm/L
4. 1/2 NS (0.45% NaCl): 77 mEq Na/L: 154 mOsm/L5. D5 1/4 NS (34 mEq Na/L): 329 mOsm/L
6. 3% NaCl 513 mEq Na/L: 1027 mOsm/L
7. 10% NaCl 1.7 mEq/cc
8. 20% NaCl 3.4 mEq/cc9. 8.4% NaHCO3 (1 meq/cc Na & HCO3): 2000 mOsm/L
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IV fluids
Lactated Ringers0-10 gram glucose/100ccNa 130 meq/LNaHCO3 28 meq/L as lactateK 4 meq/L
273 mOsm/L Amino acid 8.5 %8.5 gm protein/100 cc880 mOsm/L
Albumin 25% (salt poor)
25 gm protein/100 cc
Na 100-160 meq/L300 mOsm/L
Intralipid
2.25gm lipid/100cc 284 mOsm/L
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Requirements of FLUID
Increased requirement :
Fever
Vomiting
Renal failure Burn
Shock
Tachypnea
Gastroenteritis Diabetes (Insipidus, mellitus -
DKA)
Cystic fibrosis
Decreased requirement
CHF
Postoperatively
Oliguric ( RF )
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Maintenance Fluid and Electrolyte Requirements
Maintenance: The replacement of normal ongoing losses
Normally serum Na concentration is approximately 140 meq/land serum K concentration is approximately 4 meq/l
Maintenance solution replaces normal losses
Maintenance solution does not have an electrolyteconcentration equal to serum because the electrolytecomposition of urine and stool is not equal to that of serum
Maintenance fluids commonly provided as a 5% dextrose solution
Dextrose provides some energy and prevents hypoglycemia
Spares protein
Cannot meet patients nutritional requirements with 5% (or
10%) dextrose
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Maintenance Requirements are a Function of
Caloric Requirements
0-10 kg: 100 kcal/kg
10-20 kg: 50 kcal/kg
> 20kg: 20 kcal/kg
Examples:
8 kg: 8 kg X 100 kcal/kg = 800 kcal.
12 kg: 10 kg X 100 kcal/kg + 2 kg X 50 kcal/kg = 1000 kcal +100 kcal = 1100 kcal
20 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg = 1000 kcal
+ 500 kcal = 1500 kcal 25 kg: 10 kg X 100 kcal/kg + 10 kg X 50 kcal/kg + 5 kg X 20
kcal/kg = 1000 kcal + 500 kcal + 100 kcal = 1600 kcal
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Water and Electrolyte Requirements are
Determined by Caloric Requirements
Requirements per 100 kcal:
100 ml water (provided as a 5% dextrose solution)
2-4 meq Na
2 meq K
2 meq Cl
Plasma: Anion is a balance of Cl and base (bicarbonate)
Maintenance solution: Can provide some anion as Cl andsome as base (lactate, citrate, phosphate) or can provide
all of it as Cl But: Providing large volumes of fluid (e.g., in DKA or
hypovolemic shock) with all of the anion as Cl will promotea hyperchloremic metabolic acidosis
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Standard Maintenance Solution
D5W with 20-40 meq/l Na Cl and 20 meq/l KCl (or KAcetate orKPhosphate) will work well as a maintenance solution in mostpediatric patients
Can use D5 0.2% (or D5 0.3%) NaCl with 20 meq/l KCl (or
KAcetate or KPhosphate) as maintenance solution Recent article advocated routine use of isotonic saline solution
for pediatric maintenance solution
Some disease states: Another solution might be appropriate
E.g.: Sickle cell anemia patients may have a relatively high Na
requirement due to high urinary Na losses
0.9% NaCl (without dextrose) in head trauma patients
K should be used with caution or omitted in patients with renalinsufficiency
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Water and Electrolyte Requirements Based on
Weight
Water:
0-10 kg: 100 ml/kg
10-20 kg: 1000 mlplus50 ml/kg
> 20 kg: 1500 mlplus20 ml/kg
Electrolytes:
Na: 2-3 meq/kg
K: 1-2 meq/kg
Water requirement is the same as with the caloric-based
system
Electrolyte requirement is greater than with caloric-basedsystem: Electrolyte requirement is a direct linear function ofweight
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Fluids and Electrolytes Principles Total body water(TBW) = Intracellular fluid (ICF) +
Extracellular fluid (ECF)
ECF) = Intravascular fluid (in vessels : plasma, lymph -IVF) + Interstitial fluid (between cells - IF)
ECF ( intravascular, interstitial &trancelluler)Fluid % in child body ( 75%-80%)
Goals:
Maintain appropriate ECF volume,
Maintain appropriate ECF and ICF osmolality and ionicconcentrations
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Things to consider:Normal changes in TBW, ECF
All babies are born with an excess of TBW,
mainly ECF, which needs to be removed
Adults are 60% water (20% ECF, 40% ICF) Term neonates are 75% water (40% ECF, 35% ICF) :
lose 5-10 % of weight in first week
Preterm neonates have more water (24 wks: 85%,
60% ECF, 25% ICF): lose 5-15% of weight in first
week
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Diagnostic Evaluation
1. Anamnesis, Physical, Lab assessment
2. Type of dehydration
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Physical Assessment of FE status
Skin/Mucosa: Altered skin turgor, sunken AF, drymucosa, edema etc are not sensitive indicators inbabies
Cardiovascular: Tachycardiatoo much (ECF excess in CHF) or
too little ECF (hypovolemia)
Delayed capillary refilllow cardiac output
Hepatomegaly can occur with ECF excess
BP changes very late
Urine output
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Lab Assessment of FE status
Serum electrolytes and plasma osmolarity
Urine electrolytes, specific gravity (not very useful if
the baby is on diuretics - lasix etc), FENa Blood urea, serum creatinine (values in the first few
days reflect moms values, not babys)
Acid Base (low pH and bicarb may indicate poor
perfusion)
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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
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Physical Signsof Dehydration
Signs & sympt. MILD Moderate Severe
General Thirsty, allert,
restless
Thirsty, irritable,
or drowsy
Drowsylimp,
skin cold / sweaty
Radial pulse Normal rate Rapid, weak Rapid, feeble
Respiration Normal Deep Deep & rapid
Anterior font. Normal Sunken Very sunkenSkin turgor Pinch retracts
immediately
Retracts slowly Poor
Eyes Normal Sunken Grossly sunken
Tears Present Absent Absent
Mucous memb. Moist Dry Very dry
Urine flow Normal Dark &decreased
Oliguria / anuria
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Pediatric Fluid Therapy Principles
I. Assess water deficit by:
1. weight:
weight loss (Kg) = water loss (L)
OR
2. Estimation of water deficit by physicalexam:
Mild moderate severeInfants < 5 % 5 - 10 % >10 %
Older children < 3 % 3 - 6 % > 6 %
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Pediatric Fluid Therapy Principles
II. Maintenance H2O needs:
Weight in Kg H2O fluid needs
1-10 100cc /kg /day
11-20 1000+50cc/kg/day
> 20 1500 + 20cc/kg/dayAdd 12 % for every
0C
Therapeutic management of fluid loss
Oral rehydration therapy
Parenteral fluid therapy
Meet ongoing daily loss
Replace previous deficit
Replace ongoing abnormal losses
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Correction of Dehydration
1. Estimate Fluid Deficit (% :- Mild, Moderate, Severe).
2. Moderate to severe dehydration:
IV push 10-20cc / Kg Normal saline, May repeat.
Half deficit over 8hours, and half over 16hours.
3. Find Type of Dehydration
(Isonatremic, Hyponatremic, Hypernatremic).
4. Give daily Maintenance.
5. Give Deficit as follows:
Half volume over 8 hours, half volume over 16 hours
(Exception: in Hypernatremic Dehydration, replace deficitover 48 hours).
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Disturbance of F&E balance
1. Na 2. K 3. Ca
( Na is the primary osmatic farce )
Serum Osmolality
Defined as the number of particles per liter.May be approximated by:
2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8
Normal range: 275-295 mOsm/L300-500 cc/M2/day
Less in patients on the ventillator
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When administrating I.V fluid
Monitors the response of the fluids.
Considering the fluid volume.
Content of fluid. Patient clinical status.
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1. Isotonic fluids:
-Have a total osmolality close to that of extra cellular fluids
(ECF) and don't cause RBCs to shrink or swell.
- 3 L of isotonic solutions are needed to replace 1 L of
blood, so pt should be carefully monitored for signs offluid overload.
Examplesof Isotonic fluids:
D5W: has a serum osmolality of 252 mosm/L.
D5W s mainly used supply water and to correct an increasedserum osmolality
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NORMAL SALINE SOLUTION
NS (0.9% Sodium chloride with TO of 308
NS osmolality is contributed by electrolytes- So the solution remains within ECF.
- NS is used to treat ECF deficit.
- Ringer's solutions: Contains Ca, K and NaCl
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2. Hypotonic Fluids
- The purpose of hypotonic fluids is to replacecellular fluids, because it is hypotonic ascompared with plasma.
- It also used to provide free water for excretionof body wastes.
- It may used to treat hypernatramia (hypotonic
Na solutions).Examples of hypotonic solutions: 0.45% Nacl
Half-strength saline.
Complications of excessive use of
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Complications of excessive use of
hypotonic solutions include:
Intravascular fluid depletion.
Decreased blood pressure.
Cellular edema. Cell damage
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3.Hypertonic Solutions
Hypertonic solutions exert an osmoticpressure greater than that of ECF
Examples
* High concentrations of dextrose such as 50%dextrose in water are used to help meetcaloric requirements.
These hypertonic solutions must beadministered into control veins so that theycan be diluted by rapid blood flow.
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Saline solutions are also available in osmolar
pressures greater than that of ECF and cause
cells to shrink.
If administered rapidly or in large quantities,
they may cause an extra cellular volume
excess and cause circulatory overload and
dehydration.
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*Management and Nsg Care for certain fluid
and electrolyte balance disturbances
1-Water depletion
- Provide replacement of fluid.
-Determine and correct cause of waterdepletion.
- Measure intake and output.
- Monitor V/S
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2- Water Excess:
- Limit fluid intake.
- Administer diuretics.
- Monitor V/S
- Determine and treat cause.
- Analyze laboratory electrolyte measurementfrequently
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3- Hyponatremia
- Determine and treat cause
- Administer I.V fluids with appropriate saline
concentration 4- Hypernatramia:
- Determine and treat cause.
Administer fluids as prescribed.
- Measure intake and output.
- Monitor lab. Data.
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5- Hypokalemia:
- Determine and treat cause.
- Monitor V/S and ECG.
- Administer supplemental K.
- Assess for adequate renal output before
administration.
IV: administered slowly.
Oral: after high K fluids and foods.
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6- Hyperkalemia- Determine and treat cause.
- Monitor V/S and ECG - Administer I.V fluids if prescribed.
- Monitor serum potassium levels.
7- Hypocalcaemia:- Determine and treat cause.
- Administer calcium supp. as prescribed and administered slowly.
- Monitor serum calcium levels.
- Monitor serum protein level
8- Hypocalcaemia:
- Determine and treat cause.
- Monitor serum Ca levels.
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SODIUM
Na+ are very important for regulating blood and interstitial fluid
pressures as
well as nerve and muscle cell conduction of electrical currents.
Aldosterone causes
retention of Na+.
a. HYPONATREMIA:- Vomiting, diarrhea, sweating, and burns cause Na+ loss. Dehydration,
tachycardiaand shock (see above) can result. Intake of plain water worsens thecondition.
Pedialyte is a better fluid to drink. Explain this.b. HYPERNATREMIA
Severe water deprivation, salt retention or excessive sodium intakecauses this.Increased Na+ draws water outside of cells, resulting in tissue
dehydration.Thirst fati ue and coma result.
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CHLORIDE
Cl- anion is necessary for the making of HCl,
hyper polarization of neurons,
regulating proper acid levels, and balancing
osmotic pressures between compartments.
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CHLORIDE
a. HYPOCHLOREMIA
Excessive vomiting causes chloride loss,
resulting in blood and tissue alkalosis, and a
depressed respiration rate.
b. HYPERCLOREMIA
Dehydration or chloride gain can result in
renal failure or acidosis (increases in
Cl- are accompanied by increases in H+).
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POTASSIUM
K+ is important in the intracellular fluid. Aldosterone
causes excretion of K+.
a. HYPOKALEMIA
Caused by diarrhea, exhaustion phase of stress, excessivealdosterone secretions
in adrenal cortical hyperplasia and some diuretics. K+
loss from cells contributes to tissue
dehydration and acidosis. Flattened T waves,bradycardia, muscle spasms, a lengthened
P-R, and mental confusion can also result.
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POTASSIUM
b. HYPERKALEMIA
Caused by eating large amounts of "light salt"(KCl), kidney failure, and
decreased aldosterone secretions in Addison'sDisease; resulting in elevatedT waves and fibrillation of the heart. Themovement of K+ into cells accompanies
tissue alkalosis.
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CALCIUM
Calcium Ca++ cations are needed for bone,
muscle contraction, and synaptic
transmission.
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CALCIUM
a. HYPOCALCEMIA
Excessive calcitonin, inadequate PTH,
decreased Vita. D, or reduced Ca++
intake results in muscle cramps, and
convulsions.
b. HYPERCALCEMIA
Increased PTH, Vita. D or calcium intake can
cause kidney stones, bone spurs,
and lethargy.
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Child vs. Adult in medication administration
1. Water %
2. Body service area
3. Type of food
4. Stomach acidity
(infant much less than adult )
5. Enzyme chains not maturity
6. Rate of break down of drug ( growth&development rate )
TPN replacement for chronic case
Child Ad l i di i
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7. % of protein binding & fat distributions
8. Drug half life
9. Excretion
10. Gastric empty time
11. Eating habits
12. Exercise pattern13.sexual development
Child vs. Adult in medication
administration (2)
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Steps to give medication
1. Identification the child
2. Oral medication ( infantpreschool school
age)
3. Teach the child how to swallowing ( liqide
need hr ,Tablet (1/2-1hr)
* Safe storage of medication
* Determination of the correct dosage