elektrolit imbalance.dr ined

Electrolyte imbalance in childrenElectrolyte imbalance in children

Dr. WAN NEDRA Sp.A Bagian Ilmu Kesehatan Anak

FK YARSI2008

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Introduction 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 1CASE 1A 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 Kebutuhan MaintenanceMaintenance Mineral/kg bb/24 jamMineral/kg bb/24 jam

Mineral DosisSodium (Na) 2-3 mEq

Potasium (K) 1-2 mEqChlorida (Cl) 3-5 mEqCalcium (Ca) 50-200 mgMagnesium (Mg) 0.4-0.8 mEqPhosphate (P) 15-50 mg

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Sodium SerumSodium Serum

• Laboratory finding:

• Isonatremia• Hiponatremia• Hipernatremia

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IsonatremiIsonatremiaa

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Isonatremia-Isotonisitas Isonatremia-Isotonisitas IsoosmolalitasIsoosmolalitas

Isonatremia • Sodium serum 135-145 mEq/L

Isotonik• Osmotic gradient (-)• Tekanan osmotik : normal• Perpindahan air : tidak ada

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Isonatremia-IsotonisitasIsonatremia-IsotonisitasHiperosmolalitasHiperosmolalitas


Isotonik• Osmotic gradient (-)• Tekanan osmotik : normal• Perpindahan air : tidak ada

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Isonatremia-HipertonisitasIsonatremia-HipertonisitasHiperosmolalitasHiperosmolalitas


Hipertonisitas• Osmotic gradient (+)• Tekanan osmotik : tinggi• Perpindahan air : ICF ECF

dehidrasi sel

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HiponatremiHiponatremiaa

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Hiponatremia-Hiponatremia-Hipotonisitas Hipotonisitas

HipoosmolalitasHipoosmolalitasHiponatremia• Sodium serum < 130 mEq/LHipotonik• Osmotic gradient (+)• Tekanan osmotik : rendah

• Perpindahan air : ECF ICF edema sel

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Hiponatremia-HipertonisitasHiponatremia-Hipertonisitas

Hiponatremia• Sodium serum < 130 mEq/LHipertonik• Osmotic gradient (+)• Tekanan osmotik : tinggi • Perpindahan air : ICF ECF

dehidrasi sel

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HipernatremiaHipernatremia

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HypernatremiaHypernatremia

•Less common than hyponatremia•Relative water deficit in relation to

sodium in the plasma•Usually iatrogenic

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• Hipernatremia• Sodium serum 150 mEq/L

• Hipertonik• Osmotic gradient (+)

• Tekanan osmotik : tinggi

• Perpindahan air : ICF ECF dehidrasi sel

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Isonatremia-Isotonisitas Isonatremia-Isotonisitas IsoosmolalitasIsoosmolalitas

Hipovolume(Dehidrasi isonatremia)

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TerapiTerapiDehidrasi IsonatremikDehidrasi Isonatremik

• Hitung defisit : • Air dan Na

• Hitung maintenance• Air dan Na

• Asumsi : • Isonatremik - isotonik ~ NaCl 0.9%

• (NaCl 0.9% = 154 mEq Na/L H2O)

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TerapiTerapiDehidrasi IsonatremikDehidrasi Isonatremik

Contoh Dehidrasi 10%: (BB : 5 kg 4.5 kg)

Defisit air : 500 ml Defisit Na : 500 ml x 154 mEq/L = 77 mEqMaintenance air : 5 (kg) x 100 mL/kg = 500 mlMaintenance Na : 5 (kg) x 3 mEq/kg = 15 mEq

Total H2O / 24 hr = 500 + 500 = 1000 mlTotal Na /24 hr = 77 + 15 = 92 mEq

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Dehidrasi hiponatremikDehidrasi hiponatremik

Sodium and water losses • Gastrointenstinal losses:

• Vomiting • Diarrhea

• Urinary losses • Salt water nephropathy • Adrenal insufficiency • Diuretic

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TerapiTerapiDehidrasi HiponatremikDehidrasi Hiponatremik

Hitung jumlah natrium : Hiponatremia Isonatremia

Selanjutnya :

Sesuai : Dehidrasi Isonatremia

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Contoh Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 125 mE/LJumlah 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

TerapiDehidrasi Hiponatremik

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HyernatremiaHyernatremiaHypovolemicHypovolemic

• Water loss in excess of sodium loss•Sodium lost (hypotonic solution)

•Kidney•GI tract•Skin•Respiratory tract

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TerapiTerapiDehidrasi - HipernatremiaDehidrasi - Hipernatremia

• Dehidrasi hipernatremik

• Hitung jumlah air

• Hipernatremia isonatremia

• Selanjutnya • Sesuai : Isonatremia–Isotonik-

Hipovolemia

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TerapiDehidrasi - Hipernatremia

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

Jumlah air hipernatremiaisonatremia = X

(X+TBW) x NaD = TBW x NaAX = (NaA/NaD) x TBW- (TBW) ml

X = (170/145) x (0.6x4.5)–(0.6x4.5) = 465 ml

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

Defisit air = 500 mlDefisit Na = 500-465 = 35 mL (NaCl 0.9%)

= 35ml x 154 mEq/L = 5 mEq

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Maintenance Air 5 (kg) x 100 ml/kg = 500 ml

Maintenance Na 5 (kg) x 3 mEq/kg = 15 mEql

Jumlah Air/24 jam = 500 + 500 ml = 1000 mlJumlah Na/24 jam = 5 + 15 mEq = 20 mEq

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Hati-hati: Dehidrasi sel edema sel (otak)

Koreksi dalam 48 jam

Air = 2 x maintenance + 1 x defisit = (2x500) + (1 x 500) =1500 ml

Na = 2 x maintenance + 1 x defisit = (2x15)+(1x5) = 35 mEq

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TerapiTerapiDehidrasi HiponatremikDehidrasi Hiponatremik

• Initial resuscitation– Isotonic saline as for isotonic dehydration

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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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Diabetes Insipidus Etiology•Head trauma •Cranial surgery

– specifically post-pituitary surgery • Infectious

– meningitis, encephalitis

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Hipernatremia-Hipernatremia-HipervolemikHipervolemik

Therapy •Diuresis•Replacing urinary losses with water

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PotasiumPotasium

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Potassium balance Potassium balance

Internal Balance1. 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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Internal Balance4. 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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B. External Balance - Renal Potassium Excretion1. 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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External Balance - GI Potassium Excretion• Fecal excretion of K+ normally is small• Diarrhea disorders, K+ loss increases

significantly.

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Potassium disordersPotassium disordersHypokalemia 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

• Causes: Many

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Potassium disordersPotassium disordersHypokalemia Hypokalemia

Treatment • Repletion of K+ • Removal of the cause of hypokalemia. • Emergency situation

– In the presence of arrhythmias• 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.

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Potassium disordersPotassium disordersHyperkalemia 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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• 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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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 – 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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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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Dr.Ined

elektrolit imbalance.dr ined

Documents

episodes of diarrhea

episodes of vomiting

combination sodium

normalperpindahan air

electrolyte imbalance

mixed electrolyte disturbance

history of vomiting

chemistry panel