fluids, electrolytes and nutritionfannp.purehost.com/fannppdf14/b09 fen.pdf · 2014-10-06 ·...

Fluids, Electrolytes and Nutrition Jacqui Hoffman, DNP, ARNP, NNP-BC NNP Track Coordinator; Clinical Assistant Professor College of Nursing, University of Florida, Gainesville, FL Neonatal Nurse Practitioner Pediatrix Medical Group, Tampa, FL

The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation.

Session Summary

This session will review electrolyte management and common electrolyte disorders to prepare the participant for certification exams.

Session Objectives Upon completion of this presentation, the participant will be able to:

discuss impact of gestational and chronologic age on fluid and electrolyte homeostasis;

list the differential diagnosis for the most common electrolyte imbalances: hypo- and hypernatremia, hypo- and hyperkalemia, and metabolic acidosis and alkalosis;

calculate sodium and potassium deficit replacement;

discuss management of the most common electrolyte disorders.

Test Questions

1. You have a 28 wk infant on DOL 2 with reported repeat central K of 7.7 mEq/L. Which management modality is best for removing potassium from body?

a. Calcium gluconate bolus b. Furosemide q12h c. Glucose bolus followed by insulin infusion

2. The chemistry panel on admission of a 25 weeker showed the following: Na 130, K 4.2, Ca 8.8. The

resident wants to add NaCl to the IVF. What do you think?

a. Add maintenance sodium because apparently his kidneys are losing the sodium b. Do nothing c. Repeat the lab because you do not believe it

3. You have studied hard preparing for you NCC exam and know that which of the following will

increase with advancing gestational age?

a. Extracellular fluid b. Intracellular fluid c. Total body water

B9 FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW

B9: FLUIDS, ELECTROLYTES AND NUTRITION of 20

4. You have a term infant with hypoxic-ischemic encephalopathy who is 36 hr old and undergoing head

cooling. The morning labs reflect a serum Na of 121 and it was reported the infant is up 130 gm overnight. The total fluids of D10 TPN were ordered for 60 ml/kg/day but the infant did require PRBC transfusion and normal saline boluses x 2, placing actual fluids for the 24hr at 100 ml/kg/day. The infant’s urinary output was 0.8 ml/kg/hr. The most likely diagnosis for this infant is:

a. Dilutional hyponatremia b. Inadequate sodium supplementation c. Syndrome of inappropriate antidiuretic hormone

5. You have a 36 wk late preterm infant who is 5 days old and has weaned off IVF overnight while the

mother was exclusively breast feeding the infant. The labs this AM show a serum Na of 156 as well as an elevated serum osmolality. The infant’s weight is down 40 gram. The attending ordered urine osmolality which was reported as significantly low. The most likely diagnosis for this infant is:

a. Diabetes insipidus b. Fluid deficit (dehydration) c. Syndrome of inappropriate antidiuretic hormone

6. A 32-week, DOL2 infant with overwhelming sepsis and hypotension has a metabolic acidosis on this

AM’s labs. The morning labs reflect: Na 141, K 3.2, Cl 106, and CO2 16. Calculating the anion gap, how would you classify this metabolic acidosis?

a. Metabolic acidosis with increased anion gap b. Metabolic acidosis with low anion gap c. Metabolic acidosis with normal anion gap

References Ambalavanan, N., Carter, B., MacGilvray, S. & Windle, M. (2012). Fluid, electrolyte, and nutrition management of the

newborn. Retrieved on September 5, 2013 from http://emedicine.medscape.com/artice/976386-overview.

Blackburn, S. (2013). Renal system and fluid and electrolyte homeostasis. In: Maternal, fetal, & neonatal physiology: A clinical perspective (4th ed., pp. 378-381, 383-386). Maryland Heights, MO: Elsevier Saunders.

Brodsky, D. & Martin, C. (2010). Fluids, electrolytes, and renal system. In: Neonatology review (2nd ed., pp. 269-278. Philadelphia: Hanley & Belfus, Inc.

Chow, J. & Douglas, D. (2008). Fluid and electrolyte management in the premature infant. Neonatal Network, 27: 379-385.

Gomella, T., et al. (2013). Fluid and electrolytes. In: Neonatology: Management, procedures, on-call problems, diseases and drugs (7th ed., pp. 89-97). New York: McGraw-Hill Education.

Lorenz, J. (2008). Fluid and electrolyte therapy in the very low-birthweight neonate. NeoReviews, 9(3): e102-e111.

Nash, P. (2007). Potassium and sodium homeostasis in the neonate. Neonatal Network, 26: 125-128.

Wada, M., Kusuda, S., Takahashi, N. & Nishida, H. (2008). Fluid and electrolyte balance in extremely preterm infants < 24 weeks of gestation in the first week of life. Pediatrics International, 50: 331-336.

Session Outline

See presentation handout on the following pages.

FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW


http://emedicine.medscape.com/artice/976386-overview

Fluids, Electrolytes and Fluids, Electrolytes and NutritionNutrition

Jacqui Hoffman, DNP, ARNP, NNPJacqui Hoffman, DNP, ARNP, NNP--BCBCClinical Assistant Professor, NNP Track Coordinator, University Clinical Assistant Professor, NNP Track Coordinator, University

of Floridaof Florida

NNP, Pediatrix Medical Group, TampaNNP, Pediatrix Medical Group, Tampa

Body fluid compositionBody fluid compositionTotal Body Water

Extracellular fluid Intracellular fluid

Intravascular fluid

Interstitial fluid

http://what-when-how.com/nursing/fluid-and-electrolyte-balance-structure-and-function-nursing-part-1/

Body fluid compositionBody fluid composition

TBW = ECF + ICF

Body Water Compartments

24 wk GA

32 wk GA Term 3 mon of age

1 yr of age

TBW 90 83 80 70 65

ECF 65 53 45 35 20

ICF 25 30 35 35 45

Fanaroff & Martin, 2011

Normal Physiologic Weight LossNormal Physiologic Weight Loss

Normal changesNormal changes–– Decreased TBW Decreased TBW --> increased ICF and decreased > increased ICF and decreased

ECFECF

Term InfantsTerm InfantsTerm InfantsTerm Infants–– Lose up to 5Lose up to 5--10% of birth weight in 110% of birth weight in 1stst five daysfive days

–– Expect weight gain reflecting growth by 10 Expect weight gain reflecting growth by 10 daysdays

Preterm InfantsPreterm Infants–– Lose up to 15Lose up to 15--20% of birth weight20% of birth weight

–– Expect weight gain reflecting growth by 2 (preterm) to Expect weight gain reflecting growth by 2 (preterm) to 3 weeks (3 weeks (micropremiemicropremie))



Renal Water LossRenal Water Loss

Will discuss more in depth in renal sessionWill discuss more in depth in renal session

Preterm infants have immature Na and Preterm infants have immature Na and water homeostasis due to:water homeostasis due to:

Decreased glomerular filtration rateDecreased glomerular filtration rate–– Decreased glomerular filtration rateDecreased glomerular filtration rate

–– Reduced proximal/distal tubule Reduced proximal/distal tubule reabsorptionreabsorption

–– Ability to concentrate urine reducedAbility to concentrate urine reduced

–– Decreased bicarbonate, potassium and Decreased bicarbonate, potassium and hydrogen ion secretionhydrogen ion secretion

Renal function matures with ageRenal function matures with ageCloherty, Eichenwald, Hansen & Stark, 2012

Insensible Water LossInsensible Water Loss

Evaporation of nonEvaporation of non--measurable water measurable water losseslosses

Major routes Major routes SkiSki t 70%t 70%–– Skin Skin –– up to 70%up to 70%

–– Respiratory tract Respiratory tract –– up to 30%up to 30%

Factors Affecting Insensible Water Factors Affecting Insensible Water LossLoss

Increased IWLIncreased IWL–– Decreasing gestational age Decreasing gestational age and/or birthweightand/or birthweight

–– Increased environmental Increased environmental temperature above temperature above NTE or bodyNTE or body temperaturetemperatureNTE or body NTE or body temperaturetemperature

–– Skin Skin breakdownbreakdown

–– Congenital skin defect, such as Congenital skin defect, such as large large omphalocele, gastroschisis, neural tube omphalocele, gastroschisis, neural tube defects or epidermolysis bullosadefects or epidermolysis bullosa

–– Radiant warmerRadiant warmer

–– Phototherapy (controversial)Phototherapy (controversial)

Factors Affecting Insensible Water Factors Affecting Insensible Water LossLoss

Decreased IWLDecreased IWL–– HumidityHumidity

–– Use of plastic heat shield or doubleUse of plastic heat shield or double--walled walled isoletteisoletteisoletteisolette



Endocrine Control of Water Endocrine Control of Water MetabolismMetabolism

Antidiuretic hormone (ADH) or arginine Antidiuretic hormone (ADH) or arginine vasopressinvasopressin–– Syndrome of inappropriate ADH secretion Syndrome of inappropriate ADH secretion

(SIADH)(SIADH)(SIADH)(SIADH)

–– Nephrogenic diabetes insipidus (DI)Nephrogenic diabetes insipidus (DI)

http://www.zuniv.net/physiology/book/chapter24.html

SIADHSIADH

EtiologyEtiology–– Perinatal depression, IVH, PPV, sepsis, Perinatal depression, IVH, PPV, sepsis,

hypotension, meningitis, pneumothorax, painhypotension, meningitis, pneumothorax, pain

Clinical findingsClinical findingsClinical findingsClinical findings–– Weight gain, hyponatremia, decreased urine Weight gain, hyponatremia, decreased urine

output, increased urine osmolality, decreased output, increased urine osmolality, decreased plasma osmolalityplasma osmolality

TreatmentTreatment–– Free water restriction, NaCl replacement, Free water restriction, NaCl replacement,

Lasix therapyLasix therapy

Nephrogenic Diabetes Insipidus Nephrogenic Diabetes Insipidus (NDI)(NDI)

EtiologyEtiology–– Insensitivity of renal tubule to ADH, congenital Insensitivity of renal tubule to ADH, congenital

defects, secondary causesdefects, secondary causes

Clinical findingsClinical findingsClinical findingsClinical findings–– Increased Na hypotonic urine, serum Increased Na hypotonic urine, serum

hypertonicity, increased Ca, decreased Khypertonicity, increased Ca, decreased K

TreatmentTreatment–– Hydrate, electrolyte replacement, diuretic Hydrate, electrolyte replacement, diuretic

therapy (thiazides)therapy (thiazides)



Monitoring Monitoring Fluid BalanceFluid Balance

HistoryHistory

Physical examPhysical exam

WeightWeight

Intake and outputIntake and output

Lab monitoringLab monitoring

Physiologic/environmental factors, i.e. Physiologic/environmental factors, i.e. humidity in isolettehumidity in isolette

Case StudyCase Study

24 week, DOL 324 week, DOL 3

BW 580 gm, current weight 470 gmBW 580 gm, current weight 470 gm

Isolette with 70% humidity, double phototxIsolette with 70% humidity, double phototx

TF (TPN): 115 ml/kg/dayTF (TPN): 115 ml/kg/day

UOP: 1.8 ml/kg/hrUOP: 1.8 ml/kg/hr

Labs: Na 151, BUN 31, Creatinine 0.6Labs: Na 151, BUN 31, Creatinine 0.6

What do you think?What do you think?

Phases of Fluid ManagementPhases of Fluid Management

Initial fluid managementInitial fluid management–– Prevent shock and hypoglycemiaPrevent shock and hypoglycemia

Prediuretic phasePrediuretic phaseC id b d i ht N d iC id b d i ht N d i–– Consider body weight, serum Na and urine Consider body weight, serum Na and urine outputoutput

Diuretic phaseDiuretic phase–– Prone to hypernatremiaProne to hypernatremia

Post diuretic phase (maintenance)Post diuretic phase (maintenance)–– Increase TF, consider nutritional needsIncrease TF, consider nutritional needs



Maintenance Fluid RequirementsMaintenance Fluid Requirements

Birthweight(gm)

IWL (ml/kg/day)

DOL 1-2 DOL 3-7 DOL 8-30

<750 100+ 100-200 120-200 120-180

750-1000 60-70 80-150 100-150 120-180

1001-1500 30-65 60-100 80-150 120-180

>1500 15-30 60-80 100-150 120-180

Fanaroff & Martin, 2011

TF = IWL + sensible water loss + growth

Affect of Affect of Common Disease Common Disease States States on FEN Managementon FEN Management

HIEHIE–– Restrict Restrict fluid to <60ml/kg/dayfluid to <60ml/kg/day

Avoid fluid overload, potentially worsening cerebral Avoid fluid overload, potentially worsening cerebral edemaedema

–– Initially, limit K and during recovery, need to Initially, limit K and during recovery, need to replace Nareplace Na

RDSRDS–– Individualize Individualize fluidsfluids

Affect of Common Disease States Affect of Common Disease States on FEN Managementon FEN Management

PDAPDA–– Avoid fluid overload?Avoid fluid overload?

–– Be careful with pharmacologic therapy and Be careful with pharmacologic therapy and impact on renal functionimpact on renal functionimpact on renal functionimpact on renal function

CLDCLD–– Avoid fluid overloadAvoid fluid overload

Balance fluid needs and increased caloric needsBalance fluid needs and increased caloric needs

–– Be careful with diuretic therapyBe careful with diuretic therapyWatch for lyte abnormalities, screen for osteopeniaWatch for lyte abnormalities, screen for osteopenia

Affect of Common Disease States Affect of Common Disease States on FEN Managementon FEN Management

Abdominal wall defectsAbdominal wall defects–– Need increased TF secondary to IWLNeed increased TF secondary to IWL

S/P abdominal surgeryS/P abdominal surgeryI TF d/t thi d iI TF d/t thi d i–– Increase TF d/t third spacingIncrease TF d/t third spacing

–– With third spacing, intravascular fluid leaks With third spacing, intravascular fluid leaks into tissue and bowel wall lumeninto tissue and bowel wall lumen



ElectrolytesElectrolytes

www.drinkamara.com

ElectrolytesElectrolytes

www.austincc.edu

Electrolyte Content of Body FluidsElectrolyte Content of Body Fluids

Fluid Source Na+ (mmol/L) K+ (mmol/L) Cl- (mmol/L)

Bile 120-140 5-15 90-120

Diarrheal stool 10-90 10-80 10-110

Ileostomy 45-135 3-15 20-120

Small intestine 100-140 5-15 90-120

Stomach 20-80 5-20 100-150

Adapted from Fanaroff & Martin, 2011

BMPBMP

CaCaNaNa ClCl BUNBUN

KK CO2CO2 CreatinineCreatinine

GlucoseGlucoseGlucoseGlucose

88--1111

135135--145145 9797--110110 33--2525

3.53.5--5.55.5 2020--2828 0.30.3--11

Normal serum values



SodiumSodium

Main extracellular cation Main extracellular cation

Normal requirementsNormal requirements–– Initial phase: 0Initial phase: 0--1 mEq/kg/day1 mEq/kg/day

P di ti h 2P di ti h 2 3 E /k /d3 E /k /d–– Prediuretic phase: 2Prediuretic phase: 2--3 mEq/kg/day3 mEq/kg/day

–– Post diuretic phase: 3Post diuretic phase: 3--5 mEq/kg/day5 mEq/kg/day

http://www.austincc.edu/apreview/EmphasisItems/Electrolytefluidbalance.html

HyponatremiaHyponatremia

Serum Na < 130 mEq/LSerum Na < 130 mEq/L

DDxDDx–– FactitiousFactitious

N l ECFN l ECF–– Normal ECF Normal ECF Excessive fluid administration (dilutional), Excessive fluid administration (dilutional), Syndrome of inappropriate antidiuretic hormone Syndrome of inappropriate antidiuretic hormone (SIADH)(SIADH)

–– Inadequate sodium intakeInadequate sodium intake


DDx (continued)DDx (continued)–– ECF excess (hypervolemia) ECF excess (hypervolemia)

CHF, sepsis, renal or liver failure, NEC (late)CHF, sepsis, renal or liver failure, NEC (late)

–– ECF deficit (hypovolemia)ECF deficit (hypovolemia)–– ECF deficit (hypovolemia) ECF deficit (hypovolemia) Renal lossesRenal losses

GI losses, 3GI losses, 3rdrd spacing of fluidsspacing of fluids

–– Medication relatedMedication relatedNeuromuscular paralysis, indomethacin therapy, Neuromuscular paralysis, indomethacin therapy, diuretic therapydiuretic therapy




Diagnostic evaluationDiagnostic evaluation–– History and physicalHistory and physical

–– Weight patternWeight pattern

Total intake and outputTotal intake and output–– Total intake and outputTotal intake and output

–– Lab studiesLab studiesSerum sodium and osmolaritySerum sodium and osmolarity

Random urine for sodium, osmolality and specific Random urine for sodium, osmolality and specific gravitygravity

? CMP to assess renal function? CMP to assess renal function

? Imaging? Imaging


Etiology Clinical Findings

Renal losses Decreased weight

Increased urine Na and volume

Decreased urine osmo and specific gravity

Extrarenal losses Decreased weight

Decreased urine Na and volume

Increased urine osmo and specific gravity

Other causes(SIADH, CHF, renal failure, excess water infusion, cirrhosis, nephrotic syndrome)

Increased or normal weight

Decreased urine Na and volume (except if SIADH or water excess, urine Na may be increased or normal)

Increased urine osmo and specific gravity


Hyponatremia + increased weight gainHyponatremia + increased weight gain

SIADH Volume overload

Decreased UOP Increased UOPDecreased UOP Increased UOP

High urine osmo Low urine osmo

Hyponatremia ManagementHyponatremia Management

Symptomatic hyponatremia is medical Symptomatic hyponatremia is medical emergencyemergency–– 3% Hypertonic sodium chloride3% Hypertonic sodium chloride

–– 11--3 ml/kg over 15 minutes, followed by 13 ml/kg over 15 minutes, followed by 1--2211 3 ml/kg over 15 minutes, followed by 13 ml/kg over 15 minutes, followed by 1 2 2 ml/kg/hr until Na > 120 mmol/L; other sources ml/kg/hr until Na > 120 mmol/L; other sources state 6 ml/kg over 6 hrstate 6 ml/kg over 6 hr

–– Monitor closely for fluid overload and pulmonary Monitor closely for fluid overload and pulmonary edemaedema




Asymptomatic hyponatremia management is Asymptomatic hyponatremia management is based on underlying causebased on underlying cause–– Replace deficit Replace deficit –– don’t forget to include don’t forget to include

maintenance needsmaintenance needsInadequate Na intakeInadequate Na intake

Medication related Medication related –– only need to increase Na only need to increase Na neededneeded

–– Restrict fluidsRestrict fluidsSIADH and volume overloadSIADH and volume overload


Calculating Na deficitCalculating Na deficit

(CD (CD –– CA) X Vd x Kg = mEq requiredCA) X Vd x Kg = mEq required

Let’s practice Let’s practice –– 1.5 kg infant with a Na 1201.5 kg infant with a Na 120

(130(130--120) x 0.6 x 1.5 = 9 mEq120) x 0.6 x 1.5 = 9 mEq

Remember, this only corrects the deficitRemember, this only corrects the deficit

Must replace slowly for risk of neuro damage!Must replace slowly for risk of neuro damage!

HypernatremiaHypernatremia

Serum Na ≥ 150 mEq/LSerum Na ≥ 150 mEq/L

DDxDDx–– Hypovolemia/dehydration (decreased ECW)Hypovolemia/dehydration (decreased ECW)

E di i t k (i d ECW)E di i t k (i d ECW)–– Excess sodium intake (increased ECW)Excess sodium intake (increased ECW)

–– Medication relatedMedication related

HypernatremiaHypernatremia


Renal losses Decreased weight

Increased urine Na and volume

Decreased specific gravity

Extrarenal losses Decreased weight

Decreased urine Na and volume

Increased specific gravity

Other causes(Exogenous Na, mineralocorticoid excess, hyperaldosteronism)

Increased weight

Relatively decreased urine Na and volume

Relatively increased specific gravity



Hypernatremia ManagementHypernatremia Management

Management based on underlying causeManagement based on underlying cause

If due to excess Na intake, remove or If due to excess Na intake, remove or decrease Na, consider diuretic therapydecrease Na, consider diuretic therapy

If h l i /d h d ti l tIf h l i /d h d ti l tIf hypovolemia/dehydration, replace water If hypovolemia/dehydration, replace water deficit slowlydeficit slowly–– Serum Na should decrease no more than 0.5 Serum Na should decrease no more than 0.5

mEq/L/kg/hrmEq/L/kg/hr

–– Target correction over 12Target correction over 12--48hr period48hr period

PotassiumPotassium

Main intracellular cationMain intracellular cation–– Role : maintain normal cardiac rhythm, skeletal Role : maintain normal cardiac rhythm, skeletal

muscle contraction, acidmuscle contraction, acid--base balance, and base balance, and transmission/conduction of nerve impulsestransmission/conduction of nerve impulses

Normal requirementsNormal requirements–– AAdded dded once good UOP is once good UOP is establishedestablished

–– Initial phase: NoneInitial phase: None

–– Prediuretic phase: 1Prediuretic phase: 1--2 mEq/kg/day2 mEq/kg/day

–– Post diuretic phase: 2Post diuretic phase: 2--3 mEq/kg/day3 mEq/kg/day

HypokalemiaHypokalemia

Serum K < 3 mEq/LSerum K < 3 mEq/L

DDxDDx–– Decreased intakeDecreased intake

R l lR l l–– Renal lossesRenal losses

–– GI lossesGI losses

–– Medication relatedMedication related***Most common cause in NICU setting***Most common cause in NICU setting

–– Metabolic alkalosisMetabolic alkalosis

–– EndocrinopathiesEndocrinopathies


Diagnostic evaluationDiagnostic evaluation–– Physical examPhysical exam

–– Lab studiesLab studiesRepeat central potassium levelRepeat central potassium levelRepeat central potassium levelRepeat central potassium level

Random urine for electrolytesRandom urine for electrolytes

CMP with serum MagCMP with serum Mag

?blood gas?blood gas

?endocrine studies, ?serum insulin and C?endocrine studies, ?serum insulin and C--peptidepeptide

Imaging/Diagnostic studiesImaging/Diagnostic studies–– ?Abdominal x?Abdominal x--ray, ?head MRIray, ?head MRI

–– EKGEKG





Decreased K storesHypertension

Increased urine K

Decreased K storesNormal BP – Renal causes

Increased urine K

Decreased K storesNormal BP – Extrarenal causes

Decreased urine K

Normal K stores Increased urine K

Hypokalemia ManagementHypokalemia Management

Management based on underlying causeManagement based on underlying cause

Emergency correction: 0.5Emergency correction: 0.5--1 mEq/kg/dose 1 mEq/kg/dose over 30over 30--60 min minimum60 min minimum

If t ti b t t lif th t iIf t ti b t t lif th t iIf symptomatic but not life threatening, If symptomatic but not life threatening, correction given over 12correction given over 12--24hr to allow slow 24hr to allow slow normalization of serum levelsnormalization of serum levels

Too large or rapid of bolus may cause Too large or rapid of bolus may cause cardiac arrestcardiac arrest

Hypokalemia ManagementHypokalemia Management

Calculating Calculating KK deficitdeficit

(CD (CD –– CA) X Vd x Kg = mEq requiredCA) X Vd x Kg = mEq required

Let’s practice Let’s practice –– 1.5 kg infant with a K 2.81.5 kg infant with a K 2.8

(4.0(4.0--2.8) x 0.3 x 1.5 = 0.54 mEq2.8) x 0.3 x 1.5 = 0.54 mEq

Remember, this only corrects the deficitRemember, this only corrects the deficit

HyperkalemiaHyperkalemia

Central serum K > 6.5 mEq/LCentral serum K > 6.5 mEq/L

CHECK for ECG changesCHECK for ECG changes

DDxDDx–– FactitiousFactitious

Lab error, traumatic heel stick (hemolysis)Lab error, traumatic heel stick (hemolysis)

–– Increased K+ loadIncreased K+ loadIatrogenic (excess supplementation); tissue destruction, Iatrogenic (excess supplementation); tissue destruction, bleeding or hemolysis; PRBC or exchange transfusionbleeding or hemolysis; PRBC or exchange transfusion

–– Decreased K+ removal or excretionDecreased K+ removal or excretionAcute renal failure (ARF), Congenital adrenal hyperplasia Acute renal failure (ARF), Congenital adrenal hyperplasia (CAH), immature renal function in ELBW (especially 1(CAH), immature renal function in ELBW (especially 1stst 48 48 hr)/pretermshr)/preterms




Diagnostic evaluationDiagnostic evaluation–– Physical examPhysical exam

–– Lab Lab studiesstudiesVenous serum sampleVenous serum sampleVenous serum sampleVenous serum sample

Serum and urine electrolytesSerum and urine electrolytes

?endocrine ?endocrine studiesstudies

–– EKGEKG



Increased K stores Increased urine K

Increased K stores Decreased urine K

Normal K stores Normal urine K

Hyperkalemia ManagementHyperkalemia Management

Hyperkalemia with EKG changes is a Hyperkalemia with EKG changes is a medical emergencymedical emergency

http://medstation.yale.edu/pedres/files/www/NBSCU%20Protocols/Hyperkalemia_Management_Dec2010.pdf


Hyperkalemia with EKG changes is a Hyperkalemia with EKG changes is a medical emergencymedical emergency–– 10% Calcium gluconate10% Calcium gluconate

100 mg/kg/dose over 10100 mg/kg/dose over 10--15 min, preferably central line15 min, preferably central line

–– NaBicarbNaBicarb11--2 mEq/kg/dose over 102 mEq/kg/dose over 10--30 min30 min

–– Insulin/glucose (D10W) infusionInsulin/glucose (D10W) infusionD10W 2D10W 2--3 ml/kg IV push3 ml/kg IV push

0.050.05--0.1 U/kg bolus, the 0.1 U/kg bolus, the continuous insulin infusioncontinuous insulin infusion

–– AlbuterolAlbuterol0.10.1--0.5 mg/kg/dose0.5 mg/kg/dose




Hyperkalemia with EKG changes is a Hyperkalemia with EKG changes is a medical emergencymedical emergency–– Furosemide Furosemide

2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po

–– **Kayexelate**Kayexelate--cation exchange resin (should not cation exchange resin (should not be used in ELBW)be used in ELBW)

1 gm/kg intrarectally q6h1 gm/kg intrarectally q6h

–– **Dialysis/exchange transfusion**Dialysis/exchange transfusion

** last resort** last resort


Hyperkalemia without EKG changesHyperkalemia without EKG changes–– Remove all K+ from IVF and/or discontinue Remove all K+ from IVF and/or discontinue

supplementationsupplementation

–– Keep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal ranges

–– Correct acidosisCorrect acidosis

–– Ensure adequate fluid intakeEnsure adequate fluid intake

–– Consider LasixConsider Lasix

Hyperkalemia ManagementHyperkalemia ManagementPutting it all togetherPutting it all together

Prevent effects on cardiac muscle

Shift K back into cell Remove K

Ca Gluconate Sodium bicarbonate/THAM Lasix

Gluc/insulin infusion Kayexelate

Albuterol Exchange transfusion

ChlorideChloride

Extracellular anionExtracellular anion

Normal serum values: 98Normal serum values: 98--113 mEq/L113 mEq/L



HypochloremiaHypochloremia

Serum Cl < 98 meq/LSerum Cl < 98 meq/L

DDxDDx–– Decreased intakeDecreased intake

Chl id lChl id l–– Chloride lossesChloride losses

HyperchloremiaHyperchloremia

Serum chloride > 110 mEq/LSerum chloride > 110 mEq/L

Uncommon in newborn periodUncommon in newborn period

DDxDDx–– Excessive intakeExcessive intake

Serum CO2Serum CO2

Measure of blood bicarbonate levelMeasure of blood bicarbonate level

Low serum CO2 Low serum CO2 –– metabolic acidosismetabolic acidosis

High serum CO2 High serum CO2 –– metabolic alkalosismetabolic alkalosis

Minerals/SaltsMinerals/Salts

Calcium, magnesium and phosphorous Calcium, magnesium and phosphorous ––see endocrine/metabolic lecturesee endocrine/metabolic lecture



AcidAcid--Base BalanceBase Balance

Extracellular pH: 7.34 Extracellular pH: 7.34 –– 7.457.45

Also review ventilation lectureAlso review ventilation lecture

Acute CompensationAcute Compensation

Maintained by intracellular and Maintained by intracellular and extracellular buffersextracellular buffers


Chronic CompensationChronic Compensation

Balance between intake/production and Balance between intake/production and metabolism/excretion of acidmetabolism/excretion of acid

Metabolic AcidosisMetabolic Acidosis

Anion gap (mEq/L) = (Na) Anion gap (mEq/L) = (Na) –– ([Cl([Cl--] + ] + [HCO3[HCO3--])])

Normal range: 8Normal range: 8--15 15 U t 18 i tU t 18 i t–– Up to 18 in preterm Up to 18 in preterm




With normal anion gap (increased ClWith normal anion gap (increased Cl--))–– Renal causes, increased GI losses (diarrhea, Renal causes, increased GI losses (diarrhea,

ileal drainage), HAL, medsileal drainage), HAL, meds

With increased anion gap (normal ClWith increased anion gap (normal Cl ))With increased anion gap (normal ClWith increased anion gap (normal Cl--))Lactic acidosis, ARF, IEMLactic acidosis, ARF, IEM

With low anion gapWith low anion gap–– RareRare


ManagementManagement–– Treat underlying causeTreat underlying cause

–– Alkali therapyAlkali therapySodium bicarb administrationSodium bicarb administrationSodium bicarb administrationSodium bicarb administration

–– Not without potential complicationsNot without potential complications

THAMTHAM

AcetateAcetate

Polycitra (oral) Polycitra (oral) –– 22--3 mEq/Kg/day in 33 mEq/Kg/day in 3--4 divided 4 divided dosesdoses



Metabolic AlkalosisMetabolic Alkalosis

EtiologiesEtiologies–– With low urine chloride (< 10 mEq/L)With low urine chloride (< 10 mEq/L)

–– With high urine chloride (> 20 mEq/L)With high urine chloride (> 20 mEq/L)

Hypochloremic metabolic alkalosis probablyHypochloremic metabolic alkalosis probably–– Hypochloremic metabolic alkalosis probably Hypochloremic metabolic alkalosis probably one of the most common disorders seen due one of the most common disorders seen due to diuretic therapyto diuretic therapy




ManagementManagement–– If mild If mild –– moderate, may not require therapymoderate, may not require therapy

–– Treat underlying causeTreat underlying cause

Adjust or discontinue alkali solutionsAdjust or discontinue alkali solutions–– Adjust or discontinue alkali solutionsAdjust or discontinue alkali solutions

–– Assess whether diuretic dose can be Assess whether diuretic dose can be decreased or held temporarily; consider decreased or held temporarily; consider changing to chronic diuretic therapy if on changing to chronic diuretic therapy if on furosemide therapyfurosemide therapy



Nutrition General PrinciplesNutrition General Principles

Goal = provide adequate calories to Goal = provide adequate calories to promote growthpromote growth

Calories should be from nonCalories should be from non--protein protein caloriescaloriescaloriescalories

Factors that affect growthFactors that affect growth–– Gestational age, weight, thermal environment, Gestational age, weight, thermal environment,

activity, disease processactivity, disease process

Preterm goal: 110Preterm goal: 110--140 kcal/kg/day for 140 kcal/kg/day for growthgrowth

Caloric IntakeCaloric Intake

Parenteral (TPN)

Goal: provide adequate caloric intake and nutrients for growth

CHO : dextrose

Proteins: amino acids (Trophamine)

Fats: 20% intralipids

Trace elements

Multivitamins

Electrolytes: Na and K (mEq/kg/day) + salt

Macro Minerals (Mag and Ca)



Calculating Calories (kcal/day)Calculating Calories (kcal/day)

CHOCHO–– Dextrose: (ml/day of IVF) x (3.4cal/g) x (% Dextrose: (ml/day of IVF) x (3.4cal/g) x (%

dextrose)dextrose)

–– Feeds: (ml/day of feeds) x (amount kcal/oz)Feeds: (ml/day of feeds) x (amount kcal/oz)Example 20cal/30ml or 24cal/30mlExample 20cal/30ml or 24cal/30ml

FatsFats–– 20% IL: (ml/day of IL) x (2kcal/ml)20% IL: (ml/day of IL) x (2kcal/ml)

ProteinProtein–– Gm/kg/day amino acid (AA): (g/day of AA) x Gm/kg/day amino acid (AA): (g/day of AA) x

(4kcal/g)(4kcal/g)

Questions???



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