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Fluid and electrolyte therapy

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Fluid and electrolyte therapy Dr Ashoka Acharya Consultant Paediatrics Warwick hospital Dehydration Abnormal fluid losses overcoming renal compensating mechanisms ... – PowerPoint PPT presentation

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Title: Fluid and electrolyte therapy


1
Fluid and electrolyte therapy
  • Dr Ashoka Acharya
  • Consultant Paediatrics
  • Warwick hospital

2
Dehydration
  • Abnormal fluid losses overcoming renal
    compensating mechanisms
  • Main aim of compensation is maintaining plasma
    volume and BP at all cost
  • Loss of homeostasis hypovolaemic shock
  • Principal causes diarrhoea and DKA

3
Definition
  • Parenteral or oral fluid therapy
  • Maintain/restore volume/composition of body
    fluids
  • Takes account of corrective physiological
    mechanisms

4
Fluid therapy Goal
  • Achieve normal intracellular and extracellular
    chemical environment
  • Thereby optimise cell and organ function

5
Factors determining requirements
  • Maintenance fluid replaces usual losses of fluid
    and electrolytes
  • Deficit replacement fluid designed to replace
    abnormal losses due to disease
  • Supplemental fluid replaces measured or
    estimated continuing abnormal losses

6
Factors determining requirements
  • Each component is calculated separately
  • Fluid therapy often based on gross estimates.
    Deficit often overestimated.
  • Repeated clinical reassessment and adjustment
    needed

7
Maintenance fluid
  • Directly related to metabolic rate
  • endogenous water production
  • urinary solute excretion,
  • heat production- 25 lost through insensible
    water loss)

8
Maintenance therapy
  • Generally 100ml per 100 calories used
  • Urine obligatory loss 65 ml
  • Insensible water loss 35 ml
  • Sweating 23 ml
  • pulmonary 12 ml

9
Maintenance therapy increased requirements
  • Increased activity (30)
  • Fever (1C increases by 12)
  • Dry environment
  • Hyperventilation
  • ELBW- transcutaneous losses 100-200ml/kg/day
  • Overhead heaters, phototherapy units

10
Maintenance fluid-decreased requirements
  • Comatose
  • Hypothermia
  • Highly humidified atmospheres
  • Humidified ventilator circuits

11
Maintenance fluid increased renal losses
  • High solute load (DM, Mannitol, high protein
    diets)
  • ADH insufficiency
  • Central
  • Nephrogenic
  • Primary
  • Secondary sickle cell, obstructive uropathy,
    chronic PN, reflux nehropathy, hypokalemia,
    hypercalcemia, drugs, psychogenic polydipsia

12
Maintenance fluid decreased urinary losses
  • SIADH
  • Renal failure
  • Replace insensible water loss urine output ml/ml
    with free water

13
Maintenance sodium needs
  • Increased CF, salt losing nephropathy, chronic
    PN, obstructive uropathy, diuretics, fistulas,
    diversions, NG drainage
  • Decreased Hepatic failure, cardiac failure,
    renal failure, nephrotic syndrome

14
Maintenance potassium needs
  • Increased Chronic renal disease, gastric and
    intestinal drainage, chronic diuretics, laxative
    abuse
  • Decreased or nil Acute renal failure, adrenal
    insufficiency, severe metabolic acidosis

15
Normal maintenance requirements (holiday and segar
16
Maintenance fluids route
  • Oral or parenteral
  • Calories usually as 5 dextrose
  • TPN

17
Deficit Therapy factors affecting
  • Oral or parenteral intake
  • Pathologic body losses
  • Physiologic body losses
  • compensatory attempts to modify volume and
    composition
  • Net effect- Deficits from different causes often
    similar in magnitude and composition

18
Infant moderately severe dehydration
19
Deficit therapy
  • Severity Magnitude and rapidity
  • Estimated from recent weight or clinical
    features
  • Type Relative loss of water and electrolytes
    mainly sodium
  • pathophysiology
  • therapy
  • prognosis

20
Deficit therapy Types
  • Isotonic sodium 130-150 mmol/l, no fluid shifts,
    80 of cases
  • Hypotonic sodium lt130mmol/l, ECF to ICF, 10
    cases
  • hypertonicsodiumgt150 mmol/l, ICF to ECF, 10
    cases

21
Deficit Therapytypes and history
  • D and V for days, good intake, low salt
  • Cholera, bacillary dysentery
  • High fever, poor intake
  • Infant with NDI, poor water intake
  • Intake of dilute milk formula
  • Intake of boiled semiskimmed milk
  • wrongly prepared ORS

22
Assessment of deficit severity
23
Assessment of severity contd
24
Calculation of deficit fluid
  • Percentage dehydration x wt in kg x 10 ml of
    fluid
  • eg 7 dehydration of infant weighing 10 kgs
    7x10x10700 ml

25
Clinical features
  • Signs represent depletion of ECF
  • Plasma tachycardia, fall of BP, postural
    hypotension, cool extremities, increased CRT,
    decreased urine
  • Interstitial fluid Tenting of skin
  • Transcellular fluid dry mouth, sunken eyes,
    decreased tears, sunken fontanel

26
Signs of dehydration
  • Mild dehydration no signs
  • Severe dehydration Prolonged capillary refill
    time,dry mucosa, decreased skin turgor, general
    appearance are the most sensitive and specific
  • Acidosis Kussmauls breathing
  • Hypokalemia weakness, abd dist, ileus,cardiac
    arrhythmias
  • hypocalcemia and magnesemia tetany, muscle
    twitching

27
Signs V's type of deficit
  • Hyponatremic increased severity of signs for
    amount of fluid loss
  • Hypernatremic Less signs, irritable, hypertonic,
    hyperreflexic, warm extremities, doughy skin

28
Lab tests
  • FBC Increased Hb, PCV
  • Serum Na type of dehydration
  • serum K gut loss, acidosis needs ECG monitoring
  • Serum HCO3 acidosis- DV, DKA alkalosis-Pyloric
    stenosis, NG drainage
  • Serum chloride changes with Na, chloride
    diarrhea
  • Urea/creatinine elevated with decrease in GFR,
    may be normal!
  • Urine infection screen, specific gravity,
    electrolytes
  • stool culture, electrolytes

29
Treatment
  • Oral therapy mild to moderate dehydration
  • Parenteral therapy
  • severe dehydration
  • Persistent vomiting
  • Refusal of oral intake
  • Abdominal distension
  • No caregiver to give close attention

30
Stages of treatment
  • Initial therapy expand ECF volume
  • Subsequent therapy replace deficit/maintenance/on
    going losses
  • Final therapy Return to normal
    composition/establish oral feeds/correct
    potassium deficit

31
Commonly available crystalloids isotonic
32
Isotonic crystalloid fluids
33
Hypertonic crystalloids
34
Colloid fluids
35
Initial therapy
  • Normal saline or Hartmans solution regardless of
    type of deficit
  • 20 ml/kg rapid bolus, repeat if needed
  • IV, intraosseous line
  • Never use hyponatremic fluids
  • Adequate crystalloid dose better than colloid
  • No potassium till urine output established

36
Subsequent therapy
  • Calculate over 8 hour intervals
  • Deficit replaced over 24 hours but can be done
    over 8 to 12 hours except HYPERNATREMIA
  • Early K replacement after urine output
  • Maximum K, 40 mmol/l (ITU 80 mmol/l)

37
Isonatremic dehydration
  • Deficit plus maintenance plus ongoing losses
    calculated
  • Use 0.45saline with 2.5 or 5 dextrose for
    subsequent therapy
  • Give 50 in first 8 hours and remaining over 16
    hours
  • Subtract boluses from total fluid
  • Assess clinical state regularly and modify if
    needed

38
Hyponatremic dehydration
  • Extra Na deficit (mmol/l)desired Na-actual Na x
    0.6 x Wt kgs
  • Manage as for isonatremic dehydration but replace
    deficit Na over 12-24 hours
  • Raise serum Na by 10 mmol/l/day
  • If Na lt120mmol/l and seizures give 3 Nacl
    1ml/min max 12ml/Kg

39
Hypernatremic dehydration complications
  • Cerebral haemorrhage, thrombosis, subdural
    effusion- permanent handicap, renal vein
    thrombosis
  • During treatment- cerebral oedema, seizures,
    hypocalcemia
  • High mortality if Serum Na gt160mmol/l

40
Hypernatremic dehydration
  • Always use isonatremic boluses
  • Slow correction of deficit over 48 to 72 hours
  • Aim to decrease serum Na by 10 mmol/l/day
  • Use 0.18saline or 0.45 saline with dextrose for
    subsequent therapy
  • Seizures 3 saline, mannitol, hyperventilation,
    calcium gluconate

41
Supplemental fluids
  • Consider composition of fluid lost
  • DV 0.45 saline
  • Cholera0.9 saline
  • NG tube aspiration 0.45 to 0.9 saline plus
    potassium
  • Gut losses same

42
Composition of external losses
43
Assessment of response
  • Appearance, activity
  • Skin turgor
  • BP
  • Intake/output chart
  • UE, glucose
  • blood gas
  • CVP monitoring
  • Eyeballs, tears
  • CRT
  • Weight
  • Urine Specific gravity
  • Urine output
  • ECG monitoring

44
Oral rehydration therapy
  • Mild to moderate dehydration
  • Types of ORS high sodium- 90mmol/l, low Na- 50
    mmol/l
  • Glucose facilitated sodium absorption, sucrose
    less effective, rice based effective

45
ORS
  • Use 50ml/kg in mild and 100ml/kg in moderate
    dehydration.
  • Give over 4 hours. Allow breast feeds and formula
    after rehydration. Reassess regularly. Small
    frequent feeds decrease vomiting. Consider NG
    tube.
  • Maintenance with 100ml/kg/day till diarrhoea
    stops
  • For on going losses add 10-15ml/kg/hr

46
Hyponatremia sodium depletion
  • Renal losses Preterm, ATN, Diuretics,
    mineralocorticoid deficiency, RTA
  • Extra renal loss DV, Burns, ascites, pleural
    effusion,csf drainage, NG drainage, CF
  • Nutritional deficits Inadequate Na in TPN, oral
    intake

47
Hyponatremia water excess
  • SIADH
  • Glucocotricoid deficiency
  • Hypothyroidism
  • Excess parenteral fluid
  • Psychogenic polydipsia
  • Tap water enema

48
Hyponatremia excess Na and water
  • Nephrotic syndrome
  • Cirrhosis
  • Cardiac failure
  • Acute and chronic renal failure

49
Hyponatremia asymptomatic
  • Water Excess (urinary Na usually gt20 mmol/l)
    fluid restriction, may be needed for days
  • Salt deficiency (urinary Na lt10 mmol/l, except
    in renal salt loss) Add salt to diet

50
Hypernatremia sodium excess
  • Improperly mixed ORS or formula
  • Accidental or deliberate swap of salt for sugar
    in feeds
  • Excess Bicarb during resus
  • Hypernatremic enemas
  • Drugs penicillin, gaviscon

51
Hypernatremia water deficit
  • Diabetes insipidus
  • Solute diuresis
  • DV
  • Inadequate breast feeds
  • Intentional water with holding
  • Insensible loss in prematures

52
Hypernatremia treatment
  • Salt poisoning peritoneal dialysis
  • Phenobarbitone for seizures
  • Inotropes for heart failure

53
Hypokalemia causes
  • Diarrhoea
  • Alkalosis
  • Volume depletion
  • Primary hyperaldosteronism,cushing syn,
    thyrotoxicosis
  • Diuretic abuse
  • DKA
  • Bartters syndrome

54
Hypokalemia consequences
  • Cardiac flat T wave and prolonged QT interval
  • Orthostatic hypotension, tetany, hypotonia,
    muscle weakness, death from resp failure
  • Paralytic ileus, gastric distension
  • Failure to thrive
  • Rhabdomyolysis
  • Nephrosclerosis and interstitial fibrosis
    polyuria
  • alkalosis

55
Hypokalemia treatment
  • Replacement potassium orally or parenterally
  • 3 mmol/kg/day in Bartter syn/indomethacin
  • Up to 10 mmol/kg/day in RTA/hyperaldosteronism

56
Hyperkalemia causes
  • Renal failure
  • Acidosis
  • Adrenal insufficiency
  • Cell lysis (trauma, surgery, tumour lysis)
  • Excessive intake
  • Sampling error!

57
Hyperkalemia consequences
  • Paresthesias, flaccid paralysis
  • Tall T waves, increased P-R interval, wide QRS
    complex, VF

58
Hyperkalemiamanagement
  • If cardiac rhythm affected give calcium 1 mmol/kg
    iv/specific anti arrhythmic drug
  • If normal rhythm, give nebulised salbutamol 2.5
    to 5 mg. Check K and pH.
  • If falling K- give calcium resonium 1g/kg po or
    pr- plan dialysis if needed
  • If still high (6.5 or more) give dextrose
    infusion 0.5g/kg/hr and iv insulin infusion,
    0.05units/kg/hr if pH lt7.34
  • If pH gt7.35 give sodium bicarbonate 2.5 mmol/kg iv

59
Hypocalcemia
  • Septicemia, rickets,hypoparathyroidsm,
    pancreatitis, massive blood transfusion, renal
    failure
  • Weakness, tetany, convulsions, hypotension and
    arrhythmias
  • Calcium infusion, phosphate binders/dialysis,
    treatment of cause

60
Hypercalcemia
  • Hyperparathyroidism, Hypervitaminosis DA,
    Idiopathic hypercalcemia, malignancy thiazide
    diuretic abuse,skeletal disorders,immobilisation
  • Polyuria, polydypsia
  • Volume expansion with saline, treatment of cause

61
Hypomagnesemia
  • Chronic diarrhoea, sprue, celiac d, prolonged TPN
    low in Mg, hyperaldosteronism, Gitelmans
    syndrome, cisplatin and aminoglycosides
  • Convulsions, tetany athetoid movements,
    hyperaccusis
  • Im or iv magnesium replacement as magnesium
    sulphate

62
Hypermagnesemia
  • Usually in renal failure, Addison disease,
    toxemia of pregnancy, enemas in megacolon
  • Drowsiness, coma if levels exceed 10 meq/l. Intra
    ventricular and atrioventricular conduction
    defects at 5 meq/l
  • IV calcium gluconate rapidly reverses effects on
    heart and CNS

63
Case 1
  • 8 week old infant
  • Weight 4 kgs, poor wt gain in last 4 weeks,
  • Vomiting from 3 weeks of age, now after most
    feeds, forceful, not passing urine well last 24
    hours
  • Moderate dehydration on examination
  • Na 130, Cl 94, K 2.6, HCo3 29.8

64
Case 1
  • Maintenance 100 x 4 400 ml
  • On going losses Ng aspirate volume for volume
    with normal saline
  • Start 0.45 saline dextrose 5 to give 400 ml
    over 8 hours and remaining 400 ml over 16 hours
  • Add Kcl 4 mmol/100ml once urine output noted
  • Monitor weight, urine output, Nasogastric
    aspirate, blood gas and electrolytes,ECG.
  • Once serum K rises to 3.5 decrease Kcl to 2
    mmol/100ml
  • Deficit fluid 10 x10 x4 400 ml
  • Once stable, send for surgery

65
Case 2
  • One year old, 10 Kgs with 2 days of DV. Given
    clear fluids at home. No urine in last 6 hours.
    Some fever. Not drinking ,lethargic last 2 hours.
  • Severe dehydration on examination
  • Blood Na 136, K 2.2, Hco3 8, pH7.35

66
Case 2
  • Bolus 20 ml/kg- 0.9saline, repeat if still
    shocked
  • Deficit fluid 15 x10 x101500 ml 400ml bolus
    1100ml
  • Maintenance fluid 100 x10 1000 ml
  • Give 1050ml in 8 hours and 1050 remaining in 16
    hours as 0.45 saline 5 dextrose
  • Add Kcl 40 mmol/l after urine output
  • Monitor ECG, weight, urine output, electrolytes,
    continuing losses for replacement
  • Once rehydrated offer ORS, milk and review fluids

67
Case 3
  • Four year old weighing 14 Kgs, lethargic,
    vomiting, rapid breathing since 12 hours.
    Producing urine. Normal stools. Over 2 weeks,
    since a cold has been drinking a lot, eating a
    lot and bed wetting again.
  • Moderate dehydration
  • Glucose 30 mmol/l, Na 128 mmol/l, K 4.8 mmol/l,
    HCO3 8 mmol/l, pH 7.28

68
Case 3
  • Start normal saline infusion, 20 ml/kg over 1
    hour
  • Start insulin infusion 0.05u/kg/hr
  • 0.45 salineKcl 20mmol/500 ml, 20 ml/kg over 2nd
    hour
  • 0.45 salineKCL or Pot phos 30mmol/l over 10
    hours
  • Maintenance fluid for 36 hours100050x41200600
    1800ml
  • Deficit fluid 10x10x14 1400 ml
  • Correct 50 deficit in first 12 hours
  • Monitor ECG, glucose, UE, blood gas, weight,
    urine output, GCS hourly to 2 hourly
  • Change fluid to 0.18 saline 5 dextrose when
    blood glucose reaches 16 to 17 mmol/l. Adjust K
    and insulin infusion rates as needed. Consider an
    Antibiotic.
  • When blood gas normal, blood glucose stable,
    patient drinking, give subcutaneous insulin 0.2
    to 0.4 units/kg qds and stop iv infusions.
  • Start regular insulin dose after another 24 hours

69
DKA complication
  • Cerebral edema headache, change in
    consciousness,unequal dilated pupil,
    vomiting,incontinence,delirium,bradycardia
  • Reduce iv rate, mannitol 1gm/kg iv, repeat in 2-4
    hours
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