MANAGEMENT OF ELECTROLYTE IMBALANCE IN CHILDREN WITH ACUTE DIARRHEA

IBG Suparyatha

Objectives
1) Most common electrolyte imbalance in children with acute diarrhea 2) Recognize these imbalances
3) Apply appropriate management principles

Objectives
1) Most common electrolyte imbalance in children with acute diarrhea 2) Recognize these imbalances
3) Apply appropriate management principles

ACUTE DIARRHEA
Mayor complication :
dehidration, electrolyte imbalance, and renal failure

Electrolyte imbalance :
Ukarapol N, et al. (2002) 69,8% Shah GS, et al. (2006) 79%

ACUTE DIARRHEA

Electrolyte imbalance

Ukarapol N, et al.

Shah GS, et al.

Hyponatremia
Hypernatremia Hypokalemia Hiperkalemia

17%
9,4% 22,6% 3,4%

56%
10,4% 46% 5,2%

Objectives
1) Most common electrolyte imbalance in children with acute diarrhea 2) Recognize these electrolyte imbalances
3) Apply appropriate management principles

HYPONATREMIA
Serum sodium level <135 mEq/L
In acute diarrhea : excessive sodium loss water retention ~ volume depletion excessive free water intake Hyponatremia dehidration

Signs and Symptoms

Irritability poor feeding nausea and vomiting lethargy seizures and eventually coma and death

Treatment of Hyponatremia
ACUTE CORRECTION urgent treatment ~ neurological changes or seizures The goal : to 120-125 mEq/L or until seizures stop Hypertonic saline solution, 3% NaCl, ideally a central venous line but acceptable during emergency via peripheral IV or IO, over 15-20 minutes 1.2 ml/kg of 3% NaCl raise the level by 1 mEq/L

Treatment of Hyponatremia
SLOWER CORRECTION acute correction completed or not neurological changes More slowly at approximately 12 mEq/L per day (0.5 to 1 mEq/L every hour)

FORMULA : 0.6 x (Wt in kg) x (target Na+-measured Na+)= Total mEq of Na+required to raise sodium level to target.

Case Study

A 2 month-old child (5 kg) present with seizures and sunken eyes and fontanelle . Mother reports two days of diarrhea and is found to have a sodium level of 114 mEq/L.

First step : acute correction

You decide to give 3% saline to correct to 120 mEq/L. Amount of NaCl = 0.6 x 5 kg x (120-114)= 18 mEq of Na+ 3% NaCl = 0.5mEq/L or approx 36 mL of 3% NaCl solution

or

(1.2 mL/kg) of 3% NaCl raises the serum sodium apporx 1 mEq/L 1.2 mLx5kg x (120-114) = 36 mL of 3% NaCl solution

Second step: slower correction

To raise the serum sodium level an additional 12 mEq/L from the 120 mEq/L

0.6x5kgx(132-120) = 36 mEq/L additional sodium needed over the remainder of the 24 hours additionally, the calculated deficit is added to this and administered over 12-24 hours

Treatment of hyponatremia
Water (ml) deficit Na neeed maintenance TOTAL 500 875 375 Na (mEq) 52 36 15 103

A good fluid ~ D5% 1/2NS or normal saline, with or without (potassium 20 mEq/L)

Fluid rates : first 8 hours deficit + 1/3 maint. (44 ml/hr) next 16 hours deficit + 2/3 maint (32 ml/hr)

HYPERNATREMIA
Defined as a serum sodium level >145 mEq/L
In acute diarrhea : Excessive water loss Inadequate free water intake Increased sodium intake through ORS Hypernatremia dehidration

Signs and Symptoms

Irritability, high-pitched cry, lethargy, seizures, fever, renal failure, and rhabdomyolysis. In infants, these symptoms mimic those of infections and sepsis

Treatment of Hypernatremia
Essential to correct ~ slowly Most recommendations no more than 0.5 mEq/L/hr or 12 mEq/L/day To calculate :
Free water deficit = (Wt in kg x 0.6) x 1 (desired Na+/actual Na+) (1000mL/L) OR 4 ml/kg of free water ~ drop sodium by 1 mEq/L

Case Study

A 10 month-old child (8 kg) present with profuse diarrhea and moderate dehidration and is found to have a sodium level of 157 mEq/L.

treatment of hypernatremia
Free water deficit = (8x0.6) x 1 (145/157) x (1000 mL/L) 365 mL = 4.8 x 0.076 (1000 mL/L) Quick Calculation : 4mL x 8kg x 12mEq/L = 384 mL of free water Maintenance fluid amounts for an 8-kg child are (100mL/kg x 8) = 800 mL/24hrs 1 L of normal saline = 500 mL of free water 1 L of normal saline = 750 mL of free water 1 L of D5 NS will provite 400 mL of free water and is a good starting point

treatment of hypernatremia
Water (ml) Free water deficit Na deficit 365 Na (mEq) 47

maintenance
TOTAL

800
1165

24
71

Na deficit ~ 600-365/1000 x 140 = 47 mEq

D5 NS is a good starting point

HYPOKALEMIA
Defined as a potassium level <3.5 mEq/L In acute diarrhea : Potassium loss Volume depletion Gastric juice loss

Signs and symptoms

fatigue and paresthesias

(ECG) changes : flattened T wave,ST depressions, U waves and ventricular dysrhythmias

Treatment of hypokalemia
Oral or IV supplementation urgency of sympptoms
Oral :

Asymptomatic hypokalemia (no ECG changes) or mild hypokalemia Ability to tolerate Increase diet intake 1-3 mEq/kg/day in three or four divided doses Safest

TREATMENT OF HYPOKALEMIA

A conservative protocol for IV replacement :

3.0-3.5 mEq/L 0,25 mEq/kg of IV KCl over 1 hour

2.5-3.0 mEq/L 0.5 mEq/kg of IV KCl over 2 hours less than 2.5 mEq/L 0.75/L of IV KCl over 3 hours. A potassium level should be checked halfway through this infusion. ====>>>> SYMPTOMATIC HYPOKALEMIA

TREATMENT OF HYPOKALEMIA

IV replacement :

No more than 0.5 mEq/kg/hr of KCI in a single IV with a max dose of 10 mEq over 1 hr.
Via a central venous line If peripheral: do not exceed 40-50 mEq/L potassium

HYPERKALEMIA
Potassium levels >5.5 mEq/L In acute diarrhea :

Metabolic acidosis Exogenous potassium

Signs and Symptoms

To inadequate cardiac output ~> arrhythmias. Cardiac (ECG changes) :

Skeletal muscles and nerve: weakness and paresthesias

Treatment of Hyperkalemia
Hyperkalemia requires urgent intervention and th 1. Place a cardiorespiratory monitor 2. Recheck to confirm the hyperkalemia 3. Discontinue any exogenous potasssium 4. Administer one or more of drugs therapies 5. Emergency Hemodialysis

Administer one or more of the drug therapies :

1. Calcium gluconate, 100 mg/kg over 3 min (1mL/kg of 10% solution) IV 2. Sodium bicarbonate, 1-2 mEq/kg given IV over 10-15 min 3. Insulin, 0.1 U/kg/hr, mixed with Dextrose solution 0.5 g/kg/hr 3. An exchange resin, such as sodium polystyrene resin (Kayexalate), administered 1g/kg rectally

Summary
Hyponatremia, Hypernatremia, Hypokalemia, and Hyperkalemia are common in children with acute diarrhea Acute correction must be considered carefully for symptomatic electrolyte imbalance Strict attention to detail is important in providing safe and effective therapy