Elektrolit Imbalance.2013

Electrolyte imbalance in children
Dr. WAN NEDRA Sp.A

Bagian Ilmu Kesehatan Anak
Fakultas Kedokteran YARSI
2013
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 1
A 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.
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.
Kebutuhan Maintenance
Mineral/kg bb/24 jam
Mineral Dosis
Sodium (Na) 2-3 mEq
Potasium (K) 1-2 mEq
Chlorida (Cl) 3-5 mEq
Calcium (Ca) 50-200 mg
Magnesium (Mg) 0.4-0.8 mEq
Phosphate
8/13/2018 (P) ined/h20/elk/abIned-yarsi 15-50 mg 527/2/08
Sodium Serum
• Laboratory finding:
• Isonatremia
• Hiponatremia
• Hipernatremia

Isonatremia

Isonatremia-Isotonisitas
Isoosmolalitas
Isonatremia
• Sodium serum 135-145 mEq/L
Isotonik
• Osmotic gradient (-)
• Tekanan osmotik : normal
• Perpindahan air : tidak ada
Hiperosmolalitas
Isonatremia
Isotonik
• Osmotic gradient (-)
• Tekanan osmotik : normal
• Perpindahan air : tidak ada

Isonatremia-Hipertonisitas
Hiperosmolalitas
Isonatremia
Hipertonisitas
• Osmotic gradient (+)
• Tekanan osmotik : tinggi
• Perpindahan air : ICF  ECF 
dehidrasi sel
Hiponatremia

Hiponatremia-Hipotonisitas
Hipoosmolalitas
Hiponatremia
• Sodium serum < 130 mEq/L
Hipotonik
• Tekanan osmotik : rendah
• Perpindahan air : ECF  ICF 
edema sel
Hiponatremia-Hipertonisitas
Hiponatremia
• Sodium serum < 130 mEq/L
Hipertonik
dehidrasi sel
Hipernatremia

Hypernatremia
• Less common than hyponatremia

• Relative water deficit in relation to
sodium in the plasma
• Usually iatrogenic

Hipernatremia
• Hipernatremia
• Sodium serum 150 mEq/L
• Hipertonik
dehidrasi sel
Isoosmolalitas
Hipovolume
(Dehidrasi isonatremia)

Terapi
Dehidrasi 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)

Terapi
Dehidrasi Isonatremik
Contoh
Dehidrasi 10%: (BB  : 5 kg  4.5 kg)
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 (kg) x 3 mEq/kg = 15 mEq
Total H2O / 24 hr = 500 + 500 = 1000 ml
Total Na /24 hr = 77 + 15 = 92 mEq

Dehidrasi hiponatremik
Sodium and water losses

• Gastrointenstinal losses:
• Vomiting
• Diarrhea
• Urinary losses
• Salt water nephropathy
• Adrenal insufficiency
• Diuretic
Terapi
Dehidrasi Hiponatremik
Hitung jumlah natrium :
 Hiponatremia  Isonatremia
Selanjutnya :
 Sesuai : Dehidrasi Isonatremia

Terapi
Contoh
Dehidrasi 10% (BB  : 5 kg  4.5 kg) Na 125 mE/L
Jumlah 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
Hyernatremia
Hypovolemic
• Water loss in excess of sodium loss

• Sodium lost (hypotonic solution)
• Kidney
• GI tract
• Skin
• Respiratory tract
Terapi
Dehidrasi - Hipernatremia
• Dehidrasi hipernatremik
• Hitung jumlah air
• Hipernatremia  isonatremia
• Selanjutnya
• Sesuai : Isonatremia–Isotonik-Hipovolemia
Terapi
Contoh
Jumlah air hipernatremiaisonatremia = X
(X+TBW) x NaD = TBW x NaA

X = (NaA/NaD) x TBW- (TBW) ml
X = (170/145) x (0.6x4.5)–(0.6x4.5) = 465 ml

Terapi
Contoh
Defisit air = 500 ml

Defisit Na = 500-465 = 35 mL (NaCl 0.9%)
= 35ml x 154 mEq/L = 5 mEq

Terapi
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 ml

Jumlah Na/24 jam = 5 + 15 mEq = 20 mEq

Terapi
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
Terapi
• Initial resuscitation
– Isotonic saline as for isotonic
dehydration

Hipernatremia
Diabetes Insipidus
• Polyuria and polydipsia
– Deficient production of vasopressin or
ADH
– Called pituitary DI or central DI.
• Polyuria without hypernatremia is not DI

Hipernatremia
Diabetes Insipidus
Etiology
• Head trauma
• Cranial surgery
– specifically post-pituitary surgery
• Infectious
– meningitis, encephalitis
Hipernatremia-Hipervolemik
Therapy
• Diuresis
• Replacing urinary losses with water

Potasium

Potassium balance
Internal Balance
1. 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+
Potassium balance
Internal Balance
4. 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
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cellular uptake of K+. 3527/2/08
ined/h20/elk/abIned-yarsi
Potassium balance
B. External Balance - Renal Potassium Excretion

1. 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.

Potassium balance
External Balance - GI Potassium Excretion

• Fecal excretion of K+ normally is small
• Diarrhea disorders, K+ loss increases
significantly.

Potassium disorders
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
Potassium disorders
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
8/13/2018
correct the hypokalemia.
ined/h20/elk/abIned-yarsi 3927/2/08
Potassium disorders
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.

Potassium disorders
Hyperkalemia
• 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.
Potassium disorders
Hyperkalemia
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.
Potassium disorders
Hyperkalemia
• 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,

Potassium disorders
Hyperkalemia
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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The Loser says, "It may be possible ined/h20/elk/abIned-yarsi
8/13/2018
but it's too difficult." 4527/2/08

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Electrolyte imbalance in children

Dr. WAN NEDRA Sp.A

The pathogenesis of hyponatremia in diarrhea is due to a combination

8/13/2018 ined/h20/elk/abIned-yarsi 227/2/08

He is clinically assessed to be 5% dehydrated by clinical criteria.

Oral versus IV rehydration

It is pointed out that 360 cc is only 20 cc/kg which replaces

He is also given ondansetron (Zofran) for nausea relief.

His chemistry panel shows Na 135, K3.4, Cl 99, bicarb 15.

8/13/2018 ined/h20/elk/abIned-yarsi 627/2/08

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8/13/2018 ined/h20/elk/abIned-yarsi 1127/2/08

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• Less common than hyponatremia

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8/13/2018 ined/h20/elk/abIned-yarsi 1727/2/08

8/13/2018 ined/h20/elk/abIned-yarsi 1827/2/08

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Sodium and water losses

 Sesuai : Dehidrasi Isonatremia

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• Water loss in excess of sodium loss

Jumlah air hipernatremiaisonatremia = X

(X+TBW) x NaD = TBW x NaA

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

Defisit air = 500 ml

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Jumlah Air/24 jam = 500 + 500 ml = 1000 ml

8/13/2018 ined/h20/elk/abIned-yarsi 2727/2/08

Hati-hati: Dehidrasi sel  edema sel (otak)

Koreksi dalam 48 jam

Air = 2 x maintenance + 1 x defisit

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B. External Balance - Renal Potassium Excretion

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External Balance - GI Potassium Excretion

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8/13/2018 ined/h20/elk/abIned-yarsi 4327/2/08

Winners versus Losers

The Winner sees an answer for every problem;

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