FLUID MANAGEMENT AND ELECTROLYTE

IMBALANCE
IN CHILDREN WITH ACUTE DIARRHEA

UKK PGD

Pediatric Critical Care Working Group

Indonesian Pediatric Society

Objectives
1) Mayor complication of acute diarrhea in
children
2) Recognize dehydration and most common
of
electrolyte imbalance
3) Apply appropriate management principles

ACUTE DIARRHEA
Mayor complication :
Dehidration and
shock
Electrolyte
imbalance,
Electrolyte
and renal Ukarapol
failure N, et
al.

Shah GS, et
al.

Hyponatremia

17%

56%

Hypernatremia

9,4%

10,4%

Hypokalemia

22,6%

46%

Hiperkalemia

3,4%

5,2%

imbalance

shock and dehydration

Shock

RL 20 ml/kg

Hyponatremia dehydration
Isonatremia dehydration
Hypernatremia dehydration

Hyponatremia Dehydration
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

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% NaCI
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 dehydration

deficit

Water (ml)

Na (mEq)

375

52

Na neeed

36

maintenance

500

15

TOTAL

875

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 Dehydration
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.

hypernatremia dehydration
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 dehydration

Free water deficit

Na deficit
maintenance
TOTAL

Water (ml)

Na (mEq)

365

47

800

24

1165

71

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

D5 NS is a good starting point

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

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

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
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
4.An exchange resin, such as sodium
polystyrene resin (Kayexalate),
administered 1g/kg rectally

Thanks You