11/03/09Fluid-Electrolyte Balance in Children Dr. Wan Nedra K, Sp.ABagian Ilmu Kesehatan AnakFK.YARSI, Jakarta

Objective WaterFactsCompartmentsIntake and outputElectrolytesImbalances of Water and ElectrolytesDehydration and treatment

Water - FactsWater is the most abundant compound in the bodyAbout 50-60% of your body weight if you are young, healthy and weigh about 120 lbs.Lean tissue has more water that fat tissue so the more fat you are carrying the lower the percent body water.

Water - FactsFemales generally have slightly less water per pound of weight because their bodies (should) have more fat than male bodies.Age:Infants have more water per pound body weight than adults (may be as high as 80%).Older adults have less water per pound of body weight.

Water CompartmentsWater moves by filtration or osmosis among 3 compartments in the body:Intracellular fluid (ICF)

Extracellular fluid (ECF) PlasmaInterstitial spaces (IF) (tissue fluid); microscopic spaces between cells. Also includes lymph, CSF, synovial fluid, aqueous humor and serous fluid. The volume in this compartment varies more than in the other compartments.

Water Intake and OutputBody water homeostasis is normally regulated by processes that adjust output to intake. Processes that adjust fluid intake are secondary.Fluid Intake: *what we drink (beverages), water in foods we eat and water formed by catabolism of food.

Water Intake and OutputFluid output: via *kidneys, lungs, skin and intestines. Fluid lost from the skin and lungs is called insensible fluid loss meaning that we usually are not aware of it.Obligatory water loss: amount of water necessary to excrete wastes through the kidney. Feces

Water Intake and OutputWater output by the kidneys is the most changeable usually matching the volume of fluid we take in.The rate of water and salt reabsorption by the renal tubules is the most important factor in determining urine volume.ADH?Aldosterone?

Water Intake and OutputNeural control SignalOsmolarity = concentration of dissolved materials in fluid (Na, K, Cl, glucose, proteins, etc.). Increased materials or decreased water causes an increase in osmolarity.Osmoreceptors

ElectrolytesChemicals that dissolve in water and dissociate into positive and negative ions (including inorganic salts, acids and bases). Electrolytes also help to create the osmolarity of body fluids and therefore regulate the movement of water between compartments.Water is attracted to electrolytes, especially Na+. Water will move from a compartment with a low concentration of electrolytes to one with a high concentration of electrolytes = osmosis.

ElectrolytesCations positive ionsNa+ (sodium) - most abundant cation in the ECF; essential for electrical activity of nerve and muscle cells. The level of Na+ is regulated primarily by the kidneys.K+ (potassium) - most abundant cation in the ICF; essential for electrical activity of nerve and muscle cells.

ElectrolytesCationsCa2+ (calcium) - mostly in bones and teeth; essential for blood clotting; maintains normal nerve and muscle cell function.Mg2+ (magnesium) - more abundant in ICF than ECF; essential for ATP production and activity of nerve and muscle cells.

ElectrolytesAnions negatively charged ions.Cl- (chloride) - most abundant anion in the ECF.HCO3- (bicarbonate) part of the bicarbonate buffer system.HPO42- (phosphate)Proteins- - (negatively charged proteins) inside the cell and in plasma regulate water in those compartments and play a role in regulating electrolyte distribution.

ElectrolytesNon-electrolytes most organic compounds that do not ionize (dissociate) in solution, ex. glucose. These compounds do contribute to the osmolarity.

EdemaPresence of abnormally large amount of fluid in the intercellular tissue spaces. Causes:Retention of electrolytes, especially Na+ (remember Na+ attracts water).Increase capillary BP that pushes fluid out of the blood into the IF. Fluid shift blood volume decreases and IF increases. Common during heart failure due to venous congestion = increased pressure in the capillary beds.

EdemaCausesPlasma proteins act as water holding force, if the concentration of blood proteins decreases less water moves from the IF into the blood. Result: water will accumulate in the IF. ?WhyProteins inside the cell also act to regulate intracelluar water content.

Fluid ImbalancesDehydration

Overhydration

Diuretics

DIARE MELANJUT(>7 HARI )DIARE AKUTDIARE KRONIK( >14 HARI ) Diare: onset cepat +/- diikuti dengan gejala seperti mual,muntah, demam dan nyeri perut85%10%5%

TATALAKSANA DIARE (1)

Rehidrasi oral/parenteralDukungan nutrisiObat atas indikasiEdukasi orangtua

TATALAKSANA DIARE (2)Penanganan dehidrasi:Ask,look, and feel tanda-tanda dehidrasiKondisi anak & pemeriksaan fisis: mata, air mata, mulut & lidah. Apakah tampak kehausan, skin pinchAnterior fontanelle, arms & legs, pulse, breathingTentukan derajat dehidrasi (Berat, ringan sedang atau tanpa dehidrasi)Pilih rencana pengobatan:C: Severe dehydration (loss of >10% of Body Weight)B: Some dehydration (loss of 5-10% of BW)A: No signs of dehydration (loss of

Lihat: Kead. Umum MataAir mataMulut dan lidahRasa haus

Periksa Turgor kulitHasil pemeriksaan

Terapi Baik, sadar Normal Ada Basah Minum biasa tidak haus

Kembali cepatTanpa dehidrasi

Rencana terapi A* Gelisah, rewel Cekung Tidak ada Kering * Haus, ingin minum banyak

* Kembali lambatD. Ringan/sedang1 tanda * (+) 1 atau lebih tanda lain Rencana terapi B* Lesu, lunglai, tak sadarSangat cekung & kering Tidak ada Sangat kering * Malas minum atau tidak bisa minum

* Kembali sgt lambatDehidrasi berat1 tanda * (+) 1 atau lebih tanda lainRencana terapi CPenilaian A BC

REHIDRASI ORALDiare tanpa dehidrasi sampai dehidrasi ringan-sedang.Oralit WHOCRO lain: laritan gula-garam, larutan garam-tajin, PedialyteSegera setelah diare terjadi

PENYEBAB GAGALNYA CROKeluaran tinja yang banyakMuntah terus menerusDehidrasi beratTidak mampu atau menolak minumMalabsorpsi glukosaPerut kembung dan ileusCara penyiapan dan pemberian oralit yang tidak benar

TAHAPAN CROTAHAPAN REHIDRASIMengganti kehilangan cairan dan elektrolit yang telah terjadi

TAHAP RUMATANMengganti cairan dan elektrolit akibat diare dan muntah yang masih berlangsung

INDIKASI REHIDRASI PARENTERALDehidrasi beratTidak dapat minum (lemah, sopor atau koma)Muntah hebatOliguri atau anuri berkepanjanganKomplikasi serius lain yang menghambat keberhasilan rehidrasi oral

REHIDRASI PARENTERAL UNTUK DEHIDRASI BERATBerikan larutan RL atau DGaaBAYI (12 bln)1 jam pertama: 30 ml/kgbb*3 jam berikutnya: 70 ml/kgbb

*Ulangi biula denyut nadi masih sangat lemah atau tidak teraba

UPAYA PENCEGAHAN DIAREPemberian ASIPerbaikan cara pemberian makanan pendamping ASIPenggunaan air bersih yang cukupCuci tanganPenggunaan jambanPembuangan tinja bayi/anak yang semestinyaImunisasi campak

PLAN TREATMENT A Tanpa Dehidrasi Muntah (-) diet yg biasa pd pasien dilanjutkan Malabsorption (-) Tidak ada diet spesifik

Cairan Rehidrasi Oral (CRO) setiap BAB banyak (bukan kecipirit) atau muntah

PLAN TREATMENT B

Dehidrasi Ringan-SedangCRO (3 jam I) 75 ml x BBor

Evaluasi ualng setelah 3-4 jam rencana th/ A, B, or C

Umur< 1 tahun1-5 tahun> 5 tahundewasaTotal ORS300 ml600 ml1200 ml2400 ml

PLAN TREATMENT C

Dehidrasi berat, IVFD

Re-evaluasi setiap 1-2 jamCROSetelah 6 jam (bayi) atau 4 jam (anak) reevaluasi rencana treatment A,B,C

UmurIst treatment30 ml/KG BB dlm2nd treatment 70 ml/KG BB dlmInfant < 12 bln1 jam5 jamAnak > 12 bln - 1 jam 2 - 3 jam

TATALAKSANA DIARE DI RUMAH

Beri minum lebih banyak dari biasanyaBeri makan lebih seringBawa/rujuk ke petugas kesehatan bila keadaan tidak membaik

RUJUK ANAK KE PETUGAS KESEHATANBila anak tidak membaik dalam 3 hariBila timbul salah satu dari keadaan berikut ini: Tinja cair lebih sering/banyak Muntah berulang Rasa haus yang nyata Demam Terdapat darah dalam tinja Bila anak hanya makan/minum sedikit

KOMPOSISI ORALIT (WHO)Nama Bahan (g/L)NaCl 3,5Na3 sitrat 2,9NaH2CO3 2,5KCl 1,5Glukosa 20,0KOMPOSISI (mmol/L)Natrium 90Kalium 20Klorida 80Sitrat 10Bikarbonat 30Glukosa 111

Electrolite composition

Cholera diarrhea101279232Non-cholera diarrhea56255514 ORS WHO 90208030 Ringer Lactate 130410928 NaCl 0,9%15401540 DG ana61185227 NaCl 0,45%770770

NaKClHCO3

LiquidNa+K+HCO3Carbohy (g/L)mOsm/BWCola20.11350-150 gluc, fruc550Ginger ale3150-150 gluc, fruc

Apple Juice320100-150 gluc, fruc

Chicken Broth25050Tea000Gatorade20345 gluc, other sug

Evaluasi (clinical ssessment)

Tanda2 faktor cormobid conditions travel, animal/bird, day care, antibiotic

CharacteristicBlood : inflamatory bacterial disease aggressive work up & intervention

Gross or occult blood in the stool Shigella sp, Campylobacter sp, EHEC

Pemeriksaan Laboratorium Laboratorium rutin sesuai dg indikasi

Tergantung kebutuhan pasienJika terapi cairan rehidrasi oral gagal

Jika leukosit pada feses banyak indikasi terdapat proses inflamasi ec bakteri Pikirkan untuk Kultur Feses

Kesimpulan

Diare pd anak masih merupakan masalah yg serius

Tatalaksana utama adalah rehidrasi

Penting mengetahui penyebab diare

WHO ORS COMPOSITION

ContainSodium chlorideThree sodium citrate (dihydrate)Sodium bicarbonatePotasium chlorideGlucose (anhydrate)Gram/L3.52.92.51.520.0CompositionSodiumPotasiumChlorideCitrateBicarbonateGlucoseMmol/L9020801030111

COMPOSITION OF IV FLUID

SolutionGlukosa(g/L)K+Na+Cl-Lactate/AcetateHartmann / RLDGaaNaCl 0.9%KaEN 3B-150-27417.5-20130611545010952154502826020

THANK YOU

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