fluids and electrolytes

FLUID AND ELECTROLYTES

SCOPE

1. FLUIDS > COMPONENTS > TOTAL BODY WATER > FLUID COMPARTMENTS > REGULATION OF BODY WATER > MECHANISMS OF WATER

DISTRIBUTION > OSMOLALITY OF BODY FLUIDS

SCOPE

2. ELECTROLYTES > SODIUM > POTASSIUM > CALCIUM > MAGNESIUM > CHLORIDE > PHOSPORUS

SCOPE 3. ACID BASE BALANCE 4. FLUID THERAPY > MAINTENANCE > DEFICIT 5. DIARRHEA > ASSESSMENT OF DHN > ORS > IV > DIARRHEA TREATMENT PLANS

FLUIDS AND ELECTROLYTES

Children are prone to fluid and electrolyte problems: WHY?

1. Higher metabolic rate relative to weight ( 2x over adult) 2. Larger skin surface area in relation to

body water 3. Tend to loss more proportionate to body

weight 4. Immaturity of kidneys


Gen. Considerations: total amount of water and electrolytes as

a whole Water and solutes in various

compartments Concentration of solutes within its

compartment


Fluid compartments TBW Intracellular Extra cellular Newborn= 75-80% 40% 30-35% Children= 65% 40% 25% Intravascular=16% Insterstitial= 9% Adults= 60% 40% 20%

FLUID COMPARTMENTS

Intracellular (30-40%)

Plasma (5%)

Extracellular ( 20-25%)

Instertitial (15%)

ELECTROLYTES Extracellular Fluid Intracellular Fluid Cations Anions Cations Anions

Na=140

K=4

Ca=2.5 Mg=1.1

Cl=104

HCO3=24

Prot=14

Other=6 Phos=2

K= 140

Na=13

Phos=2

Phos=107

Prot=40

HCO3

Cl=3

Copyright 2009, John Wiley & Sons, Inc.

Fluid Balance 2 barriers separate ICF, interstitial fluid and plasma

Plasma membrane separates ICF from surrounding interstitial fluid

Blood vessel wall divide interstitial fluid from plasma Body is in fluid balance when required amounts of water

and solutes are present and correctly proportioned among compartments

An inorganic substance that dissociates into ions in solution is called an electrolyte

Water is by far the largest single component of the body making up 45-75% of total body mass

Process of filtration, reabsorption, diffusion, and osmosis all continual exchange of water and solutes among compartments


ICF differs considerably from ECF

ECF most abundant cation is Na+, anion is Cl- Sodium

Impulse transmission, muscle contraction, fluid and electrolyte balance Chloride

Regulating osmotic pressure, forming HCl in gastric acid Controlled indirectly by ADH and processes that affect renal reabsorption of

sodium ICF most abundant cation is K+, anion are proteins and phosphates

(HPO42-) Potassium

Resting membrane potential , action potentials of nerves and muscles Maintain intracellular volume Regulation of pH Controlled by aldosterone

Na+ /K+ pumps play major role in keeping K+ high inside cells and Na+ high outside cell


Intracellular volume is maintained by: 1. Active transport of electrolytes Na+ (OUT) ATP-ase pump K+ (IN) 2. Water by passive diffusion


Intravascular (ECF) volume is maintained by:

1. Filtration =at the capillary level 2. Oncotic pressure = mainly by ALBUMIN

in the plasma


BODY WATER REGULATION maintained at PLASMA OSMOLALITY=

285-295 mOSM/ k water Involved: osmoreceptors volume receptors hypothalamus posterior pituitary collecting ducts of nephron


BODY WATER REGULATION Intake regulation: by thirst Conditions that generate thirst: Plasma osmolality raised by 1-2 % Volume depletion Renin-angiotensin stimulation


BODY WATER REGULATION Disturbance in thirst mechanism: 1. CNS disorders 2. K+ deficiency 3. malnutrition


BODY WATER REGULATION Absorption in GIT- HOW? Passive diffusion 1. Na+ K+ pump= requires energy 2. Sodium-glucose co-transport 3. Others


BODY WATER REGULATION Excretion lungs: evaporative skin: evaporative obligatory losses urine


Daily Water Gain and Loss


BODY WATER REGULATION Volume of urine is regulated by: 1. Plasma osmolality ( thru the neuro-

hypophyseal-renal axis 2. GFR 3. Renal tubular epithelium 4. Plasma adrenal steroids

FLUID THERAPY

1. Maintenance A. Normal maintenance= replaces normal

losses B. Active maintenance= replaces ongoing

abnormal losses 2. Deficit = replaces PREVIOUS losses

FLUID THERAPY

MAINTENANCE GOAL: Maintain normal body water content HOW? 1. Replace normal obligatory losses 2. Replace ONGOING abnormal losses 3. Prevent dehydration from occurring even

in the presence of ongoing abnormal losses

Additional goals of maintenance fluids: 1. Prevent electrolyte disorder 2. Prevent ketoacidosis 3. Prevent protein degradation Composition of a good maintenance fluid: 1 Water 2 Glucose 3 Sodium 4 Potassium *** Glucose in D5 conc. Provides 17 calories/100 ml and

nearly 20 % of the total daily caloric need; enough to prevent ketone production and protein degradation.

A patient receiving maintenance intravenous fluids is receiving inadequate calories and will lose 0.5 to 1 % of weight each day.

DAILY MAINTENANCE FLUID VOLUME Based on body weight 0-10 kg 100 ml/kg/24 hrs 11-20 kg 1000 ml//24 hrs PLUS 50 ml for every extra kg above 10 kg >20 kg 1500 ml//24 hrs PLUS 20 ml for every extra kg above 20 kg CEILING!!! 2400 ml/24 hrs or 100 ml/hr

MAINTENANCE FLUID VOLUME HOURLY Used if 24 hrcalculation is not needed but

HOURLY!! 0-10 kg 4 ml/kg/hr 11-20 kg 40 ml/hr PLUS 2 ml for every extra kg above 10kg >20 kg 60 ml/hr PLUS 1 ml for every kg above 20 kg Ceiling: 100 ml/hr

MAINTENANCE FLUID VOLUME HOURLY > 1ST 10 kg= 4 ml/kg/hr 2nd 10 kg= 2 ml/kg/hr

3rd 10 kg = 1 ml/kg/r

Ceiling: 100 ml/hr

REMINDER!!!! 1 For obese patients there might be an

overestimation of the maintenance volume.

Instead: Base the calculation on the lean body weight or on the 50%th percentile or Median Z score of the weight for height OR

use the ceiling: 2400 ml/24 hrs

FLUID THERAPY

MAINTENANCE Based on surface area 1. Determine the surface area using the

weight in kg SA = kg x 4 + 9 100 2. Multiply SA by 1500 ml/24 hrs

FLUID THERAPY HOW TO CALCULATE RATES of FLUID ADMINISTRATION 1. Determine rate/hour= divide total fluid volume (in

ml) by 24 ( ml/hr 2. Determine rate/min = divide no. 1 by 60 (ml/min) 3. Determine rate microdrips/min = multiply no. 2

with 60= (microdrips/min) Basis: 60 udrips in one ml OR 4. Multiply no. 2 with 15 = drops per minute Basis: 15 drops in one ml 5. SHORTCUT!!! ML/HOUR = MICRODRIPS/MINUTE ML/HOUR 4 = DROPS/MIN

FLUID THERAPY

Maintenance A. Normal maintenance B. Active maintenance=replacing ONGOING

ABNORMAL LOSSES HOW? 1. Determine the amount of WATER lost (volume for volume) 2. Determine the ELECTROLYTE COMPOSITION

of the body fluid lost

DECREASES or INCREASES to the maintenance fluid Decreases: 1. Humidified gases MF x 0.75 2. Paralyzed MF x 0.7 3. High ADH (IPPV or coma) MF x 0.7 4. Hypothermia MF -12% per C core temp below 37 5 High ambient humidity MF x 0.7 6 Renal failure MF x 0.3 (+urine output)

INCREASES 1 Full activity and oral feeds MF x1.5 free fluids 2 Fever MF +12 % per C core temp above 37 3 Room temp. >31C MF +30% per C rise above 31 4 Hyperventilation MF x 1.2 5 Preterm neonate(

FLUID THERAPY Electrolytes content of Body Fluids (meq/L) Na+ K+ Cl- Gastric 20-80 5-20 100-150 Pancreatic 120-140 5-15 90-120 Small I 100-140 5-15 90-130 Bile 120-140 5-15 80-120 Ileostomy 45-135 3-15 20-115 Diarrhea 10-90 10-80 10-110 Sweat 10-30 3-10 10-35 Burns 140 5 110

IF VOLUMES OF FLUID LOST CAN NOT BE MEASURED? ESTIMATE!!!

1. DIARRHEA STOOL= 10

ML/KG/EPISODE

2. VOMITING= 2 ML/KG/EPISODE

FLUID THERAPY

Indicators that maintenance fluids are adequate:

1. Body weight maintained 2. Thirst does not occur 3. Urinary output not less than 1.0-1.5

ml/kg/hr

CASE A 14 month was admitted for fever, extensive

mouth ulcers and inability to swallow food and oral fluids. Wt: 8.6 kg. Temp: 40C. IVF administration was decided

Questions: 1. Calculate the total normal maintenance fluid

for 24 hours including the volume added for fever (Use Holliday Segar and surface area.

2 What is the IVF rate per minute in microdrips and macrodrops

Given: 8.6kg, temp: 40.0 degrees Holliday segar calculation: 8.6kg x 100ml/24hr = 860ml/24hr Inc for fever 12% mf x MF x 3= 0.12 x 860ml MF x 3= 309 860 + 309 = 1269ml MF/24hr 1170 /24hr = 49ml/hr 49 mic gtt/min 12 gtt/min

Surface area

Wt x 4 + 9/ 100 8.6 x 4 +9 /100 = 0.434 x1500ml/24hr MF/24 =651 ml/24hr 12% of 651ml x 3= 234ml 651ml + 234 ml= 885 ml/24hr 37ml/hr or 37 mic gtt/min 9 gtt/min

FLUID THERAPY

DEFICIT THERAPY Goals: 1. To correct fluid loss 2. To correct osmolality= Sodium 3. To correct other electrolyte losses 4. To correct acid-base imbalance

FLUID THERAPY

Essential problems!!! 1. How RAPID and how SEVERE the loss

was 2. TYPE of loss-depending on the

electrolyte/acid or base content of the fluid lost

FLUID THERAPY

THE BEST GUIDE FOR ASSESSMENT OF

FLUID LOSS IS THE ACUTE CHANGE IN BODY WEIGHT

FLUID THERAPY

Acute change in weight can be calculated: 1.Weight before the loss MINUS weight after

the loss 2. Determine the percent weight loss: weight loss DIVIDED by weight before

loss then MULTIPLY by 100 3. Determine severity of deficit (dehydration)

FLUID THERAPY

INFANTS CHILDREN Mild 3-5 % wt loss 3% Moderate 5-10 % wt loss 6% Severe 10 % wt loss 9%

FLUID THERAPY

To determine the amount of DEFICIT FLUID to administer based on the PERCENT WEIGHT LOSS:

Infant Children Mild 30-50 ml/kg 30 ml/kg Moderate 60-90 ml/kg 60 ml/kg Severe 100-150 ml/kg 90 ml/kg

FLUID THERAPY

Clinical Manifestations of Dehydration 1. Weight loss 2. Thirst = 5% or more of wt. loss (1-2% increase

in plasma osmolality) 3. Mucus membranes=dry 4. Skin elasticity = lost 5. Fontanelles depressed 6. Gen. condition= irritable to lethargic, coma

FLUID THERAPY Clinical manifestations of dehydration 7. Circulation > cool, mottled > tachycardic > thin, thready pulse > low BP, narrow pulse pressure (less than 20 mm Hg) > Capillary refill time (CRT) < 2 sec= loss is less than 50 ml/kg 2-3 sec = loss is 50-90 ml/kg > 3 sec = loss is 100 ml/kg or more

FLUID THERAPY Signs of dehydration acc. to severity: Mild Moderate Severe General alert irritable lethargic,coma Thirst thirsty thirsty not able todrink Fntanelles normal sunken sunken Eyes normal sunken very sunken,dry Tears normal none none Mucosa wet dry very dry Skin pinch GBQ slowly very slowly Vital signs: RR normal rapid rapid,deep Pulses normal fast fast, thready or none BP normal normal,low very low

FLUID THERAPY To determine DEGREE OF DEHYDRATION using clinical

manifestations: 1. Look at the column of Severe dehydration 2. If there are two or more signs in the column, classify

as SEVERE DHN, if one or none 3. Look at column of Moderate DHN 4. If there are two or more signs in the column, classify

as Moderate DHN, if one or none go to the column of Mild DHN

5. Classify as Mild DHN, if thirst is present even if the only sign present

6. Classify as No DHN if the child has diarrhea with no signs of DHN identified

FLUID THERAPY

To determine deficit fluid therapy based on clinical manifestations:

Infant Children Mild 30-50 ml/kg 30 ml/kg Moderate 60-90 ml/kg 60 ml/kg Severe 100-150 ml/kg 90 ml/kg

FLUID THERAPY(Method A) DURATION OF DEFICIT PHASE (3-6 hrs) Note: this method is used for dehydration sec. to diarrhea Two phases 1. Rapid phase 2. Repair Amount: Amount: Mild= no rapid phase total amount Moderate= of the total deficit 3/4 Severe = 1/3 of the total deficit 2/3 How fast: Infants = one hour 5 hrs Children= 30 minutes 2 or 3 hrs NOTE: IN SHOCK, AS FAST, AND VOLUMES CAN

BE REPEATED A NUMBER OF TIMES UNTIL OUT OF SHOCK

DEFICIT(Method B) 24- HR REHYDRATION Phase 1: Emergency= to one hour Plasma volume ( may be skipped if no circulation problems) Phase 2: Repletion= 6-7 hours ECF volume ( the 1st hour is usually faster to initiate urination) Phase 3: Early recovery= 16-18 hours ICF volume

FLUID MANAGEMENT OF DEHYDRATION (Method B) Step 1: Restore intravascular (plasma) volume (20 ml/kg in 20 minutes) Step 2: Calculate 24-hr water needs a. calculate maintenance b. calculate deficit Step 3: Calculate electrolyte needs a. calculate maintenance sodium/K b. calculate deficit sodium/K Step 4: Select an appropriate fluid based on water and electrolyte needs a. administer half the total calculated in Step 2 for the FIRST 8 HOURS Note: subtract first the boluses given in Step 1 b. administer the remaining in 16 hours Step 5: Replace ongoing losses as they occur

CASE EXERCISE: 1. 11-month old child, wt.= 8 kg, assessed to be moderately

dehydrated. No signs of circulation problem. Calculate: Total deficit fluid volume and the allocation of

volumes per unit time (hr) Calculate the normal maintenance after rehydration 2. Assume ongoing abnormal losses (one episode of

vomiting, 2 episodes of diarrhea.) How do you replace?

CASE Method A total deficit: 8 x 90 ml = 720 ml of 720 for the 1st hour= 180 ml per hour of 720 for next 5 hrs= 540/5= 108 ml per hour replacement of ongoing losses NOT DONE during deficit phase. Once hydrated if there are losses: 10mlx8x2= 160 ml ( diarrhea) 2x8x1= 16 ml (vomiting)

CASE

HOW TO REPLACE ONGOING LOSSES 1 WHAT FLUID/HOW A ORS= by sips, teaspoon, dropper B IV fluid= fast drip separate

from the deficit fluid volume 2 HOW much: A volume for volume B Estimate

CASE METHOD B Step 2: Calculate 24-hr water needs a. calculate maintenance b. calculate deficit Ans 8 X 100 = 800 ml/24 hrs 8 X 90 = 720 ml 2 Step 4: Select an appropriate fluid based on water and electrolyte needs a. administer half the total calculated in Step 2 for the FIRST 8 HOURS Note: subtract first the boluses given in Step 1 b. administer the remaining in 16 hours Ans: 800+ 720= 1520 ml 1520/ 2= 760 760/8 = 95 ml per hour 1st 8 hours 760/16= 48 ml per hour next 16 hours

CASE

TO REPLACE LOSSES USING METHOD B

1 Replace the losses as soon as lost AT ANYTIME DURING THE 24 HR FLUID PLAN

2 VOLUME FOR VOLUME OR ESTIMATE 3 ORS OR IVFLUID

ELECTROLYTE

Calculation of electrolyte maintenance and deficit:

1. Maintenance Sodium: 2-3 meq/kg/24 hrs Potassium: 1-2 meq/kg/24 hrs 2. Deficit Sodium: Water deficit x 80 meq/L Potassium: Water deficit x 30 meq/L

CASE 11 month old, 8 kg Step 3: Calculate electrolyte needs a. calculate maintenance sodium/K b. calculate deficit sodium/K Maintenance Na:3meq x 8= 24 meq K: 2 meq x 8= 16 meq Deficit Na: 0.720 L x 80meq/L= 57 meq (56.6) K: 0.720 Lx 30 meq/L= 22 meq (21.6)

IONIC COMPOSITION OF INTRAVENOUS INFUSION SOLUTIONS

Solution

Cation- mmol/L

Anion- mmol/L

Na+

K+

Cl-

Lactate

Glucose

Ringers Lactate D5 LR Dhaka soln Half-strength Darrow soln In D5W Normal saline (0.9% Nacl) Normosol M In D5W

130 130 133 61 154 40

4 4 13 17 0 13

109 109 98 51 154 40

28 28 48 27 0 16 (acetate)

0 278 140 278 278 234

FLUID THERAPY Osmolality disturbance 1. Isotonic dehydration a. serum sodium = 135-140 meq/L b. water and sodium proportionately lost 2. Hypotonic dehydration a. serum sodium = < 130 meq/L b. Na+ is lost MORE than water 3. Hypertonic dehydration a. serum sodium = 150 meq/L b. Na+ is lost LESS than water

FLUID THERAPY Signs of Iso, Hypo, Hypertonic DHN Isotonic Hypotonic Hypertonic SerumNa+ 135-140 < 130 150 Serum Os 280

ELECTROLYTES SODIUM 1. Hypernatremia ( 145 meq/L) Causes: Excessive sodium Water deficit Both water and sodium deficits Ref. Box 45 p 197 17th edition Clin. Manifestations: Dehydration CNS symptoms= brain hemorrhage,stroke Hyperglycemia Hypocalcemia Rapid overcorrection= cerebral edema

ELECTROLYTES SODIUM Hyponatremia(< 135 meq/L) Causes: Pseudohyponatremia Hyperosmolality Hypovolemic Euvolemic Hypervolemic Ref. Box 45-2 p 199 Clin. Manifestations: Brain sweling Rapid overcorrection: seizures

ELECTROLYTES POTASSIUM Hyperkalemia Causes: Box 45-4 p 204 Clini. Manifestations: Ecg changes= peak T wave, prolonged PR interval, flat P, widen QRS Renal failure Acidosis Hypokalemia Causes: Box 45-5 p 206 Ecg= flattened T wave, depressed ST segment, ventricular fib, muscle

weakness and cramps, polyuria, polydipsia, metabolic acidosis/alkalosis,

ELECTROLYTES CALCIUM HYPOCALCEMIA Causes: Box 45-6 p 210 Clin. Manifestations: neuromuscular irritability paresthesias tetany=carpopedal spasm, laryngospasm,

seizures, Chvostek, Trosseau Ecg= prolonged QT,prolonged ST, peaked

T waves, arrythmia, impaired cardiac contractility

ELECTROLYTE

CALCIUM Hypercalcemia Causes: Box 45-7 214 Clin. Manifestations: poor feed, emesis,

failure to thrive, psychiatric manif. pancreatitis

ELECTROLYTES

MAGNESIUM Hypomagnesemia (hypocalcemia) Causes: Box 45-9 p 218 Clin. manifestations=tetany, Chvostek,

Trosseau, seizures Hypermagnesemia Clin. Manifestations= hypotonia,

hyporeflexia, paralysis, CNS depression,

ELECTROLYTES

PHOSPORUS Hypophosphatemia Causes: Box 45-10 p 221 Clin. manifestations= acute and chronic,

rickets, poor mineralization, hemolysis of RBC, muscle weakness and atrophy, rhabdomyolysis, cardiac dysfunction, CNs

ELECTROLYTES

HYPERPHOSPHATEMIA Causes: Box 45-11 p 223 Clin. Manifestations= hypocalcemia

ACID-BASE

For further readings CAUSES: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

DIARRHEA

DIARRHEA

Def. increase in fluid loss in stool (> 100-200 ml/24 hrs) :increase in frequency of stools :blood in the stool

DIARRHEA Fluid Balance in the GIT:

ABSORPTION = SECRETION

DIARRHEA

ABNORMAL FLUID BALANCE: 1. Decreased absorption 2. Increased secretion 3. Combination of both 1 and 2

DIARRHEA Intestinal absorption of water Oral intake (1- 1 1/2 liters/day) + Saliva (11/2 liters + Gastric, pancreatic secretions (5 to 6 liters) TOTAL: 9 liters enters the small I/day

Normal fluid balance

Jejunum Ileum Colon

9 liters

Water with Na+, Cl-,K+ are absorbed (8 liters/day) HC03 is secreted

1 to 11/2 liters enters colon/day

Na+ and Cl- are absorbed K+ and HC03 are secreted

100-200 ml of fluid excreted in stool

DIARRHEA

Mechanisms of diarrhea 1. Invasion of the mucosa a. Virus= at the jejunum b. Invasive bacteria (Shigella) = at the terminal ileum (dysentery) 2. Toxin-mediated (Cholera, ETEC) a. site: jejunum

NORMAL GUT

villus

villus cells

crypt cells

brush borders

DESTROYED GUT

START OF REGENERATION

CRYPT CELLS AT VILLUS TIPS

NORMAL GUT

villus

villus cells

crypt cells

brush borders

NORMAL GUT

villus

villus cells

crypt cells

brush borders CAMP

NA+ X Cl-

DIARRHEA Gen. principles of fluid treatment As soon as diarrhea starts: 1. Maintain hydration or prevent dehydration HOW? A.Give Normal Maintenance= normal fluids B. Active replacement > home fluids > oral maintenance solutions (OMS) OMS= 30-60 Na+ meq/L = 20 K+ meq/L = glucose ORS= 60-90 Na+ meq/L 2. Treat dehydration, if No.1 fails

SODIUM GLUCOSE CO-TRANSPORT

DIARRHEA Oral Fluids for Active Replacement in Diarrhea 1. Home fluids OMS >soups >Glucolyte > fruit juice >Hydrite >water >Pedialyte >breast milk >Glucost >am (rice water) 3. ORS = Na+ is 75-90 meq/L

ORT-RECENT DEVELOPMENTS 1. REDUCED ORMOLARITY ORS 2. ZINC SUPPLEMENTATION

WHO GUIDELINES FOR A SAFE AND EFFECTIVE ORS (1992)

1. Total osmolarity: 200-311 2. Glucose: equal to sodium but not exceed

111 3. Sodium: 60-90 mmol/L 4. Potassium: 15-25 mmol/L 5. Citrate: 8-12 mmol/L 6. Chloride: 50-80 mmol/L

COMPOSITION OF STANDARD ORS: GLUCOSE 111 MMOLE/L SODIUM 90 MMOLE/L CHLORIDE 80 MMOLE/L POTASSIUM 20 MMOLE/L CITRATE 10 MMOLE/L TOTAL OSMOLARITY 311 MMOLE/L

Standard ORS: 1. WHO/UNICEF recommended 2. Glucose-based 3. Prevent/treat dehydration from diarrhea 4. Any age CONCERNS: 1. Slightly hyperosmolar to plasma 2. Does not reduce stool output 3. Does not shorten the diarrheal episode

Improved ORS 1. Safe and effective to treat dehydration or

prevent dehydration in all types of diarrhea

2. Reduced stool output

3. Other benefits

IMPROVED ORS

2 APPROACHES: 1. Reducing the osmolarity of ORS 2. Modifying the amount and type of organic

carriers to promote intestinal absorption How? 1. Replacing glucose with complex carbohydrate 2. Reducing the concentration of glucose and salt

Composition of standard and reduced osmolarity ORS solutions

Reduced Osmolarity ORS solutions

Standard ORS solution (meq/L

(mEq or mmol/L 21

mEq or mmol/L 6, 14, 22-27

(mEq or mmol/L 13, 15-18, 28-29

Glucose 111

111

75-90

75

Sodium

90

50

60-70

75

Chloride

80

40

60-70

65

Potassium

20

20

20

20

Citrate

10

30

10

10

Osmolarity 311 251 210-260 245

Reduced Osmolarity ORS 1. Reduction in the need for unscheduled

IVF therapy= by 35% 2. Reduction of stool output= by 20 % 3. Reduction in incidence of vomiting= by 30% 4. Incidence of hyponatremia is higher

REDUCED OSMOLARITY ORS MMOL/LITER SODIUM 75 CHLORIDE 65 GLUCOSE 75 POTASSIUM 20 CITRATE 10 TOTAL 245

ZINC SUPPLEMENTATION What happened to zinc during diarrhea: 1. Increased stool zinc loss 2. Negative zinc balance 3. Reduced tissue levels of zinc Role of zinc in body function? 1. Cellular growth 2. Positive effect on the immune system 3. Others

Although the theoretical basis of the potential role of zinc has been postulated for some time, convincing evidence of its importance in child health just recently has come after randomized control trials

ZINC SUPPLEMENTATION

BENEFITS 1. If given as soon as diarrhea starts: = reduce the duration, severity, risk of

dehydration 2. If continued for 14 days: = reduce the occurrence of new

episodes of diarrhea in the next 2-3 months

ZINC SUPPLEMENTATION

DOSAGE: for 14 days < 6 MONTHS: 10 MG/DAY 6 MONTHS: 20 MG/DAY

ACUTE DIARRHEA TREATMENT OF DIARRHEA OBJECTIVES : to prevent dehydration if there are no signs : to treat dehydration if it is present : to prevent nutritional damage : to reduce the duration and severity of diarrhea, and the occurrence of future episodes by giving supplemental zinc

DIARRHEA Fluids often used for active replacement of diarrhea loss Sodium Potassium Osmolality Soups 114-251 2.2-17 290-507 Juices 0.1-10 24-65 542-1190 (Gatorade) Sodas 1.7-5.5 0.1-1.5 523-601 Water 1 0.5 48-50 Coconut 5.4 32-53 255-333 Tea 0 5 B milk 7 13

ACUTE DIARRHEAS ASSESS FOR DEHYDRATION SIGNS 1.General condition=lethargy, stupor, irritability 2. Eyes= sunken, without tears 3. Mouth and tongue= dry 4. RR=rapid, maybe deep 5. Ability to drink= not able to drink, poorly, thirsty 6. Skin turgor= lost 7. Fontanelles = sunken 8. Circulation= signs of shock

ACUTE DIARRHEAS ASSESSMENT OF DEHYDRATION FF SIGNS ARE RELIABLE SIGNS TO ASSESS

DHN: 1. General condition=drowsy,lethargic, irritable 2. Eyes=sunken 3. Offer water= not able to drink, drinking poorly,

thirsty 4. Skin pinch= goes back very slowly, slowly

Assessment of diarrhea patients for dehydration

A B C Look at:Condition Eyes Thirst

Well, alert Normal Drinks normally

Restless,irritable Sunken Thirsty, drinks eagerly

Lethargic, unconscious Sunken Drinks poorly, or Not able to drink

Feel: Skin pinch Goes back quickly

Goes back slowly Goes back very slowly

Decide: No signs of dehydration

Two or more signs: Some Dehydration

Two or more signs: Severe Dehydration

ACUTE DIARRHEAS SKIN PINCH 1. pt. lying flat= mothers lap or crib 2. Pinch a fold of skin where: area of the abdomen between the umbilicus and side of abdomen how: >use forefinger and thumb, not fingertips >pinch along longitudinal/vertical axis >pinch the skin to INCLUDE the subcutaneous tissue > release the fingers THEN observe the TIME the fold returns to place = within 2 secs.(slowly) = more than 2 secs (very slowly)

ACUTE DIARRHEAS ASSESSMENT OF DEHYDRATION 1. Two of the ff. signs: Drowsy, lethargic Sunken eyes Not able to drink, drinking poorly Skin pinch goes back very slowly SEVERE DEHYDRATION

ACUTE DIARRHEAS

ASSESSMENT OF DEHYDRATION 2. Two of the ff signs: Restless, irritable Sunken eyes Thirsty, drinks eagerly Skin pinch goes back slowly SOME DEHYDRATION

ACUTE DIARRHEAS ASSESS DEHYDRATION 3. Not enough signs to classify as severe or

some dehydration NO DEHYDRATION

ACUTE DIARRHEAS

HOME TREATMENT- PRINCIPLES GOALS:to prevent dehydration :to prevent malnutrition/promote gut recovery 1. FLUIDS 2. Zinc 3. Food 4. ReFerral

ACUTE DIARRHEAS

HOME TREATMENT- PLAN A 1. FLUIDS WHAT? home fluids, breastmilk, rice water, soups, unsweetened juices, coconut water, water OMS= oral maintenance salts ORS= oral rehydration salts

ACUTE DIARRHEAS HOME TREATMENT- PLAN A 1. FLUIDS WHAT? HOW MUCH? > as much, as tolerated OR > 50-100 ml for < 2 yrs > 100-200 ml for 2 -10 yrs

ACUTE DIARRHEAS

1.FLUIDS 2.FOOD 0-6 MONTHS= breastfeeding, usual milk if

not breastfed, try relactation 6mos.-59 mos= follow feeding

recommendation for age

HOME TREATMENT- PLAN A

ACUTE DIARRHEAS HOME TREATMENT-PLAN A 1. FLUIDS 2. FOOD 3. reFERRAL when to seek help: - many watery stools, fever, uncontrolled vomiting, blood in stool, seem sicker, drinking

poorly, marked thirst 4. Zinc

ACUTE DIARRHEAS REHYDRATION TREATMENT PLAN B for SOME DEHYDRATION GOAL: to correct deficit fluid loss using ORS 1. DETERMINE AMOUNT of ORS TO GIVE IN 4 HOURS = using a table or 75 ml/k = < 6 months old, formula fed: 100-200ml of water in addition to ORS = SHOW the mother the amount to give in 4 hrs. 2. SHOW mother: how to give ORS slowly, by dropper or teaspoon,

when the child vomits; to stop ORS temporarily for 10 minutes, then resume more slowly.

3. MONITOR hydration status 4. REASSESS after 4 hours = select the appropriate Treatment Plan = feed the child

ACUTE DIARRHEAS

REHYDRATION TREATMENT PLAN B Indication for IV therapy: 1. Persistent vomiting 2. Fast purging 3. Prolonged oliguria/anuria 4. Abdominal distention 5. Glucose intolerance

DEHYDRATION WORSENS Dehydration worsens may give ORS by NGT

IV therapy

ACUTE DIARRHEAS REHYDRATION TREATMENT PLAN C 1. Determine amount of IVF(Lactated Ringers) to give

immediately: Age

First give 30 ml/kg in

Then give 70ml/k in

Infants under 12 mos.

1 hour 5 hours

Children (12 mos up)

30 min

2 1/2 hours

CASE EXERCISE An 11 month old infant, breastfed, had diarrhea

for 2 days. No other complaints. P.E.: sunken eyes, irritable, drinks normally, skin pinch goes back quickly. Other organ systems ok.

1 What is the degree of dehydration. 2 What is the diarrhea treatment plan. Describe

the details of the plan 3 After 4 hours the infant was reassessed: no longer irritable, eyes still slightly sunken. a What is the degree of dehydration now b What is the treatment plan. Describe.

FLUID AND ELECTROLYTESSCOPESCOPESCOPEFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUID COMPARTMENTSELECTROLYTESFluid BalanceICF differs considerably from ECFFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESFLUIDS AND ELECTROLYTESDaily Water Gain and LossFLUIDS AND ELECTROLYTESFLUID THERAPY FLUID THERAPYSlide Number 23Slide Number 24DAILY MAINTENANCE FLUID VOLUME MAINTENANCE FLUID VOLUME HOURLY MAINTENANCE FLUID VOLUME HOURLYSlide Number 28FLUID THERAPYFLUID THERAPYFLUID THERAPYSlide Number 32 FLUID THERAPYSlide Number 35FLUID THERAPY CASESlide Number 38Surface areaFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPYFLUID THERAPY(Method A)DEFICIT(Method B)Slide Number 53Slide Number 54Slide Number 55CASE CASEELECTROLYTESlide Number 60IONIC COMPOSITION OF INTRAVENOUS INFUSION SOLUTIONSFLUID THERAPYFLUID THERAPYELECTROLYTESELECTROLYTESELECTROLYTESELECTROLYTESELECTROLYTEELECTROLYTESELECTROLYTESELECTROLYTESACID-BASESlide Number 73Slide Number 74DIARRHEADIARRHEADIARRHEADIARRHEANormal fluid balanceDIARRHEASlide Number 81Slide Number 82Slide Number 83Slide Number 84Slide Number 85Slide Number 86DIARRHEASlide Number 88DIARRHEASlide Number 90Slide Number 91Slide Number 92Slide Number 93Slide Number 94IMPROVED ORSSlide Number 96Slide Number 97Slide Number 98Slide Number 99Slide Number 100ZINC SUPPLEMENTATIONZINC SUPPLEMENTATIONACUTE DIARRHEADIARRHEAACUTE DIARRHEASACUTE DIARRHEASSlide Number 107ACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASACUTE DIARRHEASSlide Number 120

fluids and electrolytes

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plasma fluids

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