fluids and electrolytes abnormalities: rafat mosalli md, frcpc, faap

Fluids and Electrolytes Fluids and Electrolytes abnormalities:abnormalities:

Rafat Mosalli MD, FRCPC, FAAPRafat Mosalli MD, FRCPC, FAAP

ObjectivesObjectives

What is the What is the abnormal?abnormal?

WhoWho is at risk? is at risk?

How it could present How it could present clinicallyclinically??

Why I should Bother?Why I should Bother?

What is the What is the treatmenttreatment??

Approach to Fluids &Electrolytes Approach to Fluids &Electrolytes problemsproblems

Is it a problem?Is it a problem?

What is the problem?What is the problem?

What is the cause of the problem?What is the cause of the problem?

What is the treatment of the problem?What is the treatment of the problem?

How I can prevent problem recurrences?How I can prevent problem recurrences?


Is it a problem?Is it a problem?

True vs false sampleTrue vs false sample

Know the normal neonatal levelKnow the normal neonatal level

Benefit/riskBenefit/risk

What is the problem?What is the problem?

HYPO-HYPER HYPO-HYPER

Clinical stability and neonatal courseClinical stability and neonatal course


What is the cause of the problem?What is the cause of the problem?

-Need for investigation!-Need for investigation!

What is the treatment of the problem?What is the treatment of the problem?

-Life threatening vs stable( benefit/risk)-Life threatening vs stable( benefit/risk)

How I can prevent problem recurrences?How I can prevent problem recurrences?

-Cause of the problem ,maintain treatment-Cause of the problem ,maintain treatment

-Communicate with the team-Communicate with the team

Case 1 Case 1

A term infant was born following a difficult delivery with A term infant was born following a difficult delivery with shoulder dystocia. extensive resuscitation at birth, with shoulder dystocia. extensive resuscitation at birth, with Low Apgar scores, He started to make irregular Low Apgar scores, He started to make irregular breathing efforts at 10 min, MBP 30 , serum Na 126breathing efforts at 10 min, MBP 30 , serum Na 126What is your hemodynamic assessment?What is your hemodynamic assessment?At what rate ,what type of the fluid you will start ?At what rate ,what type of the fluid you will start ?How you monitor the fluid and electrolytes balance?How you monitor the fluid and electrolytes balance?Mention three other electrolytes abnormalities that this Mention three other electrolytes abnormalities that this baby is at risk of, and your approach to treat?baby is at risk of, and your approach to treat?

Case2Case2

1h old 25 w in good condition but requiring 1h old 25 w in good condition but requiring ventilation for respiratory distress. His birth ventilation for respiratory distress. His birth weight 600g, MBP 23 weight 600g, MBP 23 What is your hemodynamic assessment?What is your hemodynamic assessment?How you would assess ,manage Fluid & How you would assess ,manage Fluid &

Humidity status?Humidity status?How you would monitor the fluid and How you would monitor the fluid and electrolytes balance?electrolytes balance?

Case3Case3

2h old ,34 w with antenataly undiagnosed 2h old ,34 w with antenataly undiagnosed Large Gastroschesis, born at the periphery Large Gastroschesis, born at the periphery ,had peripheral IV with shallow RR, CRF 5 ,had peripheral IV with shallow RR, CRF 5 sec.sec.

What is your initial assessment &action ?What is your initial assessment &action ?

At what rate of the fluid ? And what type?At what rate of the fluid ? And what type?

How you monitor the fluid and electrolytes How you monitor the fluid and electrolytes balance?balance?

Case3:Case3: Post operative Post operative

Baby had gastroschisis repair, Ladds Baby had gastroschisis repair, Ladds procedure, Had a total of 60ml/kg at the procedure, Had a total of 60ml/kg at the OR. came Intubated and ventilated? OR. came Intubated and ventilated?

What is your TFI target?What is your TFI target?

How you will monitor and manage the fluid How you will monitor and manage the fluid and electrolytes status?and electrolytes status?

Case 3: 12h Post opCase 3: 12h Post op

At 12 hours post operative , on D 10%, At 12 hours post operative , on D 10%, MBP: 29mmHg , TFI 120ml/kg/h and MBP: 29mmHg , TFI 120ml/kg/h and 30ml/kg Ns Boluses30ml/kg Ns Boluses. . Mottled lookingMottled looking

UOP 0.8ml/kg/h, serum Na 129UOP 0.8ml/kg/h, serum Na 129

What other blood investigations you will What other blood investigations you will ask?ask?

What is you clinical assessment and What is you clinical assessment and treatment approach?treatment approach?

In normal term Infants

In general, fluid management in the first few days In general, fluid management in the first few days is adjusted primarily on: urine output, serum is adjusted primarily on: urine output, serum sodium values and changes in weight.sodium values and changes in weight.

Term infants have a lower requirement for fluids Term infants have a lower requirement for fluids and caloriesand calories

After the first week Fluid volumes are high to After the first week Fluid volumes are high to ensure ensure good caloric intakegood caloric intake and growth in and growth in Term/preterm infantsTerm/preterm infants

What is the role of volume What is the role of volume expansion in the Sick term babyexpansion in the Sick term baby

More heterogeneous diseases.More heterogeneous diseases.Resuscitation, pulmonary hypertension ,and septic Resuscitation, pulmonary hypertension ,and septic shock,HIEshock,HIE..NoNo formal formal hemodynamic studieshemodynamic studies NoNo data to show whether a large amount of volume data to show whether a large amount of volume expansion is useful in this vasodilated situationexpansion is useful in this vasodilated situation NoNo data to document the data to document the physiologic responsesphysiologic responses to to volume expansion in these situations.volume expansion in these situations.NoNo data on data on clinical outcomes.clinical outcomes.

What is the role of volume What is the role of volume expansion in the Sick expansion in the Sick term babyterm baby

In severe HIEIn severe HIE : :

Pale Colour = Not Hypovolemic !Pale Colour = Not Hypovolemic !

myocardial effects of hypoxia and acidosis.myocardial effects of hypoxia and acidosis.

Only a Only a few are truly hypovolemic.few are truly hypovolemic.

Reasonable to give 10 ml/kg volume, If there is Reasonable to give 10 ml/kg volume, If there is no physiologicno physiologic response to volume further response to volume further volume expansion should be approached with volume expansion should be approached with caution!.caution!.

1-HIE : fluid & electrolytes issues1-HIE : fluid & electrolytes issues

Oligo / anuria.Oligo / anuria.

Hpo Natremia/ Calcemia/ MagnesemiaHpo Natremia/ Calcemia/ Magnesemia

HyperkalemiaHyperkalemia

Hypo/hyperglycemiaHypo/hyperglycemia

AcidosisAcidosis

HIE :fluid & electrolytes issuesHIE :fluid & electrolytes issues

At the resuscitationAt the resuscitation

Volume expanders? Volume expanders? RarelyRarely indicated indicated

Post resuscitation treatment:Post resuscitation treatment:

- Oligo / anuria : (pre-renal-post)- Oligo / anuria : (pre-renal-post)

must check: Echo, BP, serum ,urine Na & must check: Echo, BP, serum ,urine Na & osmolality, renal function.osmolality, renal function.

HIE fluid &Na pathophysiology:HIE fluid &Na pathophysiology:

--Prerenal +/- parenchymal injury (less Prerenal +/- parenchymal injury (less common):common):

-myocardial failure (common) -myocardial failure (common) -Volume depletion (uncommon)-Volume depletion (uncommon)RxRx Fluid challenge vs inotropes +/- steroid Fluid challenge vs inotropes +/- steroid--Renal Renal (most common(most common):):-Fluid restriction, renal failure protocol +/- -Fluid restriction, renal failure protocol +/-

inotropes/steroid (if hypotension coexist)inotropes/steroid (if hypotension coexist)- - Postrenal (rare)Postrenal (rare)Urinary catheter….Urinary catheter….

HIE &other electrolytes issueHIE &other electrolytes issue

Must Maintain NormalMust Maintain Normal

Glucose , ca++, Mg, K+Glucose , ca++, Mg, K+

2-Fluid balance in preterm 2-Fluid balance in preterm infantsinfants

Where are we now?Where are we now?

The fluid &Na management of preterm The fluid &Na management of preterm infants continue to be controversial topic. !!infants continue to be controversial topic. !!

whether babies should be given high fluidwhether babies should be given high fluid

volumes to aid nutrition, or should they be volumes to aid nutrition, or should they be fluid restricted to try to reduce the fluid restricted to try to reduce the incidence of BPD,PDA and NEC.incidence of BPD,PDA and NEC.

--Na balanceNa balance :High or Low ,early or late ? :High or Low ,early or late ?

First few days: Restrict or generous First few days: Restrict or generous what is the evidence?what is the evidence?

There is evidence that restricting There is evidence that restricting fluidfluid volumes in volumes in pretermpreterm infants in the first few infants in the first few days of life reduces the incidence of days of life reduces the incidence of PDA,PDA, NECNEC, and may decrease , and may decrease mortality ratesmortality rates..

Restricting Restricting sodiumsodium intake in preterm intake in preterm infants in the first few days may also infants in the first few days may also reduce the incidence of reduce the incidence of BPDBPD

Restrict or generous: Restrict or generous: when?when?

Fluid restrictionFluid restriction :asphyxia, renal impairment or PDA. :asphyxia, renal impairment or PDA. Higher fluid intakesHigher fluid intakes :Infants receiving phototherapy!, or :Infants receiving phototherapy!, or with high insensible losses. with high insensible losses. In general, fluid management in the first few days is In general, fluid management in the first few days is adjusted grossly on serum sodium values and changes adjusted grossly on serum sodium values and changes in weight. in weight. – High serum sodiumHigh serum sodium values usually indicate that the infant values usually indicate that the infant

requires more fluid. requires more fluid. – Low serum sodium values may indicate that the infant requires Low serum sodium values may indicate that the infant requires

less fluid, or that the infant has high sodium losses. less fluid, or that the infant has high sodium losses.

The main determinants of Fluid The main determinants of Fluid management in pretermmanagement in preterm ::

(1) an estimation of (1) an estimation of trans-epidermal water trans-epidermal water losseslosses

(2) an awareness of (2) an awareness of GFRGFR and how this is and how this is influenced by influenced by ageage, respiratory distress and , respiratory distress and medical interventionmedical intervention

(3) knowledge of (3) knowledge of tubular functiontubular function &maturation. &maturation.

This This knowledgeknowledge and appropriate and appropriate monitoringmonitoring are the are the mainstay of management of neonatal fluid mainstay of management of neonatal fluid balancebalance

1-GFR1-GFR

low in utero, but increases rapidly in the low in utero, but increases rapidly in the few hours immediately after delivery.few hours immediately after delivery.Not influenced by postnatal age once Not influenced by postnatal age once completed period of postnatal adaptation completed period of postnatal adaptation &given minimum water intake for IWL&given minimum water intake for IWLCompromisedCompromised by a by a PDAPDA & & mechanical mechanical ventilationventilation, (increasing by 15% after, (increasing by 15% after

Extubation)Extubation)

2-Renal tubualr function2-Renal tubualr function

After delivery AllAfter delivery All babies undergo a diuresis babies undergo a diuresis &natriuresis, triggered by ANP &natriuresis, triggered by ANP contraction of the ECF volume. contraction of the ECF volume.

Initial negative sodium balance, followed Initial negative sodium balance, followed by retaining sodium for growth.by retaining sodium for growth.

OverallOverall: Preterm infants have a limited : Preterm infants have a limited ability to excrete & retain Na as effectively ability to excrete & retain Na as effectively as Termas Term

3-Transepidermal water loss3-Transepidermal water loss

Humidity &IWLHumidity &IWL

3-Transepidermal water loss

Greatest in most preterm infants, Greatest in most preterm infants,

as much as as much as 15 15 times higher in infants at 25 times higher in infants at 25 weeks than in the term infants, and weeks than in the term infants, and remains significant till remains significant till 44 weeks after. weeks after.

TEWL can be substantially reducedTEWL can be substantially reduced

Maximum ambient humidity?Maximum ambient humidity?

Routine humidification of inspired gases.Routine humidification of inspired gases.

Skin care &Topical agents.Skin care &Topical agents.

Humidity protocolHumidity protocol

Ambient humidity is to be maintained at Ambient humidity is to be maintained at 85%85% for for first first 7D7D

Gradually reduce humidity and ambient Gradually reduce humidity and ambient temperature as tolerated. Humidity should temperature as tolerated. Humidity should remain at least 70-75% during first remain at least 70-75% during first 3 3 weeks of weeks of lifelife..

At At 21 days21 days (if temperature is stable) slowly (if temperature is stable) slowly reduce humidity to 60% and leave till infant reduce humidity to 60% and leave till infant reaches 1500grammes.reaches 1500grammes.

The main determinants of Fluid The main determinants of Fluid management in preterm management in preterm ::

(1) an estimation of (1) an estimation of trans-epidermal water trans-epidermal water losseslosses

(2) an awareness of (2) an awareness of GFRGFR and how this is and how this is influenced by influenced by ageage, respiratory distress and , respiratory distress and medical interventionmedical intervention

(3) knowledge of (3) knowledge of tubular functiontubular function &maturation. &maturation.

This This knowledgeknowledge and appropriate and appropriate monitoringmonitoring are the are the mainstay of management of neonatal fluid mainstay of management of neonatal fluid balancebalance

II- Monitoring fluid balanceII- Monitoring fluid balance

3-RDS: fluid & electrolytes issues3-RDS: fluid & electrolytes issues

Delayed diuresisDelayed diuresis low Na low Na

Delayed diuresis Delayed diuresis chronic lung disease. chronic lung disease.

Restrict sodium intake until diuresis.Restrict sodium intake until diuresis.

4-Post surgical and abdominal wall 4-Post surgical and abdominal wall defectdefect

Preload &SIRS (third spacing)Preload &SIRS (third spacing)SIADHSIADHIWLIWLSalinuresis.Salinuresis.

Check: in-out ,Lactate, Na,Cr., osm. And urine Na Check: in-out ,Lactate, Na,Cr., osm. And urine Na &osmolality, acid base balance&osmolality, acid base balance

RxRx Cause & type of surgery Cause & type of surgery Colloid vs crystalloids ?Colloid vs crystalloids ? Avoid Hypotonic solutionAvoid Hypotonic solution

More facts in neonatesMore facts in neonates

Hypotension = HypovolumiaHypotension = HypovolumiaThe mechanism of hypotension is different The mechanism of hypotension is different Blood pressure and blood flow are not the same Blood pressure and blood flow are not the same thingthing

BP response to fluid is inconsistent, neither BP response to fluid is inconsistent, neither sustained sustained Neither pH nor base excess are good markers of Neither pH nor base excess are good markers of circulatory compromise & no study showed any circulatory compromise & no study showed any correlation with measures of SBFcorrelation with measures of SBF

How much Bolus volume?How much Bolus volume?

The benefits of giving more than The benefits of giving more than 20 ml/kg20 ml/kg in any but the most obvious hypovolemic in any but the most obvious hypovolemic situations must be questioned!! situations must be questioned!!

the ‘Michelin Man’ appearance of many of the ‘Michelin Man’ appearance of many of these babies the day after repeated these babies the day after repeated volume infusions would suggest that the volume infusions would suggest that the fluid is not staying long in the vascular fluid is not staying long in the vascular compartmentcompartment

crystalloid or colloid

There is insufficient evidence to make firmThere is insufficient evidence to make firmrecommendations recommendations No comparative data on the effects on blood No comparative data on the effects on blood

flow or important clinical outcomes.flow or important clinical outcomes.Use Use Normal salineNormal saline for circulatory support: for circulatory support:

cheaper, it is not a blood product andcheaper, it is not a blood product andLack of evidence of any advantage form usingLack of evidence of any advantage form usingcolloid.colloid.

Future research in this area needs Future research in this area needs toto

Focus on more accurate ways to Focus on more accurate ways to diagnose diagnose hypovolemiahypovolemia

whether volume expansion used for circulatory whether volume expansion used for circulatory support produces support produces sustained hemodynamicsustained hemodynamic improvement (not just improved bloodimprovement (not just improved blood

pressure) and whether it improves pressure) and whether it improves clinical clinical outcomesoutcomes..

Back to our casesBack to our cases

Case 1Case 1 25 w premature 25 w premature

Case 2Case 2severe HIEsevere HIE

Case3Case3 gastroschesis gastroschesis

Case 4Case 4

12 h old Term with Meconium aspiration 12 h old Term with Meconium aspiration on CMV ,had 2 boluses of NS and TFI on CMV ,had 2 boluses of NS and TFI 80kg/d serum Na 128.80kg/d serum Na 128.

What is your clinical approach and likely What is your clinical approach and likely diagnosis?diagnosis?

Hyponatraemia

Serum Na+ <130 Serum Na+ <130

1-Inadequate Na+ intake. 1-Inadequate Na+ intake.

2-Excessive water.2-Excessive water. – IndomethacinIndomethacin– Reduces free water clearance and Reduces free water clearance and

fractional excretion of sodium, with the fractional excretion of sodium, with the lower free water clearance lower free water clearance

– SIADHSIADH

Hyponatraemiacauses

3-Na Loss:3-Na Loss:Renal:Renal:

-Prematurity-PrematurityRenal Na+ loss from a high fractional excretion of Na+.Renal Na+ loss from a high fractional excretion of Na+.

- Diuretic therapy ( loop diuretics)- Diuretic therapy ( loop diuretics)-Acute tubular necrosis (tubular Na+ loss) and -Acute tubular necrosis (tubular Na+ loss) and

other causes of renal failure. other causes of renal failure. GIT & other:GIT & other:

Diarrhoea, Gastric, pleural, CSF, 17OH Diarrhoea, Gastric, pleural, CSF, 17OH progesterone deficiencyprogesterone deficiency

InvestigationInvestigation

Repeat the sample. Repeat the sample.

Urinary Na+ ( sodium replacement )Urinary Na+ ( sodium replacement )

Serum and urine osmolality.Serum and urine osmolality.

Hyponatraemia

Reduce the water (fluid) intakeReduce the water (fluid) intake. .

Sodium supplementsSodium supplements

IV/OralIV/Oral : :

(1ml Po NaCl = 2mmol NaCl). (1ml Po NaCl = 2mmol NaCl).

Usually start at 3mmol/kg/day additional NaCl. Usually start at 3mmol/kg/day additional NaCl.

Occasional infants will require ≥12mmol/kg/day Occasional infants will require ≥12mmol/kg/day

--

Case 5Case 5

15 h old 25w Preterm with HMD on CMV15 h old 25w Preterm with HMD on CMV

Serum Na 155. UOP 5ml/kg/h TFI 80ml/kgSerum Na 155. UOP 5ml/kg/h TFI 80ml/kg

What is your assessment and treatment What is your assessment and treatment approach?approach?

Hypernatraemia

Na+ >150mmol/L. Na+ >150mmol/L. Excessive water loss.Excessive water loss. Very preterm esp. insensible water loss. Very preterm esp. insensible water loss. Urinary, GIT lossUrinary, GIT lossExcess Na+ intakeExcess Na+ intake.. Relatively common with sodium bicarbonate infusions. Relatively common with sodium bicarbonate infusions. infusions may contain large quantities of sodium. (e.g.; infusions may contain large quantities of sodium. (e.g.; arterial line containing 0.9% NaCl and running at arterial line containing 0.9% NaCl and running at 1ml/hour will give 3.6 mmol/day of NaCl )1ml/hour will give 3.6 mmol/day of NaCl )

HypernatraemiaTreatment

Increase Increase Fluid intakeFluid intake. .

Reduce Na+ intake Reduce Na+ intake

Case 6:Cardiac monitorCase 6:Cardiac monitor

- - 48 hours Infants born < 27 weeks’ 48 hours Infants born < 27 weeks’ gestation, serum K is 7.8mEq/L , What is gestation, serum K is 7.8mEq/L , What is this rhythm? What is your immediate this rhythm? What is your immediate treatmenttreatment

HperkalemiaHperkalemia

Case 6-b:Case 6-b:

48 hours Infants born < 27 weeks’ 48 hours Infants born < 27 weeks’ gestation, capillary sample K is 8.8mEq/Lgestation, capillary sample K is 8.8mEq/L

Baby looks stable ,EKG is normal?Baby looks stable ,EKG is normal?

What is your treatment?What is your treatment?


What is the level?What is the level? >6.7mEq/L . >6.7mEq/L .

Why I bother?Why I bother?

Hyperkalaemia is a potentially life-Hyperkalaemia is a potentially life-threatening condition.threatening condition.


WHO IS AT RISK?WHO IS AT RISK?Extreme Prematurity (< 27 weeks’ gestation)Extreme Prematurity (< 27 weeks’ gestation) Acute renal failure (most commonly perinatal Acute renal failure (most commonly perinatal asphyxia) asphyxia) Chronic renal failure – multiple causes Chronic renal failure – multiple causes Haemolysis (eg incompatible blood transfusion) Haemolysis (eg incompatible blood transfusion) Double volume transfusion / use of ‘old blood’ Double volume transfusion / use of ‘old blood’ (K+ rises after 4 days in stored blood) .(K+ rises after 4 days in stored blood) .Sepsis .Sepsis .

Hyperkalemia ConsequencesHyperkalemia Consequences

Usually minimal, +/- arrythmiasUsually minimal, +/- arrythmias

EKGEKG: Tall peaked T waves, ventricular : Tall peaked T waves, ventricular arrhythmias, widening of QRS then sine wave arrhythmias, widening of QRS then sine wave QRS complex (before cardiac arrest). QRS complex (before cardiac arrest).

Reported mortality of infants with hyperkalaemia Reported mortality of infants with hyperkalaemia (K+ > 7.0 mmol/L) has ranged from 17-30% (K+ > 7.0 mmol/L) has ranged from 17-30% despite appropriate treatment.despite appropriate treatment.

ECG changes :HyperkalemiaECG changes :Hyperkalemia

tall peaked T waves, ventricular tall peaked T waves, ventricular arrhythmias, widening of QRS, then sine arrhythmias, widening of QRS, then sine wave QRS complex (before cardiac wave QRS complex (before cardiac arrest). arrest).

Haemolysis commonly occurs in blood Haemolysis commonly occurs in blood collected by heel-prick and this results in collected by heel-prick and this results in falsely high serum potassium .falsely high serum potassium .

What are the available What are the available treatments?treatments?

1- Antagonism of membrane actions of 1- Antagonism of membrane actions of potassiumpotassiumCalcium gluconate.Calcium gluconate.2-Shift potassium intracellularly2-Shift potassium intracellularly-Insulin infusion, supply glucose-Insulin infusion, supply glucose-Salbutamol infusion.-Salbutamol infusion.-Sodium Bicarbonate .-Sodium Bicarbonate .3-Removal of potassium from the body3-Removal of potassium from the bodyNon of the above studied rigorously or proven to Non of the above studied rigorously or proven to be effective! neither superior than the other.be effective! neither superior than the other.


Key PointsKey Points

Avoid potassium in all infusions in the first Avoid potassium in all infusions in the first day of life in infants born prematurelyday of life in infants born prematurely

Monitor the serum potassium 8-12 hourly for the Monitor the serum potassium 8-12 hourly for the 1st 48 hours of infants born < 27 weeks’ 1st 48 hours of infants born < 27 weeks’ gestation gestation

Insulin/dextrose and Salbutamol are effective.Insulin/dextrose and Salbutamol are effective.

Back to the casesBack to the cases

Case 6:Case 6:

48 hours Infants born < 27 weeks’ gestation, 48 hours Infants born < 27 weeks’ gestation, serum K is 7.8mEq/L , what I should do?serum K is 7.8mEq/L , what I should do?

Case 6-b:Case 6-b:

48 hours Infants born < 27 weeks’ gestation, 48 hours Infants born < 27 weeks’ gestation, capillary sample K is 8.8mEq/Lcapillary sample K is 8.8mEq/L

Baby looks stable ,EKG is normal?Baby looks stable ,EKG is normal?

What is your treatment?What is your treatment?

Case 6 :TreatmentCase 6 :Treatment

RemoveRemove K from IV (i.e. hang 10% dextrose with K from IV (i.e. hang 10% dextrose with Na+) Na+) 10% Calcium gluconate10% Calcium gluconate :0.5ml/kg IV :0.5ml/kg IV (0.1mmol/kg) (0.1mmol/kg) Sodium bicarbonateSodium bicarbonate: 2mmols/kg IV given over 30 : 2mmols/kg IV given over 30 minutes. minutes. IV dextrose so blood glucose >12mmol/L.IV dextrose so blood glucose >12mmol/L.withwith Insulin Insulin 0.3 unit/gram of glucose. 0.3 unit/gram of glucose.

SalbutamolSalbutamol :4micrograms/kg IV over 10 minutes . :4micrograms/kg IV over 10 minutes . May be repeated after 2 hours. May be repeated after 2 hours. Peritoneal dialysisPeritoneal dialysis

Case 7Case 7

-Day 1 Postoperative Bowel resection due -Day 1 Postoperative Bowel resection due to mid gut Volvolus with stomato mid gut Volvolus with stoma

K= 2.5 mmol/LK= 2.5 mmol/L

- - Case 7-b:Case 7-b:

25w preterm (36w CGA) , BPD25w preterm (36w CGA) , BPD

K+ = 3.2mmol/LK+ = 3.2mmol/L

What is the cause and treatment if any?What is the cause and treatment if any?

Hypokalaemia

K+ <3.5mmol/LK+ <3.5mmol/LInadequate intakeInadequate intake Distributional:Distributional:Alkalosis (sodium bicarbonate infusions, over-Alkalosis (sodium bicarbonate infusions, over-ventilation, or loss of acid from gastric secretions) ventilation, or loss of acid from gastric secretions) Losses:Losses:Renal causesRenal causes GIT loss ( NGT, postop, short gut) GIT loss ( NGT, postop, short gut) MedicationsMedications (including diuretic therapy, sodium (including diuretic therapy, sodium bicarbonate infusions, salbutamol, and insulin bicarbonate infusions, salbutamol, and insulin

Hypokalaemia: treatment

Cause and the severity of the hypokalaemia ?Cause and the severity of the hypokalaemia ?

Oral potassium supplementsOral potassium supplements

2 Molar KCl supplements (1ml = 2mmol KCl). 2 Molar KCl supplements (1ml = 2mmol KCl).

start at 2mmol/kg/daystart at 2mmol/kg/day

Monitor the serum K+ carefully and adjust dose Monitor the serum K+ carefully and adjust dose accordingly. accordingly.

Intravenous potassium infusionIntravenous potassium infusion

IV cautionIV caution

Administer IV Administer IV slowly,slowly, maximum infusion rate, maximum infusion rate, 0.5-1mmol/kg/hour. 0.5-1mmol/kg/hour. Monitor K /4h-8h. Monitor K /4h-8h. DiluteDilute potassium before intravenous potassium before intravenous administration. The literature recommends administration. The literature recommends dilution to 40mmol/L, i.e, 1mmol/25ml. As this dilution to 40mmol/L, i.e, 1mmol/25ml. As this may cause volume overload dilute to may cause volume overload dilute to 1mmol/12.5ml and piggyback with IV fluids to 1mmol/12.5ml and piggyback with IV fluids to achieve further dilution. achieve further dilution. Adequate Adequate renal functionrenal function must be confirmed. must be confirmed.

IV IV Adverse Effects

Venous irritationVenous irritation, pain, soft tissue injury at the , pain, soft tissue injury at the injection site. injection site. Gastrointestinal disturbances common Gastrointestinal disturbances common (diarrhoea, vomiting, bleeding, abdominal (diarrhoea, vomiting, bleeding, abdominal discomfort). discomfort). Hyperkalaemia, indicated by weakness, Hyperkalaemia, indicated by weakness, listlessness, flaccid paralysis, hypotension, listlessness, flaccid paralysis, hypotension, cardiac arrhythmias including heart block and cardiac arrhythmias including heart block and cardiac arrest cardiac arrest Altered sensitivity to digoxinAltered sensitivity to digoxin

Case 7Case 7

2 days old premature baby with Ca level 1.7 2 days old premature baby with Ca level 1.7 mmol/l asymptomatic. mmol/l asymptomatic.

Case7-b:Case7-b:

A 14 days ,full term infant with Ca 1.0 and A 14 days ,full term infant with Ca 1.0 and seizuresseizures

What is your assessment ?What is your assessment ?

HypocalcemiaHypocalcemia

What is the level? What is the level? <1.75mmol/L(7.0mg/dl) <1.75mmol/L(7.0mg/dl)

ionized Ca ++ ionized Ca ++ < 1mmol/L< 1mmol/LWhat is the manifestation?What is the manifestation?

asymptomatic or non specific, Jitteriness asymptomatic or non specific, Jitteriness and seziures.(most common).and seziures.(most common).

High pitch cry, laryngospasm, Chvostek’s High pitch cry, laryngospasm, Chvostek’s sign, Trousseau’s sign…sign, Trousseau’s sign…

Hypcalcemia: causesHypcalcemia: causes

Early (first 3 days):Early (first 3 days):

1-Premature infants.1-Premature infants.

2-Birth asphyxia.2-Birth asphyxia.

3-Infant of diabetic mothers.3-Infant of diabetic mothers.

4-Maternal Hyperparathyroidism.4-Maternal Hyperparathyroidism.

5-Congenital parathyroid absence.5-Congenital parathyroid absence.


Late (after end of first week)Late (after end of first week)

1-High phosphate cow” milk formula.1-High phosphate cow” milk formula.

2-Intesinal malabsorbtion.2-Intesinal malabsorbtion.

3-Hypoparathyrodism.3-Hypoparathyrodism.

4-Hypomagnesemia.4-Hypomagnesemia.

5-Rickets.5-Rickets.


Decreased ionized fraction of calciumDecreased ionized fraction of calcium

Intralipid.Intralipid.

Alkalosis.Alkalosis.

Citrate (exchange transfusion)Citrate (exchange transfusion)


When I should intervene?When I should intervene?

-Symptomatic or seizure +/- < 1.5 mmol/L : -Symptomatic or seizure +/- < 1.5 mmol/L :

Maintain Ca level to achieve 75mg Maintain Ca level to achieve 75mg elemental Ca /Kg/d. elemental Ca /Kg/d.

follow up every 8 hours. follow up every 8 hours.

Try to avoid IV& avoid bolus.!Try to avoid IV& avoid bolus.!


What I should give?What I should give?

10% Calcium gluconate (1gm/10ml)10% Calcium gluconate (1gm/10ml)

IV 200mg/kg/d.IV 200mg/kg/d.

Bolus 50-100 mg/kg/dose (5-10mg/kg of Bolus 50-100 mg/kg/dose (5-10mg/kg of elemental Ca) =0.5-1ml/kg/dose .elemental Ca) =0.5-1ml/kg/dose .

Maintenance dose is 1 mmol/kg/day ( 1ml Maintenance dose is 1 mmol/kg/day ( 1ml of 10 % = 0.23mmol/Ca++)of 10 % = 0.23mmol/Ca++)


Be aware of IV Ca complicationsBe aware of IV Ca complications!!

Cardiac arrhythmia.Cardiac arrhythmia.

Skin ulceration , Burn.Skin ulceration , Burn.

Block the normal physiological adaptation Block the normal physiological adaptation in asymptomatic premature infant.in asymptomatic premature infant.

Back to the CasesBack to the Cases

Case1Case1

2 days old premature baby with Ca level 2 days old premature baby with Ca level 1.7 mmol/l a symptomatic. what should I 1.7 mmol/l a symptomatic. what should I do?do?

Case2:Case2:

A 14 days ,full term infant with Ca 1.0 and A 14 days ,full term infant with Ca 1.0 and seizures, what should I do?seizures, what should I do?

HypomagnesemiaHypomagnesemia

second most abundant intracellular second most abundant intracellular cation.cation.

Regulate cellular metabolism.Regulate cellular metabolism.

1 % extracellular conc. Is critical for 1 % extracellular conc. Is critical for muscle and nerve electrical potentials, and muscle and nerve electrical potentials, and for the impulse transmission across NMJ for the impulse transmission across NMJ (synergistically with Ca).(synergistically with Ca).

Regulated by PTH.Regulated by PTH.


What is the level?What is the level? <1.5mg/dl, sign <1.2 mg/dl<1.5mg/dl, sign <1.2 mg/dl

What is the causes?What is the causes?

Maternal diabetes.Maternal diabetes.

Maternal deficiency.Maternal deficiency.

Prematurity,IUGR.Prematurity,IUGR.

Renal loss (Acidosis, Tubular defect)Renal loss (Acidosis, Tubular defect)

GIT loss (NGT,Emesis,Diarrhea) GIT loss (NGT,Emesis,Diarrhea)


What is the clinical pictures?What is the clinical pictures?

Rarely symptomatic. Rarely symptomatic.

Non specificsNon specifics

sign of hypocalcemia!sign of hypocalcemia!

fluids and electrolytes abnormalities: rafat mosalli md, frcpc, faap

Documents