4. Volume DepletionVolume Depletion
Loss of isotonic fluid from the extracellular fluidLoss of isotonic fluid from the extracellular fluid
at a rate exceeding net intake.at a rate exceeding net intake.
Can occur through:Can occur through:
gastrointestinal tract (vomiting, diarrhea, bleeding)gastrointestinal tract (vomiting, diarrhea, bleeding)
skin (sweat, burns)skin (sweat, burns)
lungs (bronchorrhea, pleural effusion, evaporation)lungs (bronchorrhea, pleural effusion, evaporation)
urine (diuretics, osmotic diuresis, salt wastingurine (diuretics, osmotic diuresis, salt wasting
nephropathies, andnephropathies, and
hypoaldosteronism)hypoaldosteronism)
acute sequestration in the body in a "third space" thatacute sequestration in the body in a "third space" that
is not in equilibrium with the extracellular fluid (GIis not in equilibrium with the extracellular fluid (GI
5. History and Symptoms of VolumeHistory and Symptoms of Volume
DepletionDepletion
HistoryHistory
vomiting, diarrhea, diuretic use, or polyuriavomiting, diarrhea, diuretic use, or polyuria
(may identify the source of fluid loss)(may identify the source of fluid loss)
SymptomsSymptoms
lethargy, easy fatiguability, thirst, muscle cramps, andlethargy, easy fatiguability, thirst, muscle cramps, and
postural dizziness (volume depletion)postural dizziness (volume depletion)
Generalized weakness, irritability, maybe twitching,Generalized weakness, irritability, maybe twitching,
seizures (if also severely hyponatremic)seizures (if also severely hyponatremic)
muscle weakness, polyuria, polydipsia, confusionmuscle weakness, polyuria, polydipsia, confusion
(from concomitant electrolyte and acid-base disorders)(from concomitant electrolyte and acid-base disorders)
6. PEx findings in HypovolemiaPEx findings in Hypovolemia
BP, HR, and JVDBP, HR, and JVD
BP drops in upright positionBP drops in upright position
‘‘orthostatic hypotension’ – after two to five minutes of quietorthostatic hypotension’ – after two to five minutes of quiet
standing, one or more of the following is present:standing, one or more of the following is present:
At least a 20 mmHg fall in systolic pressureAt least a 20 mmHg fall in systolic pressure
At least a 10 mmHg fall in diastolic pressureAt least a 10 mmHg fall in diastolic pressure
Symptoms of cerebral hypoperfusion (dizziness)Symptoms of cerebral hypoperfusion (dizziness)
HR increase by more than 10-20 bpmHR increase by more than 10-20 bpm
Decreased JVDDecreased JVD
SkinSkin
Increased pigmentation, decreased turgor, dry axillaIncreased pigmentation, decreased turgor, dry axilla
Mucous membranesMucous membranes
Tongue and oral mucosa dryTongue and oral mucosa dry
7. Laboratory StudiesLaboratory Studies
UrineUrine
urinalysis can be normalurinalysis can be normal
sodium concentration < 25 meq/L and may be as low as 1sodium concentration < 25 meq/L and may be as low as 1
meq/Lmeq/L
chloride concentration lowchloride concentration low
osmolality >450 mosmol/kgosmolality >450 mosmol/kg
specific gravity > 1.015specific gravity > 1.015
oliguriaoliguria
BloodBlood
Elevated serum sodium = dehydrationElevated serum sodium = dehydration
If [Na] WNL then pt not dehyrated but hypovolemicIf [Na] WNL then pt not dehyrated but hypovolemic
Elevated BUN/plasma creatinine levelElevated BUN/plasma creatinine level
HCT (relative polycythemia) and plasma albumin levelHCT (relative polycythemia) and plasma albumin level
increasesincreases
8. Replacement TherapyReplacement Therapy
IVF BolusIVF Bolus
5cc/kg over 20 minutes5cc/kg over 20 minutes
Usually rounded to 500cc for adults and extended toUsually rounded to 500cc for adults and extended to
30 minutes30 minutes
Normal Saline (isotonic) bestNormal Saline (isotonic) best
Ringers lactate (has bicarb) if >4 liters will be givenRingers lactate (has bicarb) if >4 liters will be given
This prevents development of metabolic acidosisThis prevents development of metabolic acidosis
IV CathetersIV Catheters
18 gauge best18 gauge best
9. Replacement Therapy PrecautionsReplacement Therapy Precautions
Excess NS can cause pulmonary edema in someExcess NS can cause pulmonary edema in some
pts:pts:
Elderly pts with hx of CHFElderly pts with hx of CHF
Pts with known severe VHDPts with known severe VHD
Renal failure ptsRenal failure pts
In these pts use 3cc/kg over 30 minutes forIn these pts use 3cc/kg over 30 minutes for
boluses and listen to lungs often, measure SaO2boluses and listen to lungs often, measure SaO2
if possibleif possible
10. ……
When have you given enough IVF?When have you given enough IVF?
Recheck orthostatic pressuresRecheck orthostatic pressures
If still orthostatic?If still orthostatic?
Rebolus, repeat cycle until asymptomatic, makingRebolus, repeat cycle until asymptomatic, making
urine, mucous membranes moisturine, mucous membranes moist
20. Hypokalemia: treatmentHypokalemia: treatment
Determine the causeDetermine the cause
When to correct?When to correct?
How much?How much?
0.5-1 mEq/kg over 1 hour0.5-1 mEq/kg over 1 hour
What to use?What to use?
KCl po or IVKCl po or IV
21. Hypokalemia : treatmentHypokalemia : treatment
Mild loss, K+ between 3.0 and 3.5 meq/LMild loss, K+ between 3.0 and 3.5 meq/L
usually produces no symptomsusually produces no symptoms
replace lost K+ and treat underlying disorder (such asreplace lost K+ and treat underlying disorder (such as
vomiting, diarrhea)vomiting, diarrhea)
treatment is usually started with 10 to 20 meq oftreatment is usually started with 10 to 20 meq of
potassium chloridepotassium chloride given two to four times per day (20 to 80given two to four times per day (20 to 80
meq per day), depending on the severity of hypokalemia andmeq per day), depending on the severity of hypokalemia and
on whether hypokalemia developed acutely or is chronicon whether hypokalemia developed acutely or is chronic
sequential monitoring of plasma K+ is essential to determinesequential monitoring of plasma K+ is essential to determine
continued requirements, with frequency of monitoringcontinued requirements, with frequency of monitoring
dependent on the severity of hypokalemiadependent on the severity of hypokalemia
28. Hyperkalemia:
T wave in hyperkalemia is typically
tall and narrow,
but does not have to be tall
(may be just narrow and
peaked pulling ST segment).
Tall T means > 2 big boxes in
the precordial leads or >1
small box in limb leads,
or T wave taller than QRS.
32. Hyperkalemia: TreatmentHyperkalemia: Treatment
Calcium gluconateCalcium gluconate
100mg/kg IV peripheral or central100mg/kg IV peripheral or central
Insulin/glucoseInsulin/glucose
Insulin 0.1units/kg IVInsulin 0.1units/kg IV
Glucose 2ml/kg D10 or D25Glucose 2ml/kg D10 or D25
The most effective way to quickly lower K!!!The most effective way to quickly lower K!!!
Sodium bicarbonateSodium bicarbonate
1-2mEq/kg1-2mEq/kg
HemodialysisHemodialysis
KayexalateKayexalate
1gram/kg po or PR1gram/kg po or PR
38. Hypocalcemia:
Long QT that is due to a long ST segment, which is different from long
QT due to congenital long QT syndrome, drugs, or hypokalemia. T wave
is not wide, there is no T wave abnormality.
40. Hypocalcemia: TreatmentHypocalcemia: Treatment
Calcium gluconateCalcium gluconate
25-100mg/kg IV25-100mg/kg IV
Calcium chlorideCalcium chloride
10-20 mg/kg IV10-20 mg/kg IV
Must be given centrallyMust be given centrally
Treat low MagnesiumTreat low Magnesium
Treat underlying diseaseTreat underlying disease
When should you avoid treating hypocalcemia?When should you avoid treating hypocalcemia?
Tumor lysis syndrome (unless patient is symptomatic)Tumor lysis syndrome (unless patient is symptomatic)
41. Differential Diagnosis ofDifferential Diagnosis of
HypercalcemiaHypercalcemia
HyperparathyroidismHyperparathyroidism
>90% of ambulatory cases>90% of ambulatory cases
Primary hyperparathyroidism is most often due to aPrimary hyperparathyroidism is most often due to a
parathyroid adenomaparathyroid adenoma
CancerCancer
solid tumors and leukemiassolid tumors and leukemias
Local resorption of bone induced by metastases (mediated byLocal resorption of bone induced by metastases (mediated by
local release of cytokines such as tumor necrosis factor andlocal release of cytokines such as tumor necrosis factor and
interleukin-1) or the production of humoral osteoclastinterleukin-1) or the production of humoral osteoclast
activators, particularly PTH-related proteinactivators, particularly PTH-related protein
HyperthyroidismHyperthyroidism
15-20% of patients can develop mild hypercalcemia15-20% of patients can develop mild hypercalcemia
42. Evaluation of HypercalcemiaEvaluation of Hypercalcemia
Correct diagnosis in 95% of cases by evaluating:Correct diagnosis in 95% of cases by evaluating:
HistoryHistory
PExPEx
CXR (r/o malignancy or sarcoidosis) andCXR (r/o malignancy or sarcoidosis) and
Lab data: PTH (serum intact), PTHRP related peptide, serumLab data: PTH (serum intact), PTHRP related peptide, serum
protein electrophoresis (r/o multiple myeloma), creatinineprotein electrophoresis (r/o multiple myeloma), creatinine
Primary hyperparathyroidism is often associated withPrimary hyperparathyroidism is often associated with
borderline or mild hypercalcemia with the serumborderline or mild hypercalcemia with the serum
calcium concentration often being below 11 mg/dLcalcium concentration often being below 11 mg/dL
(2.75 mmol/L)(2.75 mmol/L)
43. Treatment Goals in HypercalcemiaTreatment Goals in Hypercalcemia
Lowering serum Ca++ levelLowering serum Ca++ level
Saline administration to produce volume expansionSaline administration to produce volume expansion
and increase urinary Ca++ excretion (oraland increase urinary Ca++ excretion (oral
hydration + high salt diet)hydration + high salt diet)
Concurrent tx with biphosphonates) +/- calcitoninConcurrent tx with biphosphonates) +/- calcitonin
(decrease bone resorption)(decrease bone resorption)
Oral phosphate 250-500 mg QID (decreaseOral phosphate 250-500 mg QID (decrease
absorption in gut)absorption in gut)
Correcting or decreasing underlying diseaseCorrecting or decreasing underlying disease
HyperparathyroidismHyperparathyroidism
51. Hypophosphatemia: TreatmentHypophosphatemia: Treatment
Determine underlying cause (many times it isDetermine underlying cause (many times it is
multifactorial)multifactorial)
Replace using:Replace using:
NaPhosNaPhos
Kphos 0.08-0.32 mmol/kg over 4-6 hoursKphos 0.08-0.32 mmol/kg over 4-6 hours
52. Clinical Manifestations ofClinical Manifestations of
HyponatremiaHyponatremia
Plasma Na+ 125-130 meq/LPlasma Na+ 125-130 meq/L
nausea and malaisenausea and malaise
Plasma Na+ <115-120 meq/LPlasma Na+ <115-120 meq/L
headache, lethargy, and seizures, coma andheadache, lethargy, and seizures, coma and
respiratory arrestrespiratory arrest
53. HyponatremiaHyponatremia
Causes:Causes:
Increased Free waterIncreased Free water
Increased sodium lossIncreased sodium loss
Decreased salt intakeDecreased salt intake
Most common cause in children is extra-renal GIMost common cause in children is extra-renal GI
losses like diarrhea.losses like diarrhea.
54. Hyponatremia- typesHyponatremia- types
Hypovolemic HyponatremiaHypovolemic Hyponatremia
Renal Loss: Urine Na > 20 mEq/LRenal Loss: Urine Na > 20 mEq/L
Diuretic UseDiuretic Use
Urinary tract obstruction and/or urinary tract infectionUrinary tract obstruction and/or urinary tract infection
Autosomal recessive polycystic kidney diseaseAutosomal recessive polycystic kidney disease
Tubulointerstitial nephritisTubulointerstitial nephritis
Cerebral salt wastingCerebral salt wasting
Lack of aldosterone effect (serum ↑ K+, ↓ Na+) / Deficient aldosterone (CAH)Lack of aldosterone effect (serum ↑ K+, ↓ Na+) / Deficient aldosterone (CAH)
Pseudohypoaldosteronism type IPseudohypoaldosteronism type I
Extra-renal Loss: Urine Na < 20 mEq/LExtra-renal Loss: Urine Na < 20 mEq/L
Gastrointestinal (emesis, diarrhea)Gastrointestinal (emesis, diarrhea)
Skin (CF, sweating, or burns)Skin (CF, sweating, or burns)
Third space losses (pancreatitis, burns, effusions, ascites)Third space losses (pancreatitis, burns, effusions, ascites)
Hypervolemic HyponatremiaHypervolemic Hyponatremia
Hypoalbuminemia due to gastrointestinal disease/ Nephrotic syndrome/ CirrhosisHypoalbuminemia due to gastrointestinal disease/ Nephrotic syndrome/ Cirrhosis
Congestive heart failureCongestive heart failure
Renal failureRenal failure
Capillary leak due to sepsisCapillary leak due to sepsis
55. Hyponatremia- typesHyponatremia- types
Euvolemic HyponatremiaEuvolemic Hyponatremia
Syndrome of inappropriate antidiuretic hormoneSyndrome of inappropriate antidiuretic hormone
Usually ADH secreted due to ↓ vol ↑ osm.Usually ADH secreted due to ↓ vol ↑ osm.
Can be released due to pain, nausea, vomiting, morphineCan be released due to pain, nausea, vomiting, morphine
Glucocorticoid deficiencyGlucocorticoid deficiency
HypothyroidismHypothyroidism
Water intoxication – diluted formula, swimming,Water intoxication – diluted formula, swimming,
Water enemasWater enemas
PseudohyponatremiaPseudohyponatremia
HyperglycemiaHyperglycemia
MannitolMannitol
56. Hyponatremia- DiagnosisHyponatremia- Diagnosis
Cause of Hyponatremia by Urine Specimen
Cause Urine Na Urine
Volume
Osmolarity Specific
Gravity
Hypovolemic renal Na loss ↑ >20mEq/L ↑ ↓ ↓
Hypovolemic extrarenal loss ↓ ↓ ↑ ↑
Hypervolemic HypoNa- CHF,edema ↓<20mEq/L ↓ ↑ ↑
Hypervolemic HypoNa- Renal Failure varies ↓ varies varies
SIADH-like syndrome ↑ >20mEq/L ↓ ↑ ↑
History can tell you most of the story
Laboratory studies: Urine Na and Osm compared to Serum Na and Osm
Calculate Osmolar Gap: Difference between measured & calculated osm
Gap is high with mannitol, glycerol, lactate, methanol, EtOH,
ethylene glycol
Calc Osm= 2( Serum Na + serum K+) + (BUN/2.8) + (glucose/18)
57. Hyponatremia- TreatmentHyponatremia- Treatment
Correction: in chronic hypo Na- correct by no more than 8-12mEq/L each dayCorrection: in chronic hypo Na- correct by no more than 8-12mEq/L each day
In acute hypoNa: brain doesn’t have time to adapt.In acute hypoNa: brain doesn’t have time to adapt.
Active CNS symptoms often improve after receiving 4–6mL/kg of 3% sodium chloride.Active CNS symptoms often improve after receiving 4–6mL/kg of 3% sodium chloride.
Correction by TYPE of hyponatremiaCorrection by TYPE of hyponatremia
HypovolemicHypovolemic hyponatremiahyponatremia: replace the Na and H20 deficit: replace the Na and H20 deficit
restore the intravascular volume with isotonic saline- suppresses ADH which permits excretionrestore the intravascular volume with isotonic saline- suppresses ADH which permits excretion
of the excess water.of the excess water.
monitoring of the sodium to avoid overly rapid correctionmonitoring of the sodium to avoid overly rapid correction
HypervolemicHypervolemic hyponatremia:hyponatremia: excess H20 and Na.excess H20 and Na.
Don’t give Na -causes volume overload and edema.Don’t give Na -causes volume overload and edema.
Restrict water and sodium (2/3 maintenance)Restrict water and sodium (2/3 maintenance)
DiureticsDiuretics
Infusion of albumin if low albuminInfusion of albumin if low albumin
CHF: improving cardiac output improves diuresis.CHF: improving cardiac output improves diuresis.
Renal failure: fluid restriction or dialysis.Renal failure: fluid restriction or dialysis.
IsovolemicIsovolemic hyponatremiahyponatremia: excess of water and a mild Na deficit.: excess of water and a mild Na deficit.
Eliminate the excess water.Eliminate the excess water.
For acute water intoxication, give 3% Na to reverse cerebral edema.For acute water intoxication, give 3% Na to reverse cerebral edema.
For chronicFor chronic hyponatremiahyponatremia from poor solute intake, give appropriate formula, and eliminatefrom poor solute intake, give appropriate formula, and eliminate
excess waterexcess water
58. Hyponatremia- TreatmentHyponatremia- Treatment
IVF replacementIVF replacement
3% NS: 513 mEq/L of Na3% NS: 513 mEq/L of Na
1ml/kg of 3% Na increases serum Na by 1.6 mEq/L1ml/kg of 3% Na increases serum Na by 1.6 mEq/L
NS: 154 mEq/ L of NaNS: 154 mEq/ L of Na
½ NS: 77 mEq/ L of Na½ NS: 77 mEq/ L of Na
¼ NS: 38.5 mEq/ L of Na¼ NS: 38.5 mEq/ L of Na
How much Na do you need to give?How much Na do you need to give?
Maintenance needs: Sodium: 2–3mEq/kg/24hrMaintenance needs: Sodium: 2–3mEq/kg/24hr
Deficit Replacement:Deficit Replacement:
Estimate Water = % dehydration X patient's weightEstimate Water = % dehydration X patient's weight
Calculated Na deficit from serumCalculated Na deficit from serum
Serum Na Deficit= [0.6 x Wt(kg)] x [Desired Na- Actual Na]Serum Na Deficit= [0.6 x Wt(kg)] x [Desired Na- Actual Na]
Ongoing Losses:Ongoing Losses:
Diarrhea: Na content 55 mEq/LDiarrhea: Na content 55 mEq/L
Gastric fluids: Na content 60mEq/LGastric fluids: Na content 60mEq/L
Sweat: 5–40 mEq/L of NaSweat: 5–40 mEq/L of Na
59. Hyponatremia: ComplicationsHyponatremia: Complications
Physiology review: Hyponatremia= decreased plasma osmolarityPhysiology review: Hyponatremia= decreased plasma osmolarity
(except in extreme hyperglycemia)---Water flow from low solute(except in extreme hyperglycemia)---Water flow from low solute
(low osm) to high solute (high osm)---So water flow from(low osm) to high solute (high osm)---So water flow from
extracellular space into intracellular space ---Cells SWELL!extracellular space into intracellular space ---Cells SWELL!
Brain adapts to the decreased extracellular osmolality by decreasing itsBrain adapts to the decreased extracellular osmolality by decreasing its
internal osmolality. Initially, through loss of sodium, potassium,internal osmolality. Initially, through loss of sodium, potassium,
and chloride. Chronically there is loss of intracellular osmolesand chloride. Chronically there is loss of intracellular osmoles
such as amino acids.such as amino acids.
Treatment complications: overly rapid correctionTreatment complications: overly rapid correction
Central pontine myelinolysisCentral pontine myelinolysis
Extrapontine myelinolysisExtrapontine myelinolysis
Both = osmotic demyelination syndromeBoth = osmotic demyelination syndrome
60. HypernatremiaHypernatremia
Serum Na >145 mEq/L [deficit of (TBW) relative to Na]Serum Na >145 mEq/L [deficit of (TBW) relative to Na]
Primarily hospital-acquired →in children who have restrictedPrimarily hospital-acquired →in children who have restricted
access to fluids.access to fluids.
Incidence >1% in hospitalized patients.Incidence >1% in hospitalized patients.
CAUSES:CAUSES:
Water deficitWater deficit
Salt ExcessSalt Excess
Water depletion exceeding sodium depletionWater depletion exceeding sodium depletion
Sodium is unique among electrolytes…
because water balance, not sodium balance, usually determines its concentration.
61. Hypernatremia: CausesHypernatremia: Causes
Water LossWater Loss
Water Loss/ DeficitWater Loss/ Deficit
RenalRenal
CentralCentral
NephrogenicNephrogenic
Insensible LossesInsensible Losses
Fever/ Heat exhaustion/HeatstrokeFever/ Heat exhaustion/Heatstroke
Respiratory IllnessRespiratory Illness
Prematurity-large surface areaPrematurity-large surface area
large evaporative water losseslarge evaporative water losses
Phototherapy or radiant warmersPhototherapy or radiant warmers
Inadequate IntakeInadequate Intake
63. Hypernatremia- CausesHypernatremia- Causes
Excessive SodiumExcessive Sodium
Improperly mixed formula Improperly mixed formula
Excess sodium bicarbonate Excess sodium bicarbonate
Ingestion of seawater or sodiumIngestion of seawater or sodium
chloride chloride
Intentional salt poisoningIntentional salt poisoning
(child abuse) (child abuse)
Intravenous hypertonic saline Intravenous hypertonic saline
HyperaldosteronismHyperaldosteronism
64. Hypernatremia:Hypernatremia:
signs and symptomssigns and symptoms
Note ↓ skin turgor is a LATE signNote ↓ skin turgor is a LATE sign
(doughy)(doughy)
Irritability or lethargyIrritability or lethargy
Altered conscious levelAltered conscious level
SeizuresSeizures
Increased muscle toneIncreased muscle tone
FeverFever
RhabdomyolysisRhabdomyolysis
OligouriaOligouria
Severe hypernatremic dehydrationSevere hypernatremic dehydration
induces brain shrinkageinduces brain shrinkage
tears cerebral blood vesselstears cerebral blood vessels→→
cerebral hemorrhagecerebral hemorrhage
venous sinus thrombosisvenous sinus thrombosis
seizures, paralysis, andseizures, paralysis, and
encephalopathyencephalopathy
Brain cell volume canBrain cell volume can ↓↓10% to 15%10% to 15%
acutelyacutely
Within 1 hour, the brainWithin 1 hour, the brain ↑↑
intracellular Na and K, amino acids,intracellular Na and K, amino acids,
& idiogenic osmoles& idiogenic osmoles
Within 1 week, the brain regains 98%Within 1 week, the brain regains 98%
of its water content.of its water content.
In patients with prolonged hypernatremia, rapid rehydration with hypotonic fluids
may cause cerebral edema, which can lead to coma, convulsions, and death.
66. Hypernatremia: Work-upHypernatremia: Work-up Serum sodium, glucose, osmolality, BUN, and creatinine levels must be measured.Serum sodium, glucose, osmolality, BUN, and creatinine levels must be measured.
Urine volume, urine osmolality and urine electrolyte levelsUrine volume, urine osmolality and urine electrolyte levels
Assess renal concentrating abilityAssess renal concentrating ability
Quantify the urinary free water lossesQuantify the urinary free water losses
urine osm (<800 mmol/L) with serumurine osm (<800 mmol/L) with serum hypernatremiahypernatremia = renal= renal
concentrating defectconcentrating defect
Urine tests of sodium concentration and osmolalityUrine tests of sodium concentration and osmolality
Hypovolemic hypernatremiaHypovolemic hypernatremia
Extrarenal losses show urine sodium levels of <20 mEq/LExtrarenal losses show urine sodium levels of <20 mEq/L
Renal losses urine sodium values are >20 mEq/L.Renal losses urine sodium values are >20 mEq/L.
In euvolemic hypernatremia, urine sodium data vary.In euvolemic hypernatremia, urine sodium data vary.
In hypervolemic hypernatremia, the urine sodium level is >20 mEq/L.In hypervolemic hypernatremia, the urine sodium level is >20 mEq/L.
Imaging studiesImaging studies
In alert, severely hypernatremic patients: rule out a hypothalamic lesionIn alert, severely hypernatremic patients: rule out a hypothalamic lesion
affecting the thirst center.affecting the thirst center.
CT /MRI scans show intracranial pathologies.CT /MRI scans show intracranial pathologies.
67. Hypernatremia: TreatmentHypernatremia: Treatment
Correct fluid deficit firstCorrect fluid deficit first
Rapid correction can cause cerebral edema.Rapid correction can cause cerebral edema.
Dehydration should be corrected over 48-72 hours.Dehydration should be corrected over 48-72 hours.
The rate of sodium correction: 10-12 mEq/L in 24 hours.The rate of sodium correction: 10-12 mEq/L in 24 hours.
Calculation of body water deficit:Calculation of body water deficit:
In children, TBW is 60% of lean body weight. TBW = 0.6 X weight.In children, TBW is 60% of lean body weight. TBW = 0.6 X weight.
An exception is babies, with TBW around 80% of their body weight.An exception is babies, with TBW around 80% of their body weight.
1. Water deficit (L) = [(current Na1. Water deficit (L) = [(current Na mEq/LmEq/L ÷ 145÷ 145 mEq/LmEq/L) - 1] X 0.6 X Wt (kg)) - 1] X 0.6 X Wt (kg)
oror
2. Water deficit(L)= 4ml x Wt(kg) x (desired change in Na2. Water deficit(L)= 4ml x Wt(kg) x (desired change in Na mEq/LmEq/L))
Example calculation: A child weighs 10 kg with Na= 160Example calculation: A child weighs 10 kg with Na= 160 mEq/LmEq/L..
With first equation, water deficit (L) = [(160 mEq/L ÷ 145 mEq/L) - 1] X 0.6 X 10 = 0.62 L.With first equation, water deficit (L) = [(160 mEq/L ÷ 145 mEq/L) - 1] X 0.6 X 10 = 0.62 L.
With second equation, water deficit (L)= 4ml x 10 kg x 15 mEq/L Na change = 600ml= 0.6 LWith second equation, water deficit (L)= 4ml x 10 kg x 15 mEq/L Na change = 600ml= 0.6 L
69. Treatment of Hypernatremic Dehydration
RESTORE INTRAVASCULAR VOLUME
Normal saline: 20 mL/kg over 20 min
(Repeat until intravascular volume restored)
DETERMINE TIME FOR CORRECTION BASED ON INITIAL SODIUM
[Na]:145–157 mEq/L:24 hr
[Na]:158–170 mEq/L:48 hr
[Na]:171–183 mEq/L:72 hr
[Na]:184–196 mEq/L:84 hr
ADMINISTER FLUID AT CONSTANT RATE OVER TIME FOR CORRECTION
Typical fluid: D5 ½ normal saline (with 20 mEq/L KCl unless contraindicated)
Typical rate: 1.25–1.5 times maintenance
FOLLOW SERUM SODIUM CONCENTRATION EVERY 2-4 hrs
ADJUST FLUID BASED ON CLINICAL STATUS AND SERUM SODIUM
Signs of volume depletion: administer normal saline (20 mL/kg)
Sodium decreases too rapidly
Increase sodium concentration of IVF, or Decrease rate if IVF
Sodium decreases too slowly
Decrease sodium concentration of IVF, or Increase rate if IVF