fluid and electrolyte management for sick kids and electrolyte management for sick kids© wendy...

Fluid And Electrolyte Management For Sick Kids©

Wendy Murchie, RN, BSN, CCRN

March 6, 2008

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O U T R E A C H E D U C A T I O N

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Wendy Murchie, RN, BSN Wendy Murchie, RN, BSN Nursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series March 6, 2008March 6, 2008

Fluid & Electrolyte Fluid & Electrolyte ManagementManagementFor Sick KidsFor Sick Kids

Nursing Grand RoundsNursing Grand RoundsSpring 2008Spring 2008

Wendy Murchie, RN, BSN, CCRNWendy Murchie, RN, BSN, CCRN

Wendy Murchie, RN, BSNWendy Murchie, RN, BSNNursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series

March 6, 2008March 6, 2008

Objectives Objectives

Review concepts of fluid movement and Review concepts of fluid movement and electrolyte controlelectrolyte controlAssessment and clinical presentations of Assessment and clinical presentations of fluid volume deficit & overloadfluid volume deficit & overloadElectrolyte imbalances: causes and Electrolyte imbalances: causes and managementmanagementCase Studies Case Studies


March 6, 2008March 6, 2008

Body WaterBody Water6565--80% of body weight80% of body weight is Wateris Water

Intracellular (ICF)Intracellular (ICF)Fluid located within Fluid located within cellscellsLargest component Largest component (2/3): 42% of body (2/3): 42% of body weightweightMost stable, fairly Most stable, fairly resistant to major fluid resistant to major fluid shiftsshifts

Extracellular (ECF)Extracellular (ECF)Consists of interstitial Consists of interstitial fluid, plasma, and fluid, plasma, and transcellulartranscellular water water Reserve fluid. Reserve fluid. Replaces either fluid Replaces either fluid in vessels or cells.in vessels or cells.


March 6, 2008March 6, 2008

Mechanisms Controlling Fluid and Mechanisms Controlling Fluid and Electrolyte MovementElectrolyte Movement

DiffusionDiffusionMovement of molecules from an area of high Movement of molecules from an area of high concentration to low concentrationconcentration to low concentrationElectrolytes move easilyElectrolytes move easily

OsmosisOsmosisMovement of Movement of waterwater between two compartments by between two compartments by a a semipermeablesemipermeable membrane.membrane.Osmosis is the major force in body fluid Osmosis is the major force in body fluid movement.movement.


March 6, 2008March 6, 2008

Mechanisms Controlling Fluid and Mechanisms Controlling Fluid and Electrolyte MovementElectrolyte Movement

Osmotic PressureOsmotic PressurePulling force exerted Pulling force exerted by colloids in a by colloids in a solution.solution.Plasma proteins stay Plasma proteins stay within the vessel and within the vessel and draw fluid towards draw fluid towards them.them.Water will move from Water will move from less concentratedless concentrated to to more concentratedmore concentratedside.side.


March 6, 2008March 6, 2008

QuestionQuestion……Sam is a 12 year old in septic shock. He Sam is a 12 year old in septic shock. He has a low to normal BP with the use of has a low to normal BP with the use of Dopamine and volume. Despite therapy Dopamine and volume. Despite therapy he has severe third spacing. What would he has severe third spacing. What would help with his blood pressure support but help with his blood pressure support but ALSO provide some diuresis for the third ALSO provide some diuresis for the third spacing?spacing?AlbuminAlbumin

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March 6, 2008March 6, 2008

AlbuminAlbuminMajor plasma proteinMajor plasma proteinIncreased albumin concentration results in Increased albumin concentration results in fluid moving back into the capillaries from fluid moving back into the capillaries from the interstitial spacethe interstitial spaceDecreased albumin concentrations results Decreased albumin concentrations results in fluid leaking into the interstitial spacein fluid leaking into the interstitial space


March 6, 2008March 6, 2008

Movement of Fluid between Movement of Fluid between CompartmentsCompartments

Hydrostatic pressureHydrostatic pressure and and osmotic osmotic pressurepressure regulate the movement of water regulate the movement of water and electrolytes from one compartment to and electrolytes from one compartment to another.another.


March 6, 2008March 6, 2008

Osmolality and OsmolarityOsmolality and OsmolarityRefers to the concentration of Refers to the concentration of

a solution which creates its a solution which creates its osmotic pressureosmotic pressure..

Serum Serum OsmoOsmo is the concentration of is the concentration of particles in the plasma.particles in the plasma.

Normal Serum Normal Serum OsmoOsmo: 275: 275--295mOsm/L295mOsm/L


IV Fluids and their IV Fluids and their InfluencesInfluences


March 6, 2008March 6, 2008

IsoIsotonictonicEqualEqual osmolality as plasmaosmolality as plasmaIt has no pulling effects (no It has no pulling effects (no osmotic pressure)osmotic pressure)Great for expanding the Great for expanding the vascular volume quickly vascular volume quickly (increase BP)(increase BP)Examples:Examples:

Normal Saline (sodium and Normal Saline (sodium and chloride)chloride)Lactated Ringers (sodium, Lactated Ringers (sodium, chloride, potassium, chloride, potassium, calcium, and lactate)calcium, and lactate)


March 6, 2008March 6, 2008

HypoHypotonictonicHas a Has a lower lower osmolality osmolality than plasmathan plasmaWater is pulled out of Water is pulled out of vessels into cells.vessels into cells.Contraindicated in acute Contraindicated in acute brain injuriesbrain injuries-- will will increase cerebral edemaincrease cerebral edemaExamples:Examples:

D5WD5W0.45% and 0.225% Normal 0.45% and 0.225% Normal SalineSalineD5 with normal salineD5 with normal saline

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March 6, 2008March 6, 2008

HyperHypertonictonicHas a Has a higherhigher osmolality osmolality than plasmathan plasmaWater is pulled from the Water is pulled from the cells into the vessels.cells into the vessels.Specific situations of use Specific situations of use and requires careful and requires careful control of sodium and control of sodium and serum serum osmoosmo’’ss. .

Intracranial hypertensionIntracranial hypertension

Examples:Examples:3% Saline3% Saline


March 6, 2008March 6, 2008

QuestionQuestionA 16year old is in the ICU 12 hours after a A 16year old is in the ICU 12 hours after a bicycle collision. His CT is negative for bleeding bicycle collision. His CT is negative for bleeding but he remains obtunded and being observed.but he remains obtunded and being observed.What IV fluids would be dangerous for this What IV fluids would be dangerous for this client? client?

Hypotonic fluids (D5W)Hypotonic fluids (D5W)

Why? Why? Cerebral cells will absorb free water and cause Cerebral cells will absorb free water and cause increase in cerebral edema.increase in cerebral edema.


March 6, 2008March 6, 2008

Regulation of Fluid BalanceRegulation of Fluid BalanceWater homeostasis results from the Water homeostasis results from the balance between water intake and the balance between water intake and the combined water loss from renal excretion, combined water loss from renal excretion, respiratory, skin, and GI sources. respiratory, skin, and GI sources.


March 6, 2008March 6, 2008

Maintenance FluidsMaintenance FluidsMaintenance fluidMaintenance fluid is the volume of daily fluid is the volume of daily fluid intake which intake which

replaces the insensible losses (from breathing, replaces the insensible losses (from breathing, through the skin, and in the stool), through the skin, and in the stool), allows excretion of the daily production of excess allows excretion of the daily production of excess solute load (urea, creatinine, electrolytes etc) in a solute load (urea, creatinine, electrolytes etc) in a volume of urine that is of an osmolarity similar to volume of urine that is of an osmolarity similar to plasma.plasma.

A childA child’’s maintenance fluid requirement s maintenance fluid requirement decreases proportionatelydecreases proportionately with increasing age with increasing age (and weight). (and weight).


March 6, 2008March 6, 2008

Maintenance Fluid RequirementsMaintenance Fluid RequirementsNewborn 0 Newborn 0 -- 72 hrs old72 hrs old6060--100 mL/kg/day 100 mL/kg/day

0 0 -- 10 kg10 kg100100--150 mL/kg/day150 mL/kg/day

11 11 -- 20 kg20 kg1000 mL for 11000 mL for 1stst 10kg + 10kg + 50mL/kg for each kg > 10kg50mL/kg for each kg > 10kg

21 21 -- 30 kg30 kg1500mL for 11500mL for 1stst 20kg + 20kg + 25mL/kg for each kg > 20kg 25mL/kg for each kg > 20kg Body Surface Area (BSA) Formula:

1500mL/m2 BSA/day


March 6, 2008March 6, 2008

Thoughts about KidsThoughts about Kids……The kidneys of an infant or child are functionally The kidneys of an infant or child are functionally immature as compared to the adolescent or immature as compared to the adolescent or adult kidney. adult kidney. At this stage of life, the kidney is unable to At this stage of life, the kidney is unable to concentrate or dilute urine.concentrate or dilute urine. The kidney cannot The kidney cannot conserve or excrete sodium or acidify urine.conserve or excrete sodium or acidify urine.The kidneys of an infant or child are less efficient The kidneys of an infant or child are less efficient at excreting the metabolic wastes of at excreting the metabolic wastes of metabolism.metabolism. Therefore, the pediatric patient is Therefore, the pediatric patient is less able to handle large amounts of solute. less able to handle large amounts of solute.

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March 6, 2008March 6, 2008

Chemical Regulation of WaterChemical Regulation of Water

AntidiureticAntidiuretic hormone (ADH)hormone (ADH) from the from the posterior pituitary gland causes a posterior pituitary gland causes a reductionreduction in the amount of water lost in in the amount of water lost in the urine.the urine.


March 6, 2008March 6, 2008

ADH Regulation of WaterADH Regulation of WaterProlonged fever, vomiting, diarrhea.

Blood loss

Burns

Shock

Vasodilation

Blood Pressure

Blood Volume

Blood Osmolality

Osmoreceptors in the hypothalamus stimulate the pituitary gland to secrete ADH

ADH stimulates renal tubules to reabsorption of water

Decreased and concentrated urine ( SG)

Blood Pressure

Blood volume

Blood osmolality


March 6, 2008March 6, 2008

More on ADHMore on ADHWhen drinking adequate water, the ADH When drinking adequate water, the ADH mechanism is inhibited, and more water is mechanism is inhibited, and more water is expelled in the urine. ADH is expelled in the urine. ADH is inhibitedinhibited with a with a serum osmolality of serum osmolality of < 280mmoL< 280mmoLOsmotic changes also stimulate the thirst Osmotic changes also stimulate the thirst mechanism.mechanism.A 5A 5--10% blood volume reduction can stimulate 10% blood volume reduction can stimulate the release of ADH.the release of ADH.Catecholamines and angiotensin II can Catecholamines and angiotensin II can modulate the release of ADHmodulate the release of ADH


March 6, 2008March 6, 2008

Example:Example:Diabetes Insipidus:Diabetes Insipidus:

Deficiency of ADH due to failed synthesis or Deficiency of ADH due to failed synthesis or secretion by the posterior pituitary or both. secretion by the posterior pituitary or both. Results from pituitary and Results from pituitary and suprasellarsuprasellar surgery, surgery, head trauma, cerebral edema, CNS head trauma, cerebral edema, CNS infections.infections.

So in DI, ADH is deficient and you begin toSo in DI, ADH is deficient and you begin tohave no inhibition to water loss. Urine output ishave no inhibition to water loss. Urine output isexcessive (10mL/kg/hr). excessive (10mL/kg/hr).


March 6, 2008March 6, 2008

More Examples!More Examples!Syndrome of Inappropriate ADH:Syndrome of Inappropriate ADH:

is a disorder of the bodyis a disorder of the body’’s inability to secrete water.s inability to secrete water.Excessive amounts of ADH can be secreted in response to Excessive amounts of ADH can be secreted in response to stimuli such as pulmonary disease, CHF, increased LAP, PPV, stimuli such as pulmonary disease, CHF, increased LAP, PPV, chemo etc. chemo etc. Conditions associated with SIADH:Conditions associated with SIADH:

•• MeningitisMeningitis•• Head traumaHead trauma•• Cerebral tumorsCerebral tumors•• Cerebral hemorrhageCerebral hemorrhage

•• So with SIADH, too much ADH is around and you So with SIADH, too much ADH is around and you conserve water. There is a decrease in urine conserve water. There is a decrease in urine output. (<0.5mL/kg/hr)output. (<0.5mL/kg/hr)


March 6, 2008March 6, 2008

So What does this have to do with So What does this have to do with Electrolytes??Electrolytes??

As your serum osmolality changes, so do your As your serum osmolality changes, so do your electrolyte balances.electrolyte balances.Sodium fluctuations in DI and SIADH can be Sodium fluctuations in DI and SIADH can be severe.severe.

DI causes increased serum DI causes increased serum osmoosmo and increased and increased serum sodiumserum sodiumSIADH causes decreased serum SIADH causes decreased serum osmoosmo and and decreased serum sodiumdecreased serum sodium

When there are dramatic changes in sodium When there are dramatic changes in sodium levels, the brain tries to adapt to maintain fluid levels, the brain tries to adapt to maintain fluid balance.balance.

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March 6, 2008March 6, 2008

Aldosterone Regulation of Sodium Aldosterone Regulation of Sodium and Waterand Water

K+

Na+

Blood Volume

Cardiac Output

Blood Pressure

Renal perfusion

Glomerular Filtration Rate

Renin

Conversion of Angiotensin I to Angiotensin II in the lungs

Secretion of aldosterone in the adrenal cortex

Absorption of Na+

Absorption of Water

Excretion of K+

Excretion of H ionsWendy Murchie, RN, BSNWendy Murchie, RN, BSNNursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series

March 6, 2008March 6, 2008

Regulation of Electrolyte OutputRegulation of Electrolyte Output

Cardiac RegulationCardiac RegulationAtrial natriuretic peptide (ANP) is released Atrial natriuretic peptide (ANP) is released by the cardiac atria in response to by the cardiac atria in response to increased atrial pressureincreased atrial pressureANF causes vasodilation and increased ANF causes vasodilation and increased urinary excretion of sodium and water by:urinary excretion of sodium and water by:

Aldosterone releaseAldosterone releaseADH release ADH release


March 6, 2008March 6, 2008

Infants and children have a higher metabolicInfants and children have a higher metabolicrate:rate:

a. to support rapid growtha. to support rapid growthb. because they are smallerb. because they are smallerc.c. due to the higher heart ratedue to the higher heart rated.d. due to higher activity levelsdue to higher activity levels

QuestionsQuestions


March 6, 2008March 6, 2008

Questions:Questions:Infants and small children are at greater risk ofInfants and small children are at greater risk ofdehydration for which of the following reasonsdehydration for which of the following reasons

a.a. they are smaller than adultsthey are smaller than adultsb.b. they have a larger extracellular fluid they have a larger extracellular fluid

compartment, immature kidneys, and higher compartment, immature kidneys, and higher basal metabolic rate.basal metabolic rate.

c. c. the intracellular compartment is largerthe intracellular compartment is largerd.d. they are fed more frequently, thus more they are fed more frequently, thus more

dependent on the fluiddependent on the fluid


March 6, 2008March 6, 2008

Questions:Questions:The immature pediatric kidney is unable toThe immature pediatric kidney is unable todo which of the following:do which of the following:

a.a. handle large amounts of solutehandle large amounts of soluteb.b. concentrateconcentrate or dilute urineor dilute urinec.c. acidify urineacidify urined.d. all of the aboveall of the above


So what about those So what about those electrolytes?electrolytes?

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Sodium Sodium (135(135--145 mEq/L) 145 mEq/L)

(Life threatening <120 or >160 mEq/L)(Life threatening <120 or >160 mEq/L)

For water balance and For water balance and neuromuscular membrane neuromuscular membrane

excitabilityexcitability


March 6, 2008March 6, 2008

Treat underlying Treat underlying causecause

Frequent neuro Frequent neuro assessment assessment

Fluid replacement Fluid replacement 3% saline 3% saline Monitor Na levels Monitor Na levels

N/A N/A Lethargy Lethargy Muscle cramps Muscle cramps

/weakness/weaknessN/VN/VDisorientation/Disorientation/confusionconfusionSeizuresSeizuresComa Coma

Vomiting Vomiting NG suctionNG suction↓↓Na intakeNa intakeFever Fever Excessive Excessive

diaphoresisdiaphoresis↑↑ water intake water intake Burns & woundsBurns & woundsRenal diseaseRenal diseaseDKA & hypoxiaDKA & hypoxia--

causes failure of causes failure of SodiumSodium--Potassium Potassium pumppump

Malnutrition Malnutrition SIADHSIADHHeart failureHeart failure

HyponatremiaHyponatremia

Management Management ECG ECG findingsfindings

Clinical Clinical S&SxS&SxCausesCausesElectrolyte Electrolyte ImbalanceImbalance


March 6, 2008March 6, 2008

Treat underlying causeTreat underlying causeFrequent neuro Frequent neuro

assessment assessment Strict I&OStrict I&OSlow correction of fluid Slow correction of fluid

deficit deficit Monitor lab data Monitor lab data ––

elevated serum sodium elevated serum sodium and and osmolarityosmolarity

N/AN/AIrritability/agitationIrritability/agitationHypertensionHypertensionDry, sticky mucous Dry, sticky mucous

membranes membranes Flushed skin Flushed skin Lethargy/confusion Lethargy/confusion SeizuresSeizuresComaComaMuscle weaknessMuscle weaknessMuscle twitching Muscle twitching Intense thirstIntense thirst

↑↑ Na intakeNa intakeRenal diseaseRenal diseaseFeverFever↑↑ insensible water insensible water

losslossDiabetes Diabetes insipidusinsipidushyperglycemiahyperglycemia

Hypernatremia Hypernatremia

Management Management ECG ECG findingsfindings

Clinical Clinical S&SxS&SxCausesCausesElectrolyte Electrolyte ImbalanceImbalance


PotassiumPotassium(3.5(3.5--4.5 mEq/L)4.5 mEq/L)

Critical for electrical conduction of Critical for electrical conduction of nerve impulsesnerve impulses-- particularly particularly cardiac electrical conductioncardiac electrical conduction


March 6, 2008March 6, 2008

Determine and Determine and treat causetreat cause

Monitor ECGMonitor ECGFrequent neuroFrequent neuro--

muscular muscular assessments assessments

K replacement K replacement Monitor acidMonitor acid--base base

statusstatus

Flattened, inverted Flattened, inverted T wavesT waves

Presence of UPresence of U--waveswaves

PVCPVC’’s s

Muscle weakness, Muscle weakness, cramping, stiffness, cramping, stiffness, paralysis, paralysis, hyporeflexiahyporeflexia

Hypotension Hypotension LethargyLethargyIrritability Irritability TetanyTetanyN/VN/VAbdominal distension Abdominal distension Paralytic Paralytic ileusileusIrregular, weak pulseIrregular, weak pulse

↓↓K intake K intake Starvation Starvation MalabsorptionMalabsorption

syndromessyndromesGI lossesGI lossesDiuresisDiuresisNephritis Nephritis Alkalosis Alkalosis

HypokalemiaHypokalemia

Management Management ECG findingsECG findingsClinical Clinical S&SxS&SxCausesCausesElectrolyte Electrolyte ImbalanceImbalance


March 6, 2008March 6, 2008

Determine and treat Determine and treat causecause

Monitor ECGMonitor ECGAdminister IV fluidsAdminister IV fluidsD/C K containing D/C K containing

fluids/medsfluids/medsCa Ca GluGlu 100mg/kg 100mg/kg Insulin 0.1u/kg + Insulin 0.1u/kg +

Glucose 0.5g/kgGlucose 0.5g/kgNa BicarbNa BicarbKayexalateKayexalateDialysisDialysisMonitor serum K Monitor serum K

levels levels Evaluate acidEvaluate acid--base base

statusstatus

Tall, peaked T Tall, peaked T waveswaves

Widened QRSWidened QRSProlonged PR Prolonged PR

interval interval Ventricular Ventricular

arrhythmiasarrhythmiasAsystole Asystole

Muscle weaknessMuscle weaknessAscending Ascending

paralysis paralysis HyperreflexiaHyperreflexiaConfusionConfusionApneaApneaN/VN/VDiarrheaDiarrhea↓↓ cardiac function cardiac function

↑↑ K intake K intake Renal Renal

disease/failuredisease/failureAdrenal Adrenal

insufficiencyinsufficiencyMetabolic acidosisMetabolic acidosisSevere Severe

dehydration dehydration BurnsBurnsCrushing injuries Crushing injuries HemolysisHemolysis

HyperkalemiaHyperkalemia


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CalciumCalcium((iCaiCa 1.151.15--1.34)1.34)

Required for normal skeletal muscle, Required for normal skeletal muscle, smooth muscle and cardiac muscle smooth muscle and cardiac muscle contraction. Also needed for blood contraction. Also needed for blood

clotting.clotting.


March 6, 2008March 6, 2008

Treat underlying Treat underlying cause cause

Monitor ECG Monitor ECG IV fluids IV fluids Loop diuretics Loop diuretics

Shortened QT Shortened QT interval interval

BradycardiaBradycardiaCardiac arrest Cardiac arrest

LethargyLethargyStuporStuporComaComaSeizuresSeizuresAnorexiaAnorexiaN/VN/VConstipation Constipation NM NM hypotonicityhypotonicity

Acidosis Acidosis Prolonged Prolonged

immobilization immobilization Kidney disease Kidney disease HyperparathyroidisHyperparathyroidis

m m Excessive Excessive

administration administration

HypercalcemiaHypercalcemia

Treat/control causeTreat/control causeMonitor ECGMonitor ECGIV calcium IV calcium

supplements supplements Monitor Ca & Mg Monitor Ca & Mg

levels levels

Prolonged QT Prolonged QT interval interval

NM irritability NM irritability Tingling sensation Tingling sensation

ChvostekChvostek’’ss sign sign TetanyTetanyMuscle cramps Muscle cramps LethargyLethargySeizuresSeizuresHypotension Hypotension

↓↓ dietary Ca dietary Ca Vitamin D Vitamin D

deficiency deficiency Renal insufficiency Renal insufficiency DiureticsDiureticsHypoparathyroidisHypoparathyroidis

mmAlkalosis Alkalosis ↑↑ serum protein serum protein

HypocalcemiaHypocalcemia



MagnesiumMagnesium(1.3(1.3--2.2 mEq/L)2.2 mEq/L)

Needed to prevent overNeeded to prevent over--excitability of musclesexcitability of muscles


March 6, 2008March 6, 2008

Treat cause Treat cause Monitor ECG Monitor ECG Administer Ca Administer Ca

GluGluIV hydration IV hydration Dialysis Dialysis

Prolonged PRProlonged PRProlonged QRSProlonged QRSProlonged QtProlonged QtAV Block AV Block

Lethargy Lethargy Muscle Muscle

weaknessweakness↓↓ swallowswallow↓↓ gaggag↓↓ HR HR ↓↓ BP BP

Chronic renal Chronic renal diseasedisease↓↓ GFR/GFR/↓↓

excretion excretion ECF deficit ECF deficit ↑↑ administration administration

of Mg containing of Mg containing drugs drugs

HypermagnesemiaHypermagnesemia

Treat cause Treat cause IV MG IV MG

replacement replacement Monitor ECG Monitor ECG

Neuromuscular Neuromuscular assessments assessments

PVCPVC’’ssVV--tachtachVV--fib fib

NM excitability NM excitability TetanyTetanyConfusion Confusion Dizziness Dizziness Headache Headache SeizuresSeizuresComa Coma Respiratory Respiratory

depression depression ↑↑ HR HR

↓↓ intake (NPO) intake (NPO) MalabsorptionMalabsorption

syndromes syndromes ↑↑ renal excretion renal excretion HypomagnesemiaHypomagnesemia



March 6, 2008March 6, 2008

Assessment: Volume status Assessment: Volume status

Intake? Intake? PO/NG? IVF? PO/NG? IVF?

Output? Output? Urine? Stool? Gastric? Drains?Urine? Stool? Gastric? Drains?

Appearance? Appearance? Color? Mucous membranes? Eyes? Capillary refill? Color? Mucous membranes? Eyes? Capillary refill?

Level of Activity/Consciousness? Level of Activity/Consciousness? Heart rate, rhythm, blood pressure? Heart rate, rhythm, blood pressure? Respiratory rate and quality? Respiratory rate and quality?


March 6, 2008March 6, 2008

Assessment: Volume Overload Assessment: Volume Overload Weight gain Weight gain EdemaEdemaDyspnea, crackles and/or Dyspnea, crackles and/or wheezing wheezing Jugular vein distension Jugular vein distension Increased pulse pressure Increased pulse pressure Hypertension Hypertension S3 gallopS3 gallopFull/bulging fontanel Full/bulging fontanel

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March 6, 2008March 6, 2008

EdemaEdemaFluid movement between the vascular and Fluid movement between the vascular and interstitial compartment is regulated by interstitial compartment is regulated by hydrostatic pressure and osmotic pressure. hydrostatic pressure and osmotic pressure. Low serum protein results in Low serum protein results in ↓↓ oncotic pressure oncotic pressure in the capillaries leading to leaking of fluids into in the capillaries leading to leaking of fluids into the interstitial space. Hence, the administration the interstitial space. Hence, the administration of albumin to increase cellular protein and of albumin to increase cellular protein and increase oncotic pressure.increase oncotic pressure.Increased fluid in blood vessels causes vascular Increased fluid in blood vessels causes vascular congestion, leading to fluid leaking from vessels congestion, leading to fluid leaking from vessels


March 6, 2008March 6, 2008

Diagnostic & Lab ChangesDiagnostic & Lab ChangesBUN and HCT due to BUN and HCT due to hemodilutionhemodilution

Low serum Low serum osmoosmo (<275mOsm/kg)(<275mOsm/kg)Low serum sodium (<125mEq/L)Low serum sodium (<125mEq/L)Chest xChest x--ray may show pleural effusionsray may show pleural effusionsArterial blood gases may show Arterial blood gases may show

Low POLow PO22

Low COLow CO22 then as pulmonary edema progresses to then as pulmonary edema progresses to hypoventilation and respiratory failure the COhypoventilation and respiratory failure the CO22 risesrisesLow pH with rising COLow pH with rising CO22


March 6, 2008March 6, 2008

CausesCausesHypervolemia and edemaHypervolemia and edema

Renal failureRenal failureCHFCHFExcessive fluid resuscitationExcessive fluid resuscitation

Water intoxicationWater intoxicationExcess of free water (improperly prepared Excess of free water (improperly prepared formula)formula)

SAIDHSAIDHExcess production or release of ADHExcess production or release of ADH


March 6, 2008March 6, 2008

Management of Fluid OverloadManagement of Fluid OverloadRestrict intakeRestrict intakePromote excretionPromote excretion

DiureticsDiureticsAlbuminAlbumin

Monitor during treatmentMonitor during treatmentRespiratory statusRespiratory statusI&OI&OEdema statusEdema statusLabsLabs-- especially electrolyte imbalances (Na, K) during especially electrolyte imbalances (Na, K) during drug therapydrug therapy


March 6, 2008March 6, 2008

Case Scenario 1Case Scenario 1A ten year old boy Joey is admitted to the PICU A ten year old boy Joey is admitted to the PICU with a diagnosis of meningitis. After 8 hours of with a diagnosis of meningitis. After 8 hours of being in the ICU you note his recent Na is 120, being in the ICU you note his recent Na is 120, urine urine osmoosmo is 200, BP 138/92, urine output is 200, BP 138/92, urine output < 0.3mL/kg/hr, generalized edema< 0.3mL/kg/hr, generalized edema↓↓ LOC and LOC and confusion. confusion. What could What could most likelymost likely be occurring?be occurring?a. DIa. DIb. Too little ADH secretionb. Too little ADH secretionc. SIADHc. SIADHd. Acute DKAd. Acute DKA


March 6, 2008March 6, 2008

RationaleRationaleConditions associated with SIADH:Conditions associated with SIADH:

MeningitisMeningitisHead traumaHead traumaCerebral tumorsCerebral tumorsCerebral hemorrhageCerebral hemorrhage

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March 6, 2008March 6, 2008

RationaleRationaleSIADH causes hyponatremiaSIADH causes hyponatremiaRemember: Na+ and serum Remember: Na+ and serum osmolarityosmolarityare maintained by homeostatic are maintained by homeostatic mechanisms involving thirst, ADH and mechanisms involving thirst, ADH and renal filtration.renal filtration.Increase in serum Increase in serum osmoosmo stimulates stimulates hypothalmichypothalmic osmoreceptorsosmoreceptors which in turn which in turn cause an increase in thirst, therefore cause an increase in thirst, therefore increase in ADH.increase in ADH.

↓Na, ↓serum osmo↑urine Na, ↑urine osmo, ↑SG Wendy Murchie, RN, BSNWendy Murchie, RN, BSN

Nursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series

March 6, 2008March 6, 2008

Case Scenario 2Case Scenario 2A 5 year old girl develops SIADH following neurosurgery. A 5 year old girl develops SIADH following neurosurgery. Her Her neuroneuro vital signs are stable but her serum sodium vital signs are stable but her serum sodium level is 128mEq/L, serum level is 128mEq/L, serum osmoosmo is 256mOsm/L, urine SG is 256mOsm/L, urine SG is 1.022 and urine output is 1mL/kg/hr. Which of the is 1.022 and urine output is 1mL/kg/hr. Which of the following would be the treatment of choice?following would be the treatment of choice?

a. a. Fluid restriction to 50% of maintenance Fluid restriction to 50% of maintenance requirementsrequirements

b. b. Administration of 3mL/kg of 3% Administration of 3mL/kg of 3% NaClNaCl solutionsolutionc. c. Lasix 3mg/kgLasix 3mg/kgd. d. Administration of hypertonic saline and diureticsAdministration of hypertonic saline and diuretics


March 6, 2008March 6, 2008

RationaleRationaleTreatment of choice for SIADH Treatment of choice for SIADH not not complicatedcomplicated with a severely low Na and with a severely low Na and seizures is fluid restriction.seizures is fluid restriction.If severe symptoms such as seizures or If severe symptoms such as seizures or cerebral edema, hypertonic saline and cerebral edema, hypertonic saline and diuretics are administered.diuretics are administered.


March 6, 2008March 6, 2008

Case Scenario 2 cont.Case Scenario 2 cont.You would identify the SIADH patient at You would identify the SIADH patient at severe risk for seizures and cerebral severe risk for seizures and cerebral edema by all of the following edema by all of the following except:except:

a. Lethargya. Lethargyb. Hyperthermiab. Hyperthermiac. Hypothermiac. Hypothermiad. Abnormal reflexesd. Abnormal reflexes


March 6, 2008March 6, 2008

RationaleRationaleSeizures and cerebral edema in SIADH is Seizures and cerebral edema in SIADH is due to severe hyponatremia.due to severe hyponatremia.This causes hypothermia, lethargy, This causes hypothermia, lethargy, abnormal reflexes, abdominal cramping, abnormal reflexes, abdominal cramping, diarrhea, hypotension, tachycardiadiarrhea, hypotension, tachycardia……Hyperthermia is associated with Hyperthermia is associated with hypernatremia.hypernatremia.


March 6, 2008March 6, 2008

Assessment: Fluid Volume DeficitAssessment: Fluid Volume DeficitMild dehydration (5%)Mild dehydration (5%)

Normal VS, CRNormal VS, CRComplaint of thirstComplaint of thirstUrine SG >1.020Urine SG >1.020

Moderate dehydration Moderate dehydration (10%)(10%)

Looks & acts sickLooks & acts sickIrritableIrritableDry MM, Dry MM, ↓↓ tears, tears, ↑↑ HRHRThirstyThirstyCR sluggishCR sluggishAnterior fontanel sunkenAnterior fontanel sunkenUrine SG >1.020 and Urine SG >1.020 and ↓↓UOUO

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March 6, 2008March 6, 2008

Severe Dehydration (15% loss)Severe Dehydration (15% loss)Symptoms:Symptoms:

Hyperirritable to lethargicHyperirritable to lethargicNo tear productionNo tear productionHR very HR very ↑↑’’d, BP low and d, BP low and orthostaticorthostaticSkin mottled, coolSkin mottled, coolSunken fontanelSunken fontanelCR delayedCR delayedMetabolic acidosisMetabolic acidosis

Treatment:Treatment:1.1. Restore intravascular Restore intravascular

volume and ensure volume and ensure effective systemic effective systemic perfusionperfusion

2.2. Replace volume and Replace volume and electrolyte deficitselectrolyte deficits

3.3. Provide maintenance Provide maintenance fluid and electrolyte fluid and electrolyte requirements requirements

4.4. Replace ongoing lossesReplace ongoing lossesWendy Murchie, RN, BSNWendy Murchie, RN, BSNNursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series

March 6, 2008March 6, 2008

Points to think of:Points to think of:Treat feverTreat fever-- fever increases insensible fever increases insensible losseslossesPulse increases 10Pulse increases 10--20bpm per degree 20bpm per degree Celsius increase.Celsius increase.Tachycardia is an early sign of Tachycardia is an early sign of dehydration/ volume depletiondehydration/ volume depletionDecrease in BP is a late signDecrease in BP is a late sign


March 6, 2008March 6, 2008

More PointsMore Points……Common to see some degree of acidosisCommon to see some degree of acidosis

Why??Why??Bicarb loss in stools and ketone productionBicarb loss in stools and ketone productionHypovolemia causes poor perfusion and Hypovolemia causes poor perfusion and increased lactic acid productionincreased lactic acid production↓↓ renal perfusion results in renal perfusion results in ↓↓ glomerular rate glomerular rate which causes which causes ↓↓ hydrogen ion excretionhydrogen ion excretion


March 6, 2008March 6, 2008

Types of Dehydration Types of Dehydration

Isotonic/ Isotonic/ IsonatremicIsonatremic: equal losses of all fluid : equal losses of all fluid compartmentscompartments

55--10% loss of body wt. Water loss from ECF.10% loss of body wt. Water loss from ECF.Na+ 130Na+ 130--150150Can quickly lead to shockCan quickly lead to shock

Examples: Examples: -- Vomiting and diarrhea and an increase in insensible Vomiting and diarrhea and an increase in insensible losses.losses.-- HemorrhageHemorrhage-- BurnsBurns


March 6, 2008March 6, 2008

Types of DehydrationTypes of Dehydration

Hypotonic/ Hypotonic/ HyponatremicHyponatremic: greater losses of : greater losses of electrolytes electrolytes

osmotic electrolyte fluid shifts cause Na+ loss in osmotic electrolyte fluid shifts cause Na+ loss in stools and water shifts to ICF, resulting in stools and water shifts to ICF, resulting in ↓↓intravascular volume and shock.intravascular volume and shock.Na+ Na+ <<130130Requires aggressive fluid resuscitation due to the Requires aggressive fluid resuscitation due to the intravascular volume loss.intravascular volume loss.

Examples:Examples:Severe vomiting and diarrheaSevere vomiting and diarrheaShock and third spacingShock and third spacing


March 6, 2008March 6, 2008

Hypotonic/ Hypotonic/ HyponatremicHyponatremicSerum sodium levels less than 120 mEq/L Serum sodium levels less than 120 mEq/L may result in seizures. may result in seizures. If intravascular free water excess is not If intravascular free water excess is not corrected during volume replenishment, corrected during volume replenishment, the shift of free water to the intracellular the shift of free water to the intracellular fluid compartment may cause cerebral fluid compartment may cause cerebral edema. edema.

Example: same 4yo child replenished with tap Example: same 4yo child replenished with tap water only.water only.

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March 6, 2008March 6, 2008

Types of DehydrationTypes of DehydrationHypertonic/ Hypertonic/ HypernatremicHypernatremic: : Greater water loss than Greater water loss than electrolyte loss, or greater electrolyte intake than water. electrolyte loss, or greater electrolyte intake than water.

Osmotic shifts cause water to move into vascular space; Osmotic shifts cause water to move into vascular space; s&ss&sdevelop more slowlydevelop more slowlyNa+ Na+ >>150150Careful not to volume resuscitate too fast due to dropping the Careful not to volume resuscitate too fast due to dropping the Na+ too quickly and causing neuro complications (not faster thanNa+ too quickly and causing neuro complications (not faster than10mEq/24hrs)10mEq/24hrs)

Examples:Examples:replenished with hypertonic soup, or improperly diluted infant replenished with hypertonic soup, or improperly diluted infant formula.formula.Diabetes Diabetes InspidusInspidus


March 6, 2008March 6, 2008

So What Do We Do?So What Do We Do?ABCABC’’ss-- once you get the airway establishedonce you get the airway establishedIV accessIV access-- could be IO, CVL or venous could be IO, CVL or venous cutdowncutdownBolus if Bolus if shockyshocky: 20mL/kg NS: 20mL/kg NSOnce VS corrected, start maintenance fluidsOnce VS corrected, start maintenance fluidsDaily Na+ requirements 3Daily Na+ requirements 3--4mEq/kg/day4mEq/kg/dayDaily K+ requirements 2Daily K+ requirements 2--3mEg/kg/day3mEg/kg/dayDaily fluids: D5% in 0.25NSDaily fluids: D5% in 0.25NSAdd K+ once Add K+ once u/ou/o is adequateis adequateCorrect hypernatremia slowly.Correct hypernatremia slowly.Any severe Na+ abnormality correct over 24hrs.Any severe Na+ abnormality correct over 24hrs.


March 6, 2008March 6, 2008

Diagnostic & Lab ChangesDiagnostic & Lab ChangesSerum electrolytesSerum electrolytes

for Na+ concentrationfor Na+ concentrationHCOHCO33 & K+ & K+ -- to check acidosisto check acidosis

BUN, CrBUN, CrNormal or high due to Normal or high due to hemoconcentrationhemoconcentration

Urine Specific gravity (high, >1.030 or with Urine Specific gravity (high, >1.030 or with DI: <1.010)DI: <1.010)

check if ADH issuecheck if ADH issueWendy Murchie, RN, BSNWendy Murchie, RN, BSNNursing Grand Rounds Nursing Grand Rounds Teleconference SeriesTeleconference Series

March 6, 2008March 6, 2008

Management of Fluid DeficitsManagement of Fluid DeficitsOral replacementOral replacementParenteralParenteral replacementreplacement

Isotonic dehydration: Isotonic fluidsIsotonic dehydration: Isotonic fluidsHypertonic dehydration: Isotonic fluids, Hypertonic dehydration: Isotonic fluids, hypotonic fluids given slowly to prevent too hypotonic fluids given slowly to prevent too rapid of rehydrationrapid of rehydration

MonitoringMonitoringVitals and Vitals and neuroneuro statusstatusI&OI&O


March 6, 2008March 6, 2008

Case StudiesCase Studies


March 6, 2008March 6, 2008

EmmaEmmaEmma is a 15 kg 3 year old girl with down syndrome. She is in tEmma is a 15 kg 3 year old girl with down syndrome. She is in the he CICU after cardiac surgery. She was doing well postCICU after cardiac surgery. She was doing well post--op and transfer op and transfer plans were being made when she developed fever and diarrhea. plans were being made when she developed fever and diarrhea.

You are caring for her today and in report are told that she hasYou are caring for her today and in report are told that she has had had diarrhea for 48 hrs and has not been interested in her bottle. Hdiarrhea for 48 hrs and has not been interested in her bottle. Her er fluids are at maintenance only due to her cardiac status. fluids are at maintenance only due to her cardiac status.

What questions do you have for the nurse giving you report? What questions do you have for the nurse giving you report? -- What are her labsWhat are her labs-- VS, I&OVS, I&O-- Have sample been sent for stools?Have sample been sent for stools?

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March 6, 2008March 6, 2008

The nurse tells you that Emma is fluid restricted to 126cc The nurse tells you that Emma is fluid restricted to 126cc q 3 hrs. Emma cried much of the night and drank 250cc q 3 hrs. Emma cried much of the night and drank 250cc of apple juice during night shift. She had three stools of apple juice during night shift. She had three stools during the night which is much improved, because she during the night which is much improved, because she had 6 explosive stools for the evening nurse. As the had 6 explosive stools for the evening nurse. As the nurse leaves, she tells you that Emma threw up her nurse leaves, she tells you that Emma threw up her lasixlasixand pharmacy still hasnand pharmacy still hasn’’t sent up the replacement dose. t sent up the replacement dose.

What concerns do you have? What concerns do you have? -- Fluid depletionFluid depletion

What priorities do you have in caring for her?What priorities do you have in caring for her?


March 6, 2008March 6, 2008

Assessing EmmaAssessing EmmaYou note that Emma You note that Emma is cooperative during is cooperative during the assessment and the assessment and asks for water to asks for water to drink. She looks very drink. She looks very tired, with dark circles tired, with dark circles under her eyes. You under her eyes. You add a blanket add a blanket because she feels because she feels cool. cool.

Vital Signs: Vital Signs: T: 35.8 ax. T: 35.8 ax. P: 164P: 164R: 28R: 28BP: 86/44 BP: 86/44


March 6, 2008March 6, 2008

EmmaEmma’’s lab resultss lab resultsNa 162Na 162K 2.2K 2.2ClCl 111111Mg 4 Mg 4 Cr 1.6 Cr 1.6 BUN 58 BUN 58

Thoughts on her Thoughts on her labs?labs?What orders would What orders would you suspect?you suspect?


March 6, 2008March 6, 2008

Emma is feeling betterEmma is feeling betterDiscontinue fluid restrictions Discontinue fluid restrictions Hold all diureticsHold all diureticsReplace fluid lossReplace fluid lossReplace potassium Replace potassium Keep in mind she has a fragile heart and you do Keep in mind she has a fragile heart and you do not want to tip her over into cardiac failurenot want to tip her over into cardiac failureDiarrhea is due to rotavirus not intolerance to Diarrhea is due to rotavirus not intolerance to feeding, so stooling resolves itself feeding, so stooling resolves itself


March 6, 2008March 6, 2008

What about Charles? What about Charles? Charles is a 4 month old 6.5 kg Charles is a 4 month old 6.5 kg infant transferred from the local infant transferred from the local community hospital following a community hospital following a seizure at home. Mom states seizure at home. Mom states that the infant has always done that the infant has always done well breastfeeding, but this well breastfeeding, but this weekend the infant was left weekend the infant was left with the PGM so parents could with the PGM so parents could celebrate their anniversary. celebrate their anniversary. Mom starts crying and wants to Mom starts crying and wants to know if the baby is ill because know if the baby is ill because she ran out of EBM and PGM she ran out of EBM and PGM had to use formula. had to use formula.


March 6, 2008March 6, 2008

Assessing Charles Assessing Charles Vital Signs: Vital Signs:

T: 37.2 axT: 37.2 axP: 160 P: 160 R: 62R: 62BP: 76/42BP: 76/42

Irritable, breath Irritable, breath sounds clear, but sounds clear, but infant is infant is tachypneictachypneic. . Mom attempts to Mom attempts to breastfeed but infant breastfeed but infant is too lethargic to is too lethargic to latch on. Fontanel is latch on. Fontanel is full. full.

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March 6, 2008March 6, 2008

Priorities for CharlesPriorities for CharlesCharlesCharles’’ PGM brings in the powdered formula container she used to PGM brings in the powdered formula container she used to feed Charles. She tells you she was mixing 3feed Charles. She tells you she was mixing 3--4 big bottles at a time. 4 big bottles at a time. She was adding 1 scoop of formula to 1 bottle of water. The She was adding 1 scoop of formula to 1 bottle of water. The instructions state instructions state ““one scoop per 4 oz. water.one scoop per 4 oz. water.””

What do you think occurredWhat do you think occurred……what type of problem?what type of problem?Too much free water: hyponatremia and fluid overloadToo much free water: hyponatremia and fluid overloadLow sodium which if <120 can cause seizuresLow sodium which if <120 can cause seizures

What orders do you expect the residents to write? What orders do you expect the residents to write? IV fluids. Hypertonic saline administration.IV fluids. Hypertonic saline administration.

What concerns do you have? What concerns do you have? More seizures. Correcting too fast. How often are labs monitorMore seizures. Correcting too fast. How often are labs monitored to ed to avoid this?avoid this?


March 6, 2008March 6, 2008

CharlesCharlesCharlesCharles’’ mom runs into the hallway yelling mom runs into the hallway yelling that she needs a nurse. You go to Charles that she needs a nurse. You go to Charles and find him in the crib, eyes deviated to and find him in the crib, eyes deviated to the right and right arm twitching. While you the right and right arm twitching. While you are assessing him, he becomes apneic. are assessing him, he becomes apneic.

What do you do? What do you do? -- Bag, yell for help, expect Dr. to order Bag, yell for help, expect Dr. to order ativanativan


March 6, 2008March 6, 2008

Call a Code for CharlesCall a Code for CharlesAfter bag/mask ventilating him and administering After bag/mask ventilating him and administering ativanativan, , iSTATiSTAT labs are drawn. The labs are handed to you with a labs are drawn. The labs are handed to you with a sodium of 119 mEq/L. sodium of 119 mEq/L.

Why is the sodium low? Why is the sodium low? -- Too much free water and electrolyte lossToo much free water and electrolyte loss

What do you anticipate the team will do next? What do you anticipate the team will do next? -- Due to severe hyponatremia: 3% saline Due to severe hyponatremia: 3% saline administration and Q6h serum administration and Q6h serum osmoosmo’’ss and serum and serum Na+Na+


March 6, 2008March 6, 2008

Frankie Frankie A young boy, Frankie, had a skate boardingA young boy, Frankie, had a skate boardingaccident and a subsequent craniotomy due to aaccident and a subsequent craniotomy due to ahead bleed at Harborview. He is transferred tohead bleed at Harborview. He is transferred toChildrenChildren’’s on POD #3 intubated. His urine output begins tos on POD #3 intubated. His urine output begins tolook like clear water and is ~5mL/kg/hr. You suspect:look like clear water and is ~5mL/kg/hr. You suspect:

a.a. SIADHSIADHb.b. Acute high output renal failureAcute high output renal failurec.c. OverhydrationOverhydration in the ORin the ORd.d. DIDI


March 6, 2008March 6, 2008

The resident orders The resident orders lyteslytes, urine osmolality, urine osmolalityand sodium and a specific gravity. If this isand sodium and a specific gravity. If this isDI, your labs will show:DI, your labs will show:

a. hypernatremia, a. hypernatremia, urine urine osmoosmo, , ↓↓urine sodium, urine sodium, SG.SG.

b. hypernatremia, b. hypernatremia, ↓↓urine urine osmoosmo, , ↓↓urine sodium, urine sodium, ↓↓SG.SG.

c. hyponatremia, c. hyponatremia, urine urine osmoosmo, , urine sodium, urine sodium, ↓↓SGSG

d. hyponatremia, d. hyponatremia, ↓↓urine urine osmoosmo, , urine sodium, urine sodium, SGSG


March 6, 2008March 6, 2008

Interpretation of Tests in Interpretation of Tests in Diabetes Insipidus:Diabetes Insipidus:

Hypernatremia and Hypernatremia and serumserum hyperosmolality hyperosmolality are due to water loss and are due to water loss and hemoconcentrationhemoconcentrationLow SG and urine osmolality are due to Low SG and urine osmolality are due to the kidneys inability to reabsorb water and the kidneys inability to reabsorb water and concentrate urine.concentrate urine.Remember: Remember: High & DryHigh & Dry

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March 6, 2008March 6, 2008

Frankie needsFrankie needs……Frankie suddenly becomes hypotensive,Frankie suddenly becomes hypotensive,tachycardic and his urine output has increased totachycardic and his urine output has increased to10mL/kg. In light of a shock situation, acute10mL/kg. In light of a shock situation, acuteresuscitation of DI includes:resuscitation of DI includes:

a. a. N/S 10N/S 10--20mL/kg then 1:1 replacement for 20mL/kg then 1:1 replacement for urine lossurine loss

b. b. N/S replacement 1:1 and ADH replacementN/S replacement 1:1 and ADH replacementc. c. Allow unlimited drinking of waterAllow unlimited drinking of waterd. d. Begin CRRT.Begin CRRT.


March 6, 2008March 6, 2008

Treatment for Central DI:Treatment for Central DI:Decision to use fluid or ADH replacement Decision to use fluid or ADH replacement therapy or both depends on the severity of therapy or both depends on the severity of the DI.the DI.In an acute symptomatic stage, resuscitate In an acute symptomatic stage, resuscitate with NS or LR 10with NS or LR 10--20mL/kg, reassess, and 20mL/kg, reassess, and replace urine 1:1 with hypotonic fluid.replace urine 1:1 with hypotonic fluid.


Questions?Questions?

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