MANAGEMENT OF

ELECTROLYTE IMBALANCE
IN CHILDREN

Budi Hartawan
 Objectives

• 1) Most common electrolyte imbalance

in children with acute diarrhea

• 2) Recognize these imbalances

• 3) Apply appropriate management principles

 Objectives

• 1) Most common electrolyte imbalance

in children with acute diarrhea

• 2) Recognize these imbalances

• 3) Apply appropriate management principles

 ACUTE DIARRHEA
Mayor complication :
• dehidration,
• electrolyte imbalance,
• and renal failure

• Electrolyte imbalance :
• Ukarapol N, et al. (2002)  69,8%
• Shah GS, et al. (2006)  79%
 ACUTE DIARRHEA

Electrolyte imbalance Ukarapol N, et al. Shah GS, et al.

Hyponatremia 17% 56%

Hypernatremia 9,4% 10,4%

Hypokalemia 22,6% 46%

Hiperkalemia 3,4% 5,2%

 Objectives

• 1) Most common electrolyte imbalance

in children with acute diarrhea

• 2) Recognize these electrolyte imbalances

• 3) Apply appropriate management principles

 HYPONATREMIA

Serum sodium level <135 mEq/L

In acute diarrhea :
• excessive sodium loss
• water retention ~ volume
depletion
• excessive free water intake

Hyponatremia dehidration
 Signs and Symptoms

• Irritability
• poor feeding
• nausea and vomiting
• lethargy
• seizures
• and eventually coma and death
Treatment of Hyponatremia
ACUTE CORRECTION

 urgent treatment ~ neurological changes or seizures

• The goal : to 120-125 mEq/L or until seizures stop

• Hypertonic saline solution, 3% NaCl, ideally a central

venous line but acceptable during emergency via
peripheral IV or IO, over 15-20 minutes

• 1.2 ml/kg of 3% NaCl  raise the level by 1 mEq/L

Treatment of Hyponatremia
SLOWER CORRECTION

 acute correction completed or

not neurological changes

• More slowly at approximately 12 mEq/L per day

(0.5 to 1 mEq/L every hour)

• FORMULA :
0.6 x (Wt in kg) x (target Na+-measured Na+)= Total mEq
of Na+required to raise sodium level to target.
 Case Study

A 2 month-old child (5 kg) present with seizures

and sunken eyes and fontanelle . Mother reports
two days of diarrhea and is found to have a
sodium level of 114 mEq/L.
First step : acute correction
You decide to give 3% saline to correct to 120 mEq/L.

Amount of NaCl = 0.6 x 5 kg x (120-114)= 18 mEq of Na+

3% NaCl = 0.5mEq/L or approx 36 mL of 3% NaCl

solution
or

(1.2 mL/kg) of 3% NaCl raises the serum sodium apporx 1

mEq/L

1.2 mLx5kg x (120-114) = 36 mL of 3% NaCl solution

Second step: slower correction

To raise the serum sodium level

an additional 12 mEq/L from the 120 mEq/L

0.6x5kgx(132-120) = 36 mEq/L additional

sodium needed over the remainder of the 24
hours

additionally, the calculated deficit is

added to this and administered over 12-24
hours
 Treatment of hyponatremia

Water (ml) Na (mEq)

deficit 375 52
Na neeed 36
maintenance 500 15
TOTAL 875 103

• A good fluid ~ D5% 1/2NS or normal saline, with or without

(potassium 20 mEq/L)

• Fluid rates :
• first 8 hours  ½ deficit + 1/3 maint. (44 ml/hr)
• next 16 hours  ½ deficit + 2/3 maint (32 ml/hr)
 HYPERNATREMIA

Defined as a serum sodium level >145 mEq/L

In acute diarrhea :
•Excessive water loss
•Inadequate free water intake
•Increased sodium intake through ORS

Hypernatremia dehidration
 Signs and Symptoms

• Irritability,
• high-pitched cry,
• lethargy,
• seizures,
• fever,
• renal failure,
• and rhabdomyolysis.
• In infants, these symptoms mimic those of
infections and sepsis
 Treatment of Hypernatremia
• Essential to correct ~ slowly
• Most recommendations  no more than 0.5
mEq/L/hr or 12 mEq/L/day

To calculate :
• Free water deficit = (Wt in kg x 0.6) x 1 – (desired
Na+/actual Na+) (1000mL/L)
OR
• 4 ml/kg of free water ~ drop sodium by 1 mEq/L
 Case Study

A 10 month-old child (8 kg) present with profuse

diarrhea and moderate dehidration and is found
to have a sodium level of 157 mEq/L.
 treatment of hypernatremia
• Free water deficit = (8x0.6) x 1 – (145/157) x (1000 mL/L)
365 mL = 4.8 x 0.076 (1000 mL/L)

• Quick Calculation :
4mL x 8kg x 12mEq/L = 384 mL of free water

• Maintenance fluid amounts for an 8-kg child are (100mL/kg x 8)

= 800 mL/24hrs

• 1 L of ½ normal saline = 500 mL of free water

• 1 L of ¼ normal saline = 750 mL of free water

1 L of D5 ½ NS will provite 400 mL of free water and is a good

starting point
 treatment of hypernatremia

Water (ml) Na (mEq)

Free water deficit 365 -

Na deficit - 47

maintenance 800 24

TOTAL 1165 71

Na deficit ~ 600-365/1000 x 140 = 47 mEq

D5 ½ NS is a good starting point

 HYPOKALEMIA
• Defined as a potassium level <3.5 mEq/L

• In acute diarrhea :
• Potassium loss
• Volume depletion
• Gastric juice loss
 Signs and symptoms

• fatigue and paresthesias

• (ECG) changes :
flattened T wave,ST depressions,
U waves and ventricular dysrhythmias
 Treatment of hypokalemia
• Oral or IV supplementation  urgency of
sympptoms

• Oral :
• Asymptomatic hypokalemia (no ECG changes)
or mild hypokalemia
• Ability to tolerate
• Increase diet intake
• 1-3 mEq/kg/day in three or four divided doses
• Safest
 TREATMENT OF HYPOKALEMIA

A conservative protocol for IV replacement :

3.0-3.5 mEq/L  0,25 mEq/kg of IV KCl over 1 hour

2.5-3.0 mEq/L  0.5 mEq/kg of IV KCl over 2 hours

less than 2.5 mEq/L  0.75/L of IV KCl over 3 hours.

A potassium level should be checked halfway through this

infusion.

====>>>> SYMPTOMATIC HYPOKALEMIA

 TREATMENT OF HYPOKALEMIA

IV replacement :
• No more than 0.5 mEq/kg/hr of KCI in a single IV
with a max dose of 10 mEq over 1 hr.

• Via a central venous line

• If peripheral: do not exceed 40-50 mEq/L potassium

 HYPERKALEMIA

• Potassium levels >5.5 mEq/L

• In acute diarrhea :
• Metabolic acidosis
• Exogenous potassium
 Signs and Symptoms
• To inadequate cardiac output ~> arrhythmias.
• Cardiac (ECG changes) :

• Skeletal muscles and nerve: weakness and paresthesias

Treatment of Hyperkalemia
Hyperkalemia requires urgent intervention and th

1. Place a cardiorespiratory monitor

2. Recheck to confirm the hyperkalemia
3. Discontinue any exogenous potasssium
4. Administer one or more of drugs therapies
5. Emergency Hemodialysis
Administer one or more of the drug therapies :

1. Calcium gluconate, 100 mg/kg over 3 min

(1mL/kg of 10% solution) IV
2. Sodium bicarbonate, 1-2 mEq/kg given IV over
10-15 min

3. Insulin, 0.1 U/kg/hr, mixed with Dextrose

solution 0.5 g/kg/hr

3. An exchange resin, such as sodium polystyrene

resin (Kayexalate), administered 1g/kg rectally
 Summary
• Hyponatremia, Hypernatremia, Hypokalemia, and
Hyperkalemia are common in children with acute
diarrhea

• Acute correction must be considered carefully for

symptomatic electrolyte imbalance

• Strict attention to detail is important in providing safe

and effective therapy