Electrolytes

Pediatric Emergency division

Department of Child Health,
Faculty of Medicine
Universitas Sumatera Utara
 Electrolytes
● Dissolved in the body fluids;
● Chemicals that can carry an electrical
charge;
● Fluid and electrolyte levels are
interdependent (electrolyte increases,
water is added; electrolyte levels low,
water is removed
mEq/L Extracellular Fluid Intracellular Fluid
200

180

160 Plasma Interstitial Fluid

140

120

100 Na+
K+
80 Ca++
60 Mg++
HCO3-
40 Cl-
Org P-, Pr-
20 UA
0 Protein
Gamblegram of plasma, ISF, and ICF (Winters RW, 1973)
 Hyponatremia
Serum Na < 135 mmol/l

●The most common electrolyte disorders

●USA: 1.5% among hospitalized pediatric
patients
●Neonates and infants are most likely to develop
hyponatremia
 Hyponatremia
Thiazide diuretics; Hypothyroidism; Adrenal insufficiency;
Normo Syndrome of inappropriate secretion of antidiuretic
volemia hormone; Postoperative hyponatraemia; Decreased
excretion of solutes (Beer potomania, tea-and-toast diet)

Renal sodium loss: Diuretic agents, Osmotic diuresis

(glucose, urea, mannitol), Adrenal insufficiency, Cerebral
salt-wasting, Bicarbonaturia (renal tubular, acidosis,
Hypo disequilib-rium stage of vomiting), Ketonuria
volemia Extrarenal sodium loss: Diarrhoea, Vomiting, Blood loss,
Excessive sweating (e.g. in marathon runners), Fluid
sequestration in ‘third space’ (Bowel obstruction,
Peritonitis, Pancreatitis, Muscle trauma, Burns)

Hyper Congestive heart failure, Cirrhosis, Nephrotic syndrome,

volemia Renal failure (acute or chronic), Pregnancy
 Symptoms & signs
CNS
Early signs Advanced signs Far-advanced signs
[Na] 120-130 mmol/l [Na] < 120 mmol/l [Na] <<< 120 mmol/l
• Anorexia • Impaired response to • Decorticate or
• Headache verbal stimuli decerebrate posturing
• Nausea • Impaired response to • Bradycardia
• Emesis painful stimuli • Hypertension or
• Bizarre behavior hypotension
• Hallucinations • Altered temperature
Cardiovascular • Obtundation regulation
• Hypotension • Incontinence • Dilated pupils
• Tachycardia • Respiratory • Seizure activity
insufficiency • Respiratory arrest
Musculoskeletal • Coma
• Weakness
• Muscular cramps
Hyponatremia Treatment

Hypovolemic
● Establish hemodynamic stability: replete
with normal saline
● Correct hyponatremia: maximum rate of
correction: 8-10 mmol/day
● If symptomatic, correct at 1-2 mmol/hour
until symptoms resolves
● Choice of fluids: 3% NaCl: 513 mEq Na+,
0.9% NaCl (NS): 154 mEq Na+
Hyponatremia Treatment

Sodium deficit calculation

[(normal Na(mEq/L)) – (measured Na(mEq/L)] X TBW (L)

· Use 135mEq/L as normal Na

· Estimate TBW as 0.6 L/kg X body weight (kg)
· Determine the patient’s overall fluid status to help clarify cause of hyponatremia
 Hypovolemic Euvolemic Hypervolemic
Hyponatremia Hyponatremia Hyponatremia

- Fluid restriction
- Replace deficit - All IVF should be - Free Water removal-
with isotonic isotonic Diuresis
- Loop diuretics - Water restriction
solution
- Treat underlying and hypertonic
cause saline if more
rapid correction
desired
- Treat Underling
cause
 Hypernatremia
Serum Na >145 mmol/l

●A deficit of total body water (TBW) relative to total body

sodium levels due to either loss of free water, or the
administration of hypertonic sodium solutions
●An acute onset of hypernatremia causes the brain to shrink,
leading to vascular injury and intracranial bleeding
Etiology
 Plasma Sodium >145 mmol/L

Evaluated for contributing factors

Excess free water loss

- Gi Loss (Diarrhea)
- Renal : Diabetes Insipidus, osmotic diuresis, obstructive
uropathy, renal dysplasia, diuretics
- ⇡ insensible losses : Fever, burns,exercise
 Plasma Sodium >145 mmol/L

Evaluated for contributing factors

Inadequate free water intake

- Fluid restriction
- Neurologic impairment
- Ineffective breastfeeding
 Plasma Sodium >145 mmol/L

Evaluated for contributing factors

Excess sodium Intake

- Nacl, NaHCO3 administration

- Salt Poisoning
- Mineralocorticoid excess
 Symptoms & signs
● Largely reflect CNS dysfunction
● Insomnia, Irritability
● High-pitched cry or wail
● Altered sensorium: lethargy, coma
● Muscle weakness
● Convulsions in inadvertent sodium loading or
aggressive rehydration
● Fever, hyperpnoea
● Rhabdomyolysis
● Oligoanuria or excessive diuresis
 Correction of hypernatremia
● Restore circulating volume depletion first,
volume expansion with isotonic crystalloid or
colloid
● Estimate and correct EFW deficit
● Rule of thumb : EFW deficit (ml) =
● 4 ml x lean body weight (kg) x desired change
in Pna mmol/L
● Do not rapidly decrease the sodium level (can
cause cerebral edema)
 Correction of hypernatremia
● The recommended rate of sodium reduction:
0.5 mEq/h or 10-12 mEq/L in 24 hours
● Dehydration should be corrected over 48-72
hours
● With hyperglycemia: use 2.5% dextrose
solution; insulin treatment not recommended
(acute decrease in glucose, lowers plasma
osmolality, precipitate cerebral edema)
 Hypokalemia
Serum potassium < 3.5 mmol/L or
Plasma potassium < 3.0 mmol/L
● An 1 meq/L decrease in serum potassium
corresponds to a loss of approximately 10- 30
% of body potassium
● Severe hypokalemia/life threatening symptoms
is defined as a serum potassium of less then 2.0
mmol/L
● Daily K+ requirement 1-3 meq/kg body weight
Hypokalemia
Causes
● Decreased intake: Inadequate intake, Starvation, unusual
diet (tea and toast), parenteral fluids deficient in K+
● Increased excretion: Renal (hyperaldosteronism, volume
depletion vomiting, cirrhosis, CHF, osmotic diuresis,
Chronic diuretic use, renal tubular acidosis, Renal tubular
defect intrinsic or secondary to nephrotoxins
hypomagnesemia), Gastrointestinal (Chronic diarrhea or
vomiting, nasogastric suction)
● Intracellular shift: Hormonal (insulin, beta adrenergics,
aldosteron), Physical (alkalemia, correction of met
acidosis), miscellaneous (hypokalemic periodic paralysis,
thyrotoxic periodic paralysis, Diabetic ketoacidosis)
Hypokalemia
The clinical features
Cardiac prolonged QRS, U-Wave, low voltage T-
wave, atrial & ventricular ectopy, increased
sensitivity to digitalis, ventricular & atrial
tachycardias, Torsades de pointes
Skeletal muscle weakness, hypotonicity, ascending
paralysis, ventilatory failure, cramps,
rhabdomyolysis
Gastro intestinal constipation, ileus
CNS depression, lethargy, confusion, coma
Renal nephrogenic diabetes insipidus, metabolic
alkalosis
Endocrine glucose intolerance
Hypokalemia Treatment

Oral administration
● Mild hypokalemia
● Safest, although solutions may cause diarrhea
● Potassium salts (chloride, bicarbonate/citrate)
● Dosage : 2-4 meq/kg body weight in divided
doses
● The potassium content : bananas, 7-8
meq/100 g; orange juice, 5 meq/100 g; meat,
10 meq/100 g
Hypokalemia Treatment

Intra venous administration

● Peripheral: do not exceed 40-50 mEq
● Delivery rate : 10-40 mEq/hour; avoid
temptation to rapidly bolus
● Central: 0.5 -1 mEq/kg over 1-3 hours,
depending on severity
● Severe hypokalemia : > 40 mEq/hour, split
into two portions and administer via two
separate lines
● Close monitoring of serum potassium level
● Replace magnesium also (25-50 mg/kg
MgSO4) if low
 Hiperkalemia
Serum potassium >5.5 mEq/L
● Can cause lethal cardiac arrhythmia
● One of the most serious electrolyte
disturbances
Hyperkalemia

Causes
● Increased intake of potassium (orally or
intravenously)
● Decreased renal excretion of potassium: renal
failure, hypoaldosteronism (e.g., Addison's
disease and pseudohypoaldosteronism),
potassium-sparing diuretics (e.g.,
spironolactone, amiloride), other drugs
● Extracellular shift of potassium: metabolic
acidosis, cell destruction, hemolysis, tissue
necrosis, drugs, hormonal deficiency
Hyperkalemia

Symptoms/Signs
● Depend on the degree of hyperkalemia
● Primarily relate to cardiac conduction
● High serum levels interfere cellular membrane
repolarization
● Mild: asymptomatic, nausea, vomiting, and
paresthesias (eg, tingling)
● Severe: EKG changes (peaked T-wave, increased
P-R interval, widened QRS, depressed ST
segment, AV or intraventricular heart block,
ventricular flutter, fibrillation, cardiac arrest)
● Respiratory failure and weakness that progresses
to paralysis
Hyperkalemia

Treatment
● Stop potassium & potassium-sparing diuretics
● Antagonism of membrane actions of K: CaCl
10-20 mg/kg over 5 min; may repeat x2
● Shift potassium intracellularly: Glucose 1
gm/kg + 0.1 unit/kg regular insulin; Alkalinize
(increase ventilator rate; Na Bic 1 mEq/kg IV);
Inhaled 2 adrenergic agonist (albuterol)
● Removal of potassium from the body: Loop/
thiazide diuretics; Cation exchange resin:
sodium polstyrene sulfonate (Kayexelate®) 1
gm/kg PO or PR (or both); Dialysis
 Hyperkalemia

►
True?

No (Pseudo) Yes

►
Serum
No treatment potassium?

< 6 mEq/L > 6 mEq/L > 6.5 mEq/L

Asymptomatic? Symptomatic, with EKG changes?

►

►
Kayexalate 0.5-1.0 g/kg PO/PR in 5ml 20% Sorbitol Calcium 100 mg/kg slow IV
►

►
Monitor K+ Na Bic 1-2 mEq/kg IV

►
Glucose 1-2 g/kg as D25 4-8 ml/kg IV bolus followed by continuous
infusion of D15 0.2 % NS + 4 U regular Insulin/100 ml, at infusion
rate = patient’s fluid requirements

►
Monitor K+

►
Consider peritoneal or hemodialysis for refractory/
renal failure cases
 Hipokalsemia
• Definisi : kadar total kalsium < 2,12 mmol/L
(<8,5 mg/dL) atau kalsium ion < 1 mmol/L
• Penyebab
­ rendahnya asupan / kekurangan vitamin D
atau hormone paratiroid (misal : defisiensi PTH
kongenityal pada DiGeorge syndrome)
­ anak dengan penyakit kritis, kebanyakan akibat
hipoalbuminemia
Gejala dan tanda Hipokalsemia
• Tetani
• Iritabilitas
• Hiperrefleksia
• Kelemahan dan parestesia, kelelahan otot
• Stridor dan laringospasme merupakan
manifestasi neuromuscular dari hipokalsemia
• Efek terhadap kardiovaskular seperti
hipotensi, bradikardia dan aritmia
 Tatalaksana Hipokalsemia
• Suplementasi kalsium agresif dilakukan pada
keadaan terbukti hipokalsemia dan
simptomatik
• Penting untuk mengevaluasi fungsi renal dan
elektrolit lainnya
• Untuk mencari penyebab dibutuhkan
pemeriksaan fungsi PTH, fungsi ginjal dan
kadar vitamin D
 Tatalaksana Hipokalsemia
• Calcium chloride : Dosis 10-20 mg/kg/IV
selama 5-10 menit melalui vena sentral;
Pemberian cepat dapat menimbulkan
bradikardia dan hipotensi; Larutan calcium
chloride 10% mengandung 1,36 mEq/L ion Ca
• Calcium gluconate: lebih dianjurkan bagi
bayi; diberikan secara oral atau IV pada anak
yang lebih besar; Calcium gluconate 10%
mengandung ion Ca 0,45 mEq/mL;
Neonatus :50-200 mg/kg/IV selama 5-10
menit; Bayi dan anak :Dosis 50-125 mg/kg/IV
selama 5-10 menit
 Hiperkalsemia
Definisi
•kalsium total > 11 mg/dL (>2,75 mmol/L) atau
•ion kalsium >1,3 mmol/L

Etiologi
•Resorbsi tulang ↑ (hiperparatiroid primer,
metastase tulang,, sarcoidisis, tiroroksikpsis)
•Absorbsi gastrointestinal ↑ (intoksikasi Vitamin D,
milk-alkali syndrome, hiperkalsemia idiopatik)
•↓clearance kalsium di ginjal (penggunaan tiazid)
Gejala dan tanda klinis Hiperkalsemia
• Penurunan kesadaran dan hipertensi
• Pemendekan interval QT
• Iritabel
• Letargi
• Kejang, koma
• Mual, muntah dan nyeri perut

33
 Tatalaksana Hiperkalsemia
• Hidrasi dengan saline isotonis sebanyak 200-250
mL/kg/hari bersamaan pemberian furosemid (1 mg/kg/6
jam/IV); Pantau ketat elektrolit, termasuk fosfor dan
magnesium, selama diuresis
• Calcitonin recombinant : bekerja cepat dan memblokade
penyerapan tulang dan mencetuskan kalsiuria; Dosis : 10
U/kg/IV, dan dapat diulangi tiap 4-6 jam
• Terapi alternatif : Mithramycin, Aspirin, Indometasin
• Glukokortikoid: dapat mengurangi absorpsi kalsium di
saluran cerna; Hidrokortison sebanyak 1mg/kg tiap 6 jam
efektif mengurangi absorpsi kalsium namun kurang
berguna pada hiperkalsemia akut
 Magnesium / Mg2+

• Magnesium merupakan ko-faktor adenosine

triphosphate (ATP), seperti sintesis protein dan
transkripsi DNA
• Magnesium ini banyak terdapat dalam makanan
dan asupan harian
• Magnesium intrasel berperan dalam fungsi
fisiologis yang membutuhkan ATP dan magnesium
• Kadar plasma normal berkisar 1,6-2,4 mg/dL
 Hypomagnesium
• Kadar < 2 mg/dL
• cukup sering pada pasien di ruang
perawatan intensif  sering karena kurang
atau tidak adanya asupan disertai
kehilangan dari saluran cerna dan ginjal
• Pankreatitis
• Disfungsi ginjal akibat gagal
mengekskresikan magnesium melalui urine
• Hipomagnesemia sering berhubungan dengan
hipokalsemia, sehingga timbul gejala seperti :
kelemahan neuromuskular; Perubahan EKG
(peningkatan interval PR, pemanjangan QT dan
gelombang T datar)
• Hipokalemia juga sering berhubungan dengan
hipomagnesemia
• Laringospasme dan kejang juga dapat terlihat pada
beberapa kasus berat
 Penyebab hipomagnesemia

• Keadaan puasa dan kekurangan suplemen melalui

IV
• Malabsorpsi akibat :
– Familial hypomagnesemia
– Penggunaan laksatif
– Short bowel syndrome
• Peningkatan kehilangan sekunder melalui ginjal
(penggunaan diuretik, amfoterisin B,
aminoglikosida, acute tubular necrosis
 Tatalaksana hipomagnesemia
• Magnesium sulfat 25-50 mg/kg infus
lambat selama 3-4 jam
• Kadar Mg serum >2mg/dL, maka ginjal
akan membuang sisanya tidak ada guna
substitusi cepat melalui IV
 Hipermagnesemia
• Kelebihan magnesium biasanya diekskresikan
melalui ginjal
• Hipermagnesemia jarang terjadi kecuali pada
disfungsi ginjal
• Simtomatik hipermagnesemia terjadi pada
level > 5 mg/dL
 Gejala dan tanda hipermagnesemia
• Mual, muntah
• Penurunan refleks tendon
• Blokade neuromuskular
• Efek di kardiovaskular : bradikardia, depresi
miokardium, perubahan EKG (pemanjangan
interval PR dan blok AV)
• Neonatus : apnu dan hipotonia
Tatalaksana hipermagnesemia
• Kalsium glukonas 50-100
mg/kg/IV
• Restriksi asupan
• Diuresis bila fungsi ginjal baik
 Phosphate (PO4)
• Fosforus terdapat dalam makanan
• Dalam tubuh, tersedia dalam bentuk garam
fosfat dan berhubungan dengan asupan
kalsium
• Kadar fosfat dipengaruhi regulasi filtrasi ginjal
dan reabsorpsi tubular proximal ginjal
• Fungsi utama di fosfolipid membran, ATP,
tulang dan 2,3-difosfogliserat
 Hipofosfatemia
Penyebab
•Ketoasidosis diabetikum
•Disfungsi renal
•Pasien hanya mendapat cairan infus tanpa
suplemen fosfor
•Konsumsi antasida yang mengandung
aluminium
•Keadaan kritis
Gejala dan tanda hipofosfatemia
• Kelemahan otot
• Hipoventilasi
• Disfungsi miokardium
• Kejang
• Koma
 Tatalaksana hipofosfatemia
• Penambahan fosfat ke dalam cairan IV jika kadar
fosfor dibawah 1 mg/dL
• Sodium fosfat mengandung 3 mmol (94 mg) PO4
dan 4,4 mEq kalium / mL
• Koreksi secara IV : 0,16-0,32 mmol/kg/IV
selama 4-6 jam
• Jika ada disfungsi renal, digunakan potassium
fosfat  pengawasan ketat
• Jangan berikan suplemen fosfat jika dijumpai
hiperkalsemia
 Hiperfosfatemia
Penyebab
• Asupan yang berlebihan
• Berkurangnya ekskresi :
­ Gagal ginjal
­ Hipoparatiroidisme
­ Pseudohipoparatiroidisme
• Sampel darah yang mengalami hemolisis
Efek hiperfosfatemia
•Timbulnya hipokalsemia akibat khelasi ketika
total pengukuran kalsium dikalikan produk fosfor
inorganik mencapai > 60 mg/dL
Tatalaksana hiperfosfatemia
•Antasida aluminium hidroksida secara enteral
•Rehidrasi dengan cairan isotonis
•Koreksi hipokalsemia secara agresif
Terima Kasih