Which electrolyte disturbances need to be carefully monitored and controlled in sick children

Transcription

1 Which electrolyte disturbances need to be carefully monitored and controlled in sick children Andrew C Argent Red Cross War Memorial Children s Hospital and University of Cape Town

2 introduc6on severe illness is frequently associated with changes and abnormaliaes in electrolyte concentraaons interrelaaonship of fluid and electrolytes when are changes likely? acute illness medicaaon such as diureacs when are the changes significant or what do they mean? changes may be more relevant in paracular situaaons how should they be corrected? it depends... can also be used therapeuacally

3 fluids and electrolytes

4 Lang F, Comprehensive Human Physiology, 1996

5 electrolyte distribu6on approximately 40% of body Na (in adults) is in bone Lang, J Am Coll Nutr, 2007

6 what changes electrolyte levels?

7 the hand-basin principle what is coming in fluids and electrolytes mostly what we are administering what is going out fluids and electrolytes dependant on renal, gut and skin funcaon affected by the endocrine milieu affected by the use of drugs such as diureacs and anabioacs Polderman & Girbes, Intensive Dare Med, 2002 what is moving around in the basin ship between different compartments cell funcaon acid-base and endocrine milieu the paaent in PICU is not actually a closed system...

8 Vincent et al, CriJcal Care, 2014

9 sodium

10 sodium in body fluids Fluid Gastro-intestinal Saliva 80 Gastric 60 Bile 140 Pancreatic fluids 140 Small bowel content 120 Sodium concentration (mmoles/l) variable Na in diarrhoea depending on cause Renal GFR 140 Urine <1 to 300 dependant on situation Sweat 5-80 normal adult kidney filters approximately 1.3 kg of sodium chloride (NaCl) through the glomeruli each day Lang, J Am Coll Nutr, 2007 beware of the consequences of fluid losses on Na

11 why worry about Na? increasing recogniaon that dysnatraemia is associated with adverse outcomes in adults Wald et al, Arch Intern Med, 2010 Zilberberg et al, Curr Med Res Opin, 2008 children and neonates Guarner et al, Pediatr Dev Pathol, 2011 Moritz ML & Ayus, Pediatrics, 2009 difficult to separate the prognosis related to dysnatraemia from the prognosis of the underlying illness, but outcomes are related to the severity of the dysnatraemia Vandergheynst et al, Eur J Clin Invest, 2013 Luu et al, J Pediatr, 2013 adult intensive care studies show correcaon of dysnatraemia is associated with improved outcome Darmon et al, Shock, 2014

12 does the fluid content ma=er during resuscita6on? no difference in outcome of severe sepsis using NS or balanced salt soluaon Weiss et al, J Pediatr, 2017 no difference in outcomes of DKA if use NS or balanced salt soluaon Yung et al, J Pediatr Child Health, 2017 in paaents with TBI (n = 308), LR was associated with higher adjusted mortality compared with NS (hazard rate [HR] = 1.78, confidence interval [CI] , p = 0.035). Bulgar et al, J Neurotrauma, 2016 higher % Ringers associated with reduced hospital mortality and with less acute kidney injury from days 3-7 aper adult ICU admission Zampieri et al, Crit Care Med, 2016

13 does the fluid content ma=er during maintenance? in children with CNS infecaons reduced hyponatraemia with 0.9% saline Pemde et al, Indian J Pediatr, 2015 analysis of 11 RCTs showed that among hospitalized children receiving maintenance IVF therapy, isotonic soluaons significantly decreased the risk of developing hyponatremia [relaave risk (RR) 0.50, 95% confidence interval (CI) ] without significantly increasing the risk for hypernatremia (RR 0.83, 95% CI ) Padua et al, Pediatr Nephrol, 2015 use of isotonic intravenous fluid with a sodium concentraaon of 140 mmol/ L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/l of sodium Macnab et al, Lancet, 2015 reduced volume isotonic fluid results in fewer episodes of hyponatremia than hypotonic fluid in sick children during the first 48 hours of intravenous fluid therapy Shamim et al, Indian Pediatr, 2014

14 dysnatraemia asymptomaac hyponatraemia is not actually asymptomaac Decaux et al, Am J Med, 2006 recent protocols for treatment of adult hyponatraemia Achinger & Ayus, Crit Care Med, 2017 normal saline is a safe iniaal rehydraaon fluid in children with diarrhea-related hypernatremia. Bayoumi et al, Eur J Pediatr, 2012 children with diarrhea-related hyponatremic-hypernatremic dehydraaon need to take into account specifics of individual child Kocaoglu et al, Med Glas (Zenica), 2014 Robertson et al, J Paediatr Child Health, 2007

15 potassium

16 Cummings et al, Journal of Intensive Care Medicine, 2014

17 Chime et al, Pediatr Crit Care Med, 2015

18 potassium clearly hyperkalaemia MUST be recognised and treated urgently Hypokalemia, hyperkalemia and potassium variability were independently associated with increased mortality Hessels et al, CriJcal Care, 2015 serum levels do not reflect body stores (most K is inside cells) we need to consider the relaaonship between risk and benefit of IV vs oral / enteral replacement of hypokalaemia White et al, Pediatric Crit Care Med, 2005 Moffe_ et al, Pediatr Crit Care Med, 2011

19 magnesium

20 magnesium normal adult total body Mg content approximately 25 g (2000 meq or 1 mol) of total Mg stores approximately 53% in bone, 27% in muscle 19% in sop Assues, 0.5% in erythrocytes, and 0.3% in the serum (a poor reflecaon of total body Mg content) Tong & Rude, J Intensive Care Med, 2005 approximately 2g of Mg is filtered daily by the human kidney and approximately 100 mg appears in the urine MarJn et al, J Am Soc Nephrol, 2009 serum values lower or higher than the mmol/l range require diagnosis and treatment but values in the normal range also do not rule out the possibility of total body deficit compensated for by the release of Mg from the bone pool. Arnaud, Br J Nutr, 2008

21 magnesium hypomagnesaemia associated with wide variety of abnormaliaes electrolyte abnormaliaes hypokalemia, hypocalcemia neuromuscular carpopedal spasm, tetany, muscle cramps, muscle fasciculaaons neurologic verago, nystagmus, aphasia, hemiparesis, depression, delirium, choreoathetosis cardiovascular ventricular arrhythmias, torsade de points, supraventricular tachycardia, enhanced sensiavity to digoxin MarJn et al, J Am Soc Nephrol, 2009

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24 magnesium used therapeuacally in a variety of seongs persistent pulmonary hypertension of the newborn Ho & Rasa, Cochrane Database Syst Rev, 2007 Uslu et al, J Trop Pediatr, 2011 tetanus Mathew et al, Anaesth Intensive Care, 2010 torsade de pointes asthma seizures, phaeochromocytoma

25 calcium

26 calcium hypocalcaemia is clearly related to poor outcome and a variety of deleterious effects on organ funcaon Kelly & Levin, Intensive Care Med, 2013 impact of CaCl infusion on cardiac output in neonates with low cardiac output Averin et al, Pediatr Cardiol, 2016 but... calcium may improve cardiovascular status in criacally ill paaents, but at the cellular level its administraaon may be deleterious Jankowski & Vincent, J Intensive Care Med, 1995 there is no clear evidence that parenteral calcium supplementaaon impacts the outcome of criacally ill paaents Forsythe et al, Cochrane Database Syst Rev, 2008

27 phosphate

28 hypophosphataemia significant associaaon was found between hypophosphatemia and the duraaon of mechanical venalaaon and between hypophosphatemia and pediatric intensive care unit length of stay (P =.02 and P =.001, respecavely). Kilic et al, J Crit Care, 2012 severe hypophosphataemia is an emergency, however relaave hypophosphataemia may be a symptom and not something that needs urgent aqenaon.

29 tes8ng

30 tes6ng... on admission use of intra-osseus specimens in i-stat Veldhoen et al, ResuscitaJon, 2014 during admission depending on context more frequent if already abnormal but really only if you are prepared to address it...

31 conclusions all the electrolytes are likely to change during criacal illness many of the changes are associated with changes in paaent outcome correcaon of some abnormaliaes is clearly associated with changes in paaent outcomes some electrolytes can also be used therapeuacally