Fluids, Electrolytes and Nutrition Jacqui Hoffman, DNP, ARNP, NNP-BC NNP Track Coordinator; Clinical Assistant Professor College of Nursing, University of Florida, Gainesville, FL Neonatal Nurse Practitioner Pediatrix Medical Group, Tampa, FL The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation. Session Summary This session will review electrolyte management and common electrolyte disorders to prepare the participant for certification exams. Session Objectives Upon completion of this presentation, the participant will be able to: discuss impact of gestational and chronologic age on fluid and electrolyte homeostasis; list the differential diagnosis for the most common electrolyte imbalances: hypo- and hypernatremia, hypo- and hyperkalemia, and metabolic acidosis and alkalosis; calculate sodium and potassium deficit replacement; discuss management of the most common electrolyte disorders. Test Questions 1. You have a 28 wk infant on DOL 2 with reported repeat central K of 7.7 mEq/L. Which management modality is best for removing potassium from body? a. Calcium gluconate bolus b. Furosemide q12h c. Glucose bolus followed by insulin infusion 2. The chemistry panel on admission of a 25 weeker showed the following: Na 130, K 4.2, Ca 8.8. The resident wants to add NaCl to the IVF. What do you think? a. Add maintenance sodium because apparently his kidneys are losing the sodium b. Do nothing c. Repeat the lab because you do not believe it 3. You have studied hard preparing for you NCC exam and know that which of the following will increase with advancing gestational age? a. Extracellular fluid b. Intracellular fluid c. Total body water B9 FANNP 25TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW B9: FLUIDS, ELECTROLYTES AND NUTRITION Page 1 of 20
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Fluids, Electrolytes and Nutrition Jacqui Hoffman, DNP, ARNP, NNP-BC NNP Track Coordinator; Clinical Assistant Professor College of Nursing, University of Florida, Gainesville, FL Neonatal Nurse Practitioner Pediatrix Medical Group, Tampa, FL
The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation.
Session Summary
This session will review electrolyte management and common electrolyte disorders to prepare the participant for certification exams.
Session Objectives Upon completion of this presentation, the participant will be able to:
discuss impact of gestational and chronologic age on fluid and electrolyte homeostasis;
list the differential diagnosis for the most common electrolyte imbalances: hypo- and hypernatremia, hypo- and hyperkalemia, and metabolic acidosis and alkalosis;
calculate sodium and potassium deficit replacement;
discuss management of the most common electrolyte disorders.
Test Questions
1. You have a 28 wk infant on DOL 2 with reported repeat central K of 7.7 mEq/L. Which management modality is best for removing potassium from body?
a. Calcium gluconate bolus b. Furosemide q12h c. Glucose bolus followed by insulin infusion
2. The chemistry panel on admission of a 25 weeker showed the following: Na 130, K 4.2, Ca 8.8. The
resident wants to add NaCl to the IVF. What do you think?
a. Add maintenance sodium because apparently his kidneys are losing the sodium b. Do nothing c. Repeat the lab because you do not believe it
3. You have studied hard preparing for you NCC exam and know that which of the following will
increase with advancing gestational age?
a. Extracellular fluid b. Intracellular fluid c. Total body water
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4. You have a term infant with hypoxic-ischemic encephalopathy who is 36 hr old and undergoing head
cooling. The morning labs reflect a serum Na of 121 and it was reported the infant is up 130 gm overnight. The total fluids of D10 TPN were ordered for 60 ml/kg/day but the infant did require PRBC transfusion and normal saline boluses x 2, placing actual fluids for the 24hr at 100 ml/kg/day. The infant’s urinary output was 0.8 ml/kg/hr. The most likely diagnosis for this infant is:
a. Dilutional hyponatremia b. Inadequate sodium supplementation c. Syndrome of inappropriate antidiuretic hormone
5. You have a 36 wk late preterm infant who is 5 days old and has weaned off IVF overnight while the
mother was exclusively breast feeding the infant. The labs this AM show a serum Na of 156 as well as an elevated serum osmolality. The infant’s weight is down 40 gram. The attending ordered urine osmolality which was reported as significantly low. The most likely diagnosis for this infant is:
a. Diabetes insipidus b. Fluid deficit (dehydration) c. Syndrome of inappropriate antidiuretic hormone
6. A 32-week, DOL2 infant with overwhelming sepsis and hypotension has a metabolic acidosis on this
AM’s labs. The morning labs reflect: Na 141, K 3.2, Cl 106, and CO2 16. Calculating the anion gap, how would you classify this metabolic acidosis?
a. Metabolic acidosis with increased anion gap b. Metabolic acidosis with low anion gap c. Metabolic acidosis with normal anion gap
References Ambalavanan, N., Carter, B., MacGilvray, S. & Windle, M. (2012). Fluid, electrolyte, and nutrition management of the
newborn. Retrieved on September 5, 2013 from http://emedicine.medscape.com/artice/976386-overview.
Blackburn, S. (2013). Renal system and fluid and electrolyte homeostasis. In: Maternal, fetal, & neonatal physiology: A clinical perspective (4th ed., pp. 378-381, 383-386). Maryland Heights, MO: Elsevier Saunders.
Brodsky, D. & Martin, C. (2010). Fluids, electrolytes, and renal system. In: Neonatology review (2nd ed., pp. 269-278. Philadelphia: Hanley & Belfus, Inc.
Chow, J. & Douglas, D. (2008). Fluid and electrolyte management in the premature infant. Neonatal Network, 27: 379-385.
Gomella, T., et al. (2013). Fluid and electrolytes. In: Neonatology: Management, procedures, on-call problems, diseases and drugs (7th ed., pp. 89-97). New York: McGraw-Hill Education.
Lorenz, J. (2008). Fluid and electrolyte therapy in the very low-birthweight neonate. NeoReviews, 9(3): e102-e111.
Nash, P. (2007). Potassium and sodium homeostasis in the neonate. Neonatal Network, 26: 125-128.
Wada, M., Kusuda, S., Takahashi, N. & Nishida, H. (2008). Fluid and electrolyte balance in extremely preterm infants < 24 weeks of gestation in the first week of life. Pediatrics International, 50: 331-336.
Session Outline
See presentation handout on the following pages.
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Normal Physiologic Weight LossNormal Physiologic Weight Loss
Normal changesNormal changes–– Decreased TBW Decreased TBW --> increased ICF and decreased > increased ICF and decreased
ECFECF
Term InfantsTerm InfantsTerm InfantsTerm Infants–– Lose up to 5Lose up to 5--10% of birth weight in 110% of birth weight in 1stst five daysfive days
–– Expect weight gain reflecting growth by 10 Expect weight gain reflecting growth by 10 daysdays
Preterm InfantsPreterm Infants–– Lose up to 15Lose up to 15--20% of birth weight20% of birth weight
–– Expect weight gain reflecting growth by 2 (preterm) to Expect weight gain reflecting growth by 2 (preterm) to 3 weeks (3 weeks (micropremiemicropremie))
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Renal Water LossRenal Water Loss
Will discuss more in depth in renal sessionWill discuss more in depth in renal session
Preterm infants have immature Na and Preterm infants have immature Na and water homeostasis due to:water homeostasis due to:
–– Ability to concentrate urine reducedAbility to concentrate urine reduced
–– Decreased bicarbonate, potassium and Decreased bicarbonate, potassium and hydrogen ion secretionhydrogen ion secretion
Renal function matures with ageRenal function matures with ageCloherty, Eichenwald, Hansen & Stark, 2012
Insensible Water LossInsensible Water Loss
Evaporation of nonEvaporation of non--measurable water measurable water losseslosses
Major routes Major routes SkiSki t 70%t 70%–– Skin Skin –– up to 70%up to 70%
–– Respiratory tract Respiratory tract –– up to 30%up to 30%
Factors Affecting Insensible Water Factors Affecting Insensible Water LossLoss
Increased IWLIncreased IWL–– Decreasing gestational age Decreasing gestational age and/or birthweightand/or birthweight
–– Increased environmental Increased environmental temperature above temperature above NTE or bodyNTE or body temperaturetemperatureNTE or body NTE or body temperaturetemperature
–– Skin Skin breakdownbreakdown
–– Congenital skin defect, such as Congenital skin defect, such as large large omphalocele, gastroschisis, neural tube omphalocele, gastroschisis, neural tube defects or epidermolysis bullosadefects or epidermolysis bullosa
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Monitoring Monitoring Fluid BalanceFluid Balance
HistoryHistory
Physical examPhysical exam
WeightWeight
Intake and outputIntake and output
Lab monitoringLab monitoring
Physiologic/environmental factors, i.e. Physiologic/environmental factors, i.e. humidity in isolettehumidity in isolette
Case StudyCase Study
24 week, DOL 324 week, DOL 3
BW 580 gm, current weight 470 gmBW 580 gm, current weight 470 gm
Isolette with 70% humidity, double phototxIsolette with 70% humidity, double phototx
TF (TPN): 115 ml/kg/dayTF (TPN): 115 ml/kg/day
UOP: 1.8 ml/kg/hrUOP: 1.8 ml/kg/hr
Labs: Na 151, BUN 31, Creatinine 0.6Labs: Na 151, BUN 31, Creatinine 0.6
What do you think?What do you think?
Phases of Fluid ManagementPhases of Fluid Management
Initial fluid managementInitial fluid management–– Prevent shock and hypoglycemiaPrevent shock and hypoglycemia
Prediuretic phasePrediuretic phaseC id b d i ht N d iC id b d i ht N d i–– Consider body weight, serum Na and urine Consider body weight, serum Na and urine outputoutput
Diuretic phaseDiuretic phase–– Prone to hypernatremiaProne to hypernatremia
–– Be careful with pharmacologic therapy and Be careful with pharmacologic therapy and impact on renal functionimpact on renal functionimpact on renal functionimpact on renal function
CLDCLD–– Avoid fluid overloadAvoid fluid overload
Balance fluid needs and increased caloric needsBalance fluid needs and increased caloric needs
–– Be careful with diuretic therapyBe careful with diuretic therapyWatch for lyte abnormalities, screen for osteopeniaWatch for lyte abnormalities, screen for osteopenia
Affect of Common Disease States Affect of Common Disease States on FEN Managementon FEN Management
Abdominal wall defectsAbdominal wall defects–– Need increased TF secondary to IWLNeed increased TF secondary to IWL
S/P abdominal surgeryS/P abdominal surgeryI TF d/t thi d iI TF d/t thi d i–– Increase TF d/t third spacingIncrease TF d/t third spacing
–– With third spacing, intravascular fluid leaks With third spacing, intravascular fluid leaks into tissue and bowel wall lumeninto tissue and bowel wall lumen
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ElectrolytesElectrolytes
www.drinkamara.com
ElectrolytesElectrolytes
www.austincc.edu
Electrolyte Content of Body FluidsElectrolyte Content of Body Fluids
N l ECFN l ECF–– Normal ECF Normal ECF Excessive fluid administration (dilutional), Excessive fluid administration (dilutional), Syndrome of inappropriate antidiuretic hormone Syndrome of inappropriate antidiuretic hormone (SIADH)(SIADH)
Symptomatic hyponatremia is medical Symptomatic hyponatremia is medical emergencyemergency–– 3% Hypertonic sodium chloride3% Hypertonic sodium chloride
–– 11--3 ml/kg over 15 minutes, followed by 13 ml/kg over 15 minutes, followed by 1--2211 3 ml/kg over 15 minutes, followed by 13 ml/kg over 15 minutes, followed by 1 2 2 ml/kg/hr until Na > 120 mmol/L; other sources ml/kg/hr until Na > 120 mmol/L; other sources state 6 ml/kg over 6 hrstate 6 ml/kg over 6 hr
–– Monitor closely for fluid overload and pulmonary Monitor closely for fluid overload and pulmonary edemaedema
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Hyponatremia ManagementHyponatremia Management
Asymptomatic hyponatremia management is Asymptomatic hyponatremia management is based on underlying causebased on underlying cause–– Replace deficit Replace deficit –– don’t forget to include don’t forget to include
maintenance needsmaintenance needsInadequate Na intakeInadequate Na intake
Medication related Medication related –– only need to increase Na only need to increase Na neededneeded
–– Restrict fluidsRestrict fluidsSIADH and volume overloadSIADH and volume overload
Hyponatremia ManagementHyponatremia Management
Calculating Na deficitCalculating Na deficit
(CD (CD –– CA) X Vd x Kg = mEq requiredCA) X Vd x Kg = mEq required
Let’s practice Let’s practice –– 1.5 kg infant with a Na 1201.5 kg infant with a Na 120
(130(130--120) x 0.6 x 1.5 = 9 mEq120) x 0.6 x 1.5 = 9 mEq
Remember, this only corrects the deficitRemember, this only corrects the deficit
Must replace slowly for risk of neuro damage!Must replace slowly for risk of neuro damage!
E di i t k (i d ECW)E di i t k (i d ECW)–– Excess sodium intake (increased ECW)Excess sodium intake (increased ECW)
–– Medication relatedMedication related
HypernatremiaHypernatremia
Etiology Clinical Findings
Renal losses Decreased weight
Increased urine Na and volume
Decreased specific gravity
Extrarenal losses Decreased weight
Decreased urine Na and volume
Increased specific gravity
Other causes(Exogenous Na, mineralocorticoid excess, hyperaldosteronism)
Increased weight
Relatively decreased urine Na and volume
Relatively increased specific gravity
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Hypernatremia ManagementHypernatremia Management
Management based on underlying causeManagement based on underlying cause
If due to excess Na intake, remove or If due to excess Na intake, remove or decrease Na, consider diuretic therapydecrease Na, consider diuretic therapy
If h l i /d h d ti l tIf h l i /d h d ti l tIf hypovolemia/dehydration, replace water If hypovolemia/dehydration, replace water deficit slowlydeficit slowly–– Serum Na should decrease no more than 0.5 Serum Na should decrease no more than 0.5
mEq/L/kg/hrmEq/L/kg/hr
–– Target correction over 12Target correction over 12--48hr period48hr period
PotassiumPotassium
Main intracellular cationMain intracellular cation–– Role : maintain normal cardiac rhythm, skeletal Role : maintain normal cardiac rhythm, skeletal
muscle contraction, acidmuscle contraction, acid--base balance, and base balance, and transmission/conduction of nerve impulsestransmission/conduction of nerve impulses
Normal requirementsNormal requirements–– AAdded dded once good UOP is once good UOP is establishedestablished
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HypokalemiaHypokalemia
Etiology Clinical Findings
Decreased K storesHypertension
Increased urine K
Decreased K storesNormal BP – Renal causes
Increased urine K
Decreased K storesNormal BP – Extrarenal causes
Decreased urine K
Normal K stores Increased urine K
Hypokalemia ManagementHypokalemia Management
Management based on underlying causeManagement based on underlying cause
Emergency correction: 0.5Emergency correction: 0.5--1 mEq/kg/dose 1 mEq/kg/dose over 30over 30--60 min minimum60 min minimum
If t ti b t t lif th t iIf t ti b t t lif th t iIf symptomatic but not life threatening, If symptomatic but not life threatening, correction given over 12correction given over 12--24hr to allow slow 24hr to allow slow normalization of serum levelsnormalization of serum levels
Too large or rapid of bolus may cause Too large or rapid of bolus may cause cardiac arrestcardiac arrest
Hypokalemia ManagementHypokalemia Management
Calculating Calculating KK deficitdeficit
(CD (CD –– CA) X Vd x Kg = mEq requiredCA) X Vd x Kg = mEq required
Let’s practice Let’s practice –– 1.5 kg infant with a K 2.81.5 kg infant with a K 2.8
(4.0(4.0--2.8) x 0.3 x 1.5 = 0.54 mEq2.8) x 0.3 x 1.5 = 0.54 mEq
Remember, this only corrects the deficitRemember, this only corrects the deficit
HyperkalemiaHyperkalemia
Central serum K > 6.5 mEq/LCentral serum K > 6.5 mEq/L
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Hyperkalemia ManagementHyperkalemia Management
Hyperkalemia with EKG changes is a Hyperkalemia with EKG changes is a medical emergencymedical emergency–– Furosemide Furosemide
2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po2 mg/kg/dose q12h IV or 4 mg/kg/dose q12h po
–– **Kayexelate**Kayexelate--cation exchange resin (should not cation exchange resin (should not be used in ELBW)be used in ELBW)
Hyperkalemia without EKG changesHyperkalemia without EKG changes–– Remove all K+ from IVF and/or discontinue Remove all K+ from IVF and/or discontinue
supplementationsupplementation
–– Keep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal rangesKeep Ca and Mag levels in normal ranges
Balance between intake/production and Balance between intake/production and metabolism/excretion of acidmetabolism/excretion of acid
Metabolic AcidosisMetabolic Acidosis
Anion gap (mEq/L) = (Na) Anion gap (mEq/L) = (Na) –– ([Cl([Cl--] + ] + [HCO3[HCO3--])])
Normal range: 8Normal range: 8--15 15 U t 18 i tU t 18 i t–– Up to 18 in preterm Up to 18 in preterm
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Metabolic AcidosisMetabolic Acidosis
With normal anion gap (increased ClWith normal anion gap (increased Cl--))–– Renal causes, increased GI losses (diarrhea, Renal causes, increased GI losses (diarrhea,
–– With high urine chloride (> 20 mEq/L)With high urine chloride (> 20 mEq/L)
Hypochloremic metabolic alkalosis probablyHypochloremic metabolic alkalosis probably–– Hypochloremic metabolic alkalosis probably Hypochloremic metabolic alkalosis probably one of the most common disorders seen due one of the most common disorders seen due to diuretic therapyto diuretic therapy
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Metabolic AlkalosisMetabolic Alkalosis
ManagementManagement–– If mild If mild –– moderate, may not require therapymoderate, may not require therapy
–– Treat underlying causeTreat underlying cause
Adjust or discontinue alkali solutionsAdjust or discontinue alkali solutions–– Adjust or discontinue alkali solutionsAdjust or discontinue alkali solutions
–– Assess whether diuretic dose can be Assess whether diuretic dose can be decreased or held temporarily; consider decreased or held temporarily; consider changing to chronic diuretic therapy if on changing to chronic diuretic therapy if on furosemide therapyfurosemide therapy
CHOCHO–– Dextrose: (ml/day of IVF) x (3.4cal/g) x (% Dextrose: (ml/day of IVF) x (3.4cal/g) x (%
dextrose)dextrose)
–– Feeds: (ml/day of feeds) x (amount kcal/oz)Feeds: (ml/day of feeds) x (amount kcal/oz)Example 20cal/30ml or 24cal/30mlExample 20cal/30ml or 24cal/30ml
FatsFats–– 20% IL: (ml/day of IL) x (2kcal/ml)20% IL: (ml/day of IL) x (2kcal/ml)
ProteinProtein–– Gm/kg/day amino acid (AA): (g/day of AA) x Gm/kg/day amino acid (AA): (g/day of AA) x
(4kcal/g)(4kcal/g)
Questions???
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