兒童輸液與電解質平衡

1. 兒童輸液與電解質平衡 台大醫院雲林分院小兒肝膽腸胃科 主治醫師 吳嘉峰醫師

2. 學習目標 • 基本輸液的給予 • 靜脈營養的給予 基本輸液 部份靜脈營養 全靜脈營養

3. Fluid and Nutrition • Basics of fluid management • Nutrition • Enteral nutrition • Parenteral nutrition • Total parenteral nutrition • Partial parenteral nutrition

4. ABC of Fluid Management • Maintenance Fluid • Previous loss (dehydration) • Ongoing loss

5. Maintenance fluid • 1st 10 Kg: 100 mL/kg/day • 2nd 10 Kg (10~20 kg): 50 mL/kg/day • 3rd 10 Kg (> 20 kg): 20 mL/kg/day Or • 1500 ml/M2/Day

6. Previous loss (dehydration) • 方法A: 病史--BW loss? • 方法B: 理學檢查-- mild, moderate, severe dehydration: % BW

7. Ongoing loss • Diarrhea • Vomiting • Stomy: (jejunostomy, ileostomy, colostomy) • Drain tube: NG, penrose drain, PTCD drain, Ascites

8. Ongoing loss • 方法 1: Record I/O (400 cc/m2/day) • 方法 2: Diarrhea: • Mild to moderate: 10-20 g/kg/d • Severe: > 20 g/kg/d

9. 給什麼fluid • Water • NaCl • K • Glucose

10. 口服電解質液

11. How to calculate maintenance fluid and electrolyte ??

12. Average water and e- needed (ml/100 calories/D)

13. Holiday-Segar methodabove 14 days old

14. BSA method

15. How to estimate severity and degree of dehydration ??

17. Percent of deficit from ECF vs ICF

18. Electrolyte composition of ECF & ICF

19. 試算: • 9 kg infant, watery diarrhea 4 day • Previous BW: 10 Kg • Na: 140 mEq/L • 他需要多少 fluid? 多少電解值?

20. Case • Maintenance: 1000 ml/day • Previous loss: 1000 ml (ECF 600 ml, ICF 400ml) • Total : 2000 ml • Ongoing loss

21. Electrolytes • Maintenance: 1000 ml/day Na 30 mEq, K 20 mEq • Previous loss: 1000 ml ECF 600 ml Na 140 x 0.6 = 84 mEq ICF 400 ml K 150 x 0.4 = 60 mEq

22. Fluid needed • 1st 8hrs Total fluid: 833 ml Na 10 + 42 = 52 mEq K 7 + 30 = 37 mEq Infusion rate: 833 / 8 = 104 cc/hr Concentration Na 62 mEq/L, K 44 mEq/L

23. Fluid needed • 16hrs Total fluid: 1167 ml Na 20 + 42 = 62 mEq K 13 + 30 = 43 mEq Infusion rate: 1167 / 16 = 73 cc/hr Concentration Na 53 mEq/L, K 37 mEq/L

24. Hypo or hypertonic dehydration • Hypotonic dehydration: Extra Na needed in IVF 0.6 x BW X (135 – Na) • Hypertonic dehydration: Extra fluid needed 4ml/Kg x BW x (Na – 145)

25. [Na] in Taita Solution • Normal Saline: mEq/L • Taita 1: • Taita 2: • Taita 3: • Taita 5: • 2.5% G/S:

26. [Na] in Taita Solution • Normal Saline: 150 mEq/L • Taita 1: 25 mEq/L (1/6 NS) • Taita 2: 40 mEq/L (1/4 NS) • Taita 3: 75 mEq/L (1/2 NS) • Taita 5: 36 mEq/L • 2.5% G/S: 75 mEq/L

27. [Na] • Lactate Ringer: mEq/L • 3% Saline: mEq/L • FFP: mEq/L • Albumin: mEq/L • Sodium Bicarbonate: mEq/L • Antibiotics:

28. [Na] • Lactate Ringer: 150 mEq/L • FFP: 140-150 mEq/L • Albumin: 140-150 mEq/L • 3% Saline: 500 mEq/L • Sodium Bicarbonate (7%): 830 mEq/L • Antibiotics:

29. How to estimate the amount of ongoing loss and electrolyte composition ??

30. Electrolyte of body fluid

31. How to monitor fluid status ?? • Urine output 小便量 • Heart rate 心跳 • Pulse quality 脈搏 • Capillary refill time 微血管血液回流 • Conscious level 精神狀況 • Activity 活動力 • Fontanel and Eye 囟門與眼窩 • ……………..

32. Overview of rehydration • 口服電解質液— 輕度到中度脫水 • 靜脈點滴補充— 中度到嚴重脫水

33. Parenteral rehydration • Phase I (emergent) management 20 cc / kg isotonic fluid infusion 30 mins 10 cc / kg colloid (plasma, blood..) • Phase II (maintenance, dehydration, ongoing loss)

34. Electrolyte imbalence

35. Hypokalemia 低血鉀 • Decreased stores Hypertension-renovascular disease, excess renin, Cushing syndrome Normal BP-loss from renal or GI Renal-RTA, Fanconi syndrome, Amp-B.. GI-diarrhea, Enema abuse, AN,… • Normal stores Metabolic alkalosis, hyperinsulinemia,….

36. Hypokalemia 低血鉀 • 臨床症狀: weakness, ileus, arrhythmia (ECG: flat or absent T, U wave) • 檢驗: 血液(electrolyte, BUN, Cre, CK, Glucose, Renin, ABG, Cortisol), 尿液(UA, electrolyte, Osmolality, 17-KS), EKG

37. Hyperkalemia 高血鉀 • Increased stores Increased urine K-aged blood transfusion, medications Decreased urine K-renal failure, diuretics, hyperaldosteronism, CAH • Normal stores cell lysis syndrome, Type IV RTA, metabolic acidosis, malignant hyperthermia,..

38. Hyperkalemia 高血鉀 Serum level ECG Symptoms ~ 7.5 Peaked T wave weakness ~ 8.0 loss of T, wide QRS ~ 9.0 ST elevation tetany wide QRS ~ 10.0 Bardycardia, VT 1st AV block, cardiac arrest

39. 如何處理高血鉀 • Mild to moderate (6-7) Cardiac monitor, elimination K from IVF and diet Kayexalate po or retention enema q4-6h • Severe (>7) RI 0.1 U/Kg with D25W 2ml/kg for 30 mins NaHCO3 1-2 ml/kg IV over 5-10 mins Ca gluconate (10%) 1 ml/kg/dose over 3-5 mins Kayexalate po or enema Dialysis

40. Hyponatremia 低血鈉 • 病患體重減輕 腎臟流失-利尿劑, 腎上腺功能低下 非腎臟流失-腸胃道流失, 皮膚流失, 3rd space • 病患體重正常或增加 腎衰竭, 心臟衰竭, SIADH,水中毒 , 醫療造成(iatrogenic)

41. Hyponatremia • 假性低血鈉 高血脂 Na↓ 0.002 x lipid (mg/dL) 高血蛋白 Na↓ 0.25 x (protein-8) (g/dl) 高血糖 Na↓ 1.6 mEq/L for 100 mg/dL raise in glucose • 臨床症狀: lethargy, weakness, CNS s/s

42. Hypernatremia • Decreased weight Renal loss: nephropathy, Diuretics, DI, ATN,.. Extrarenal: GI loss, skin and lung loss • Increased weight Exogenous Na, hyperaldosteronism, mineralcorticoid excess

43. Hypernatremia • Clinical symptoms: seizure, lethargy, weakness, altered mental status, irritability, respiratory failure… • Management: Replace free water loss

44. Parenteral nutrition in Children

45. Indications for parenteral nutrition • 無法從腸道攝取足夠營養者 • Intestinal disease(malabsorption, ileus, short bowel, fistula) • Severe malnutrition • Pancreatitis • Very low birth weight • Others

46. TPN: indication • 應先考慮腸道營養，再考慮靜脈營養 • Poor intake for 1 week • Peripheral parenteral nutrition • Failure of oral intake for more than 2-4 weeks • Total parenteral nutrtion

47. TPN • 如何開 TPN • 如何監測 Monitor • 併發症及預防 Complications

48. 如何開TPN • 1. 決定fluid/day的量 • 2. 決定calorie/day的量 (與給予途徑有關） • 3. 決定energy composition (%) • 4. 決定其他添加物的量 ： • electrolyte, vitamins, trace elements, (heparin)

49. TPN route • PPN: carbohydrate concentration <13%; Osmolarity: 300~900mOsm/L, No Ca • Central PN: carbohydrate concentration up to 35%; Osmolarity > 900mOsm/L

50. Calorie requirement • Determine ideal body weight, present body weight • Infant: 100 kcal/kg/d, 每三年減少10kcal/kg/d Adult 30-35 kcal/kg/d