Fluid-Electrolyte Balance

in Children
Dr. Wan Nedra K, Sp.A
Bagian Ilmu Kesehatan Anak
FK.YARSI, Jakarta
11/03/09

Objective
Water
Facts
Compartments
Intake and output

Electrolytes
Imbalances of Water and Electrolytes
Dehydration and treatment

Water - Facts
Water is the most abundant compound in
the body
About 50-60% of your body weight if you are
young, healthy and weigh about 120 lbs.
Lean tissue has more water that fat tissue so the
more fat you are carrying the lower the percent
body water.

Water - Facts
Females generally have slightly less water
per pound of weight because their bodies
(should) have more fat than male bodies.
Age:
Infants have more water per pound body weight
than adults (may be as high as 80%).
Older adults have less water per pound of body
weight.

Water Compartments
Water moves by filtration or osmosis among 3
compartments in the body:
Intracellular fluid (ICF)
Extracellular fluid (ECF)
Plasma
Interstitial spaces (IF) (tissue fluid); microscopic spaces
between cells. Also includes lymph, CSF, synovial fluid,
aqueous humor and serous fluid. The volume in this
compartment varies more than in the other compartments.

Water Intake and Output

Body water homeostasis is normally
regulated by processes that adjust output to
intake. Processes that adjust fluid intake
are secondary.
Fluid Intake: *what we drink (beverages),
water in foods we eat and water formed by
catabolism of food.

Water Intake and Output

Fluid output: via *kidneys, lungs, skin and
intestines.
Fluid lost from the skin and lungs is called
insensible fluid loss meaning that we usually
are not aware of it.
Obligatory water loss: amount of water
necessary to excrete wastes through the kidney.
Feces

Water Intake and Output

Water output by the kidneys is the most
changeable usually matching the volume of fluid
we take in.
The rate of water and salt reabsorption by the
renal tubules is the most important factor in
determining urine volume.
ADH?
Aldosterone?

Water Intake and Output

Neural control
Signal
Osmolarity = concentration of dissolved materials in fluid
(Na, K, Cl, glucose, proteins, etc.). Increased materials or
decreased water causes an increase in osmolarity.

Osmoreceptors

Electrolytes
Chemicals that dissolve in water and dissociate
into positive and negative ions (including
inorganic salts, acids and bases).
Electrolytes also help to create the osmolarity of
body fluids and therefore regulate the movement
of water between compartments.
Water is attracted to electrolytes, especially Na+.
Water will move from a compartment with a low
concentration of electrolytes to one with a high
concentration of electrolytes = osmosis.

Electrolytes
Cations positive ions
Na+ (sodium) - most abundant cation in the
ECF; essential for electrical activity of nerve
and muscle cells. The level of Na+ is regulated
primarily by the kidneys.
K+ (potassium) - most abundant cation in the
ICF; essential for electrical activity of nerve
and muscle cells.

Electrolytes
Cations
Ca2+ (calcium) - mostly in bones and teeth;
essential for blood clotting; maintains normal
nerve and muscle cell function.
Mg2+ (magnesium) - more abundant in ICF than
ECF; essential for ATP production and activity
of nerve and muscle cells.

Electrolytes
Anions negatively charged ions.
Cl- (chloride) - most abundant anion in the ECF.
HCO3- (bicarbonate) part of the bicarbonate
buffer system.
HPO42- (phosphate)
Proteins- - (negatively charged proteins) inside
the cell and in plasma regulate water in those
compartments and play a role in regulating
electrolyte distribution.

Electrolytes
Non-electrolytes most organic compounds
that do not ionize (dissociate) in solution,
ex. glucose. These compounds do
contribute to the osmolarity.

Edema
Presence of abnormally large amount of
fluid in the intercellular tissue spaces.
Causes:
Retention of electrolytes, especially Na+ (remember Na+
attracts water).
Increase capillary BP that pushes fluid out of the blood
into the IF. Fluid shift blood volume decreases and
IF increases.
Common during heart failure due to venous congestion
= increased pressure in the capillary beds.

Edema
Causes
Plasma proteins act as water holding force, if the
concentration of blood proteins decreases less water
moves from the IF into the blood. Result: water will
accumulate in the IF. ?Why
Proteins inside the cell also act to regulate intracelluar
water content.

Fluid Imbalances
Dehydration

Overhydration
Diuretics

DIARE AKUT

85%

DIARE MELANJUT

10%

(>7 HARI )

DIARE KRONIK
( >14 HARI )

5%

Diare: onset cepat +/- diikuti dengan gejala seperti mual,

muntah, demam dan nyeri perut

TATALAKSANA DIARE (1)

Rehidrasi oral/parenteral
Dukungan nutrisi
Obat atas indikasi
Edukasi orangtua

TATALAKSANA DIARE (2)

Penanganan dehidrasi:
Ask,look, and feel tanda-tanda dehidrasi
Kondisi anak & pemeriksaan fisis: mata, air mata, mulut
& lidah. Apakah tampak kehausan, skin pinch
Anterior fontanelle, arms & legs, pulse, breathing
Tentukan derajat dehidrasi (Berat, ringan sedang atau tanpa
dehidrasi)
Pilih rencana pengobatan:
C: Severe dehydration (loss of >10% of Body Weight)
B: Some dehydration (loss of 5-10% of BW)
A: No signs of dehydration (loss of <5% of BW)
Jangan lupa timbang BB (BB sebelum sakit ?, saat sakit )

Penilaian
Lihat: Kead. Umum
Mata
Air mata
Mulut dan lidah
Rasa haus

A
Baik, sadar

B
* Gelisah,

rewel

C
* Lesu,

lunglai, tak sadar

Normal

Cekung

Ada

Tidak ada

Tidak ada

Basah

Kering

Sangat kering

Minum biasa
tidak haus

* Haus, ingin
minum banyak

* Malas minum atau

tidak bisa minum

Periksa Turgor kulit

Kembali cepat

* Kembali

Hasil pemeriksaan

Tanpa dehidrasi

D. Ringan/sedang

Dehidrasi berat

1 tanda * (+) 1 atau

lebih tanda lain

1 tanda * (+) 1 atau lebih

tanda lain

Rencana terapi B

Rencana terapi C

Terapi

Rencana terapi A

lambat

Sangat cekung & kering

* Kembali

sgt lambat

REHIDRASI ORAL
Diare tanpa dehidrasi sampai dehidrasi
ringan-sedang.
Oralit WHO
CRO lain: laritan gula-garam, larutan
garam-tajin, Pedialyte
Segera setelah diare terjadi

PENYEBAB GAGALNYA
CRO
Keluaran tinja yang banyak
Muntah terus menerus
Dehidrasi berat
Tidak mampu atau menolak minum
Malabsorpsi glukosa
Perut kembung dan ileus
Cara penyiapan dan pemberian oralit yang tidak
benar

TAHAPAN CRO
TAHAPAN REHIDRASI
Mengganti kehilangan cairan dan elektrolit
yang telah terjadi
TAHAP RUMATAN
Mengganti cairan dan elektrolit akibat diare
dan muntah yang masih berlangsung

INDIKASI REHIDRASI
PARENTERAL
Dehidrasi berat
Tidak dapat minum (lemah, sopor atau
koma)
Muntah hebat
Oliguri atau anuri berkepanjangan
Komplikasi serius lain yang menghambat
keberhasilan rehidrasi oral

REHIDRASI PARENTERAL
UNTUK DEHIDRASI BERAT
Berikan larutan RL atau DGaa
BAYI (<12 bln)
1 jam pertama: 30 ml/kgbb*
5 jam berikutnya: 70 ml/kgbb
ANAK (>12 bln)
1 jam pertama: 30 ml/kgbb*
3 jam berikutnya: 70 ml/kgbb
Ulangi biula denyut nadi masih sangat lemah atau tidak teraba

UPAYA PENCEGAHAN
DIARE
Pemberian ASI
Perbaikan cara pemberian makanan pendamping
ASI
Penggunaan air bersih yang cukup
Cuci tangan
Penggunaan jamban
Pembuangan tinja bayi/anak yang semestinya
Imunisasi campak

PLAN TREATMENT A
Tanpa Dehidrasi
Muntah (-) diet yg biasa pd pasien
dilanjutkan
Malabsorption (-) Tidak ada diet spesifik

Cairan Rehidrasi Oral (CRO) setiap

BAB banyak (bukan kecipirit) atau muntah

PLAN TREATMENT B
Dehidrasi Ringan-Sedang
CRO (3 jam I) 75 ml x BB
Umur

< 1 tahun

Total ORS

300 ml

or
1-5 tahun
600 ml

> 5 tahun

dewasa

1200 ml

2400 ml

Evaluasi ualng setelah 3-4 jam rencana th/ A,

B, or C

PLAN TREATMENT C
Dehidrasi berat, IVFD

Umur

Ist treatment
30 ml/KG BB dlm

2nd treatment
70 ml/KG BB dlm

Infant < 12 bln

1 jam

5 jam

Anak > 12 bln

- 1 jam

2 - 3 jam

Re-evaluasi setiap 1-2 jam

CRO
Setelah 6 jam (bayi) atau 4 jam (anak) reevaluasi
rencana treatment A,B,C

TATALAKSANA DIARE DI
RUMAH
Beri minum lebih banyak dari biasanya
Beri makan lebih sering
Bawa/rujuk ke petugas kesehatan bila
keadaan tidak membaik

RUJUK ANAK KE PETUGAS

KESEHATAN
Bila anak tidak membaik dalam 3 hari
Bila timbul salah satu dari keadaan berikut
ini:
Tinja cair lebih sering/banyak
Muntah berulang
Rasa haus yang nyata
Demam
Terdapat darah dalam tinja
Bila anak hanya makan/minum sedikit

KOMPOSISI ORALIT
(WHO)
Nama Bahan (g/L)
NaCl
3,5
Na3 sitrat 2,9
NaH2CO3

2,5

KCl
Glukosa

1,5
20,0

KOMPOSISI (mmol/L)
Natrium
90
Kalium
20
Klorida
80
Sitrat
10
Bikarbonat 30
Glukosa
111

Electrolite composition
Na

Cl

HCO3

Cholera diarrhea

101

27

92

32

Non-cholera diarrhea

56

25

55

14

ORS WHO

90

20

80

30

Ringer Lactate

130

109

28

NaCl 0,9%

154

154

DG ana

61

18

52

27

NaCl 0,45%

77

77

Liquid

Na+

K+

HCO3

Cola

0.1

13

Ginger
ale

50-150 gluc, fruc

Apple
Juice

20

100-150 gluc, fruc

Chicken 250
Broth

Carbohy (g/L)
50-150 gluc, fruc

Tea

Gatora
de

20

45 gluc, other sug

mOsm/BW
550

Evaluasi (clinical ssessment)

Tanda2 faktor cormobid conditions
travel, animal/bird, day care, antibiotic

Characteristic
Blood : inflamatory bacterial disease aggressive
work up & intervention

Gross or occult blood in the stool

Shigella sp, Campylobacter sp, EHEC

Pemeriksaan Laboratorium

Laboratorium rutin sesuai dg indikasi

Tergantung kebutuhan pasien
Jika terapi cairan rehidrasi oral gagal

Jika leukosit pada feses banyak

indikasi terdapat proses inflamasi ec bakteri
Pikirkan untuk Kultur Feses

Kesimpulan
Diare pd anak masih merupakan masalah yg serius

Tatalaksana utama adalah rehidrasi

Penting mengetahui penyebab diare

WHO ORS COMPOSITION

Contain
Sodium chloride
Three sodium citrate
(dihydrate)
Sodium bicarbonate
Potasium chloride
Glucose (anhydrate)

Gram/L
3.5
2.9
2.5
1.5
20.0

Composition
Sodium
Potasium
Chloride
Citrate
Bicarbonate
Glucose

Mmol/L
90
20
80
10
30
111

COMPOSITION OF IV
FLUID
Solution

Glukosa
(g/L)

K+

Na+

Cl-

Lactate/
Acetate

Hartmann / RL
DGaa
NaCl 0.9%
KaEN 3B

150
27

4
17.5
20

130
61
154
50

109
52
154
50

28
26
0
20

THANK YOU