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 5%
( >14 HARI )

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 A B C
Lihat: Kead. Umum Baik, sadar * Gelisah, rewel * Lesu, lunglai, tak sadar
Mata Normal Cekung Sangat cekung & kering
Air mata Ada Tidak ada Tidak ada
Mulut dan lidah Basah Kering Sangat kering
Rasa haus Minum biasa * Haus, ingin * Malas minum atau
tidak haus minum banyak tidak bisa minum

Periksa Turgor kulit Kembali cepat * Kembali lambat * Kembali sgt lambat

Hasil pemeriksaan Tanpa dehidrasi D. Ringan/sedang Dehidrasi berat

1 tanda * (+) 1 atau 1 tanda * (+) 1 atau lebih
lebih tanda lain tanda lain

Terapi Rencana terapi A Rencana terapi B Rencana terapi C

 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
or
Umur < 1 tahun 1-5 tahun > 5 tahun dewasa
Total ORS 300 ml 600 ml 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 2nd treatment
30 ml/KG BB dlm 70 ml/KG BB dlm
Infant < 12 bln 1 jam 5 jam
Anak > 12 bln ½ - 1 jam 2 ½ - 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) KOMPOSISI (mmol/L)
NaCl 3,5 Natrium 90
Na3 sitrat 2,9 Kalium 20
NaH2CO3 2,5 Klorida 80
KCl 1,5 Sitrat 10
Glukosa 20,0 Bikarbonat 30
Glukosa 111
Electrolite composition
Na K Cl HCO3
Cholera diarrhea 101 27 92 32
Non-cholera diarrhea 56 25 55 14

ORS WHO 90 20 80 30
Ringer Lactate 130 4 109 28
NaCl 0,9% 154 0 154 0
DG ana 61 18 52 27
NaCl 0,45% 77 0 77 0
Liquid Na+ K+ HCO3 Carbohy (g/L) mOsm/BW

Cola 2 0.1 13 50-150 gluc, fruc 550

Ginger 3 1 50-150 gluc, fruc

ale

Apple 3 20 100-150 gluc, fruc

Juice
Chicken 250 5 0
Broth
Tea 0 0 0

Gatora 20 3 45 gluc, other sug

de
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 Gram/L
Sodium chloride 3.5
Three sodium citrate 2.9
(dihydrate) 2.5
Sodium bicarbonate 1.5
Potasium chloride 20.0
Glucose (anhydrate)
Composition Mmol/L
Sodium 90
Potasium 20
Chloride 80
Citrate 10
Bicarbonate 30
Glucose 111
 COMPOSITION OF IV
FLUID
Solution Glukosa K+ Na+ Cl- Lactate/
(g/L) Acetate

Hartmann / RL - 4 130 109 28

DGaa 150 17.5 61 52 26
NaCl 0.9% - - 154 154 0
KaEN 3B 27 20 50 50 20
THANK YOU