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Chapter 73 1009 C h a p t e r 73 Fluid and Electrolyte Issues in Pediatric Critical Illness Robert Lynch, Ellen Glenn Wood, and Tara M. Neumayr intraoperative fluids influence acid-base and electrolyte status, PEARLS particularly of vulnerable patients.4 The choice of Na+ content • Hypotonic maintenance IV fluids are associated with mild to and balancing ions of IVF for postoperative or critical care moderate hyponatremia in postoperative patients. maintenance may be important for some patients thus justify- Anesthesia, stress, and inflammatory mediators probably ing additional expense. Clearly 0.18 and 0.225 mM saline is 5,6 contribute. Electrolyte monitoring in patients at risk is associated with a higher incidence of mild hyponatremia, essential for detection and management of the occasional although controlled trials do not show this effect for 0.46 mM 7,8 patient who develops severe hyponatremia. This critical saline. Severe hyponatremia has been associated with pul- effect of the syndrome of inappropriate antidiuretic hormone monary or CNS illness in pediatrics and is infrequent even may occur even in patients on isotonic IV fluids. within those categories, with the exception of children with • Medical patients with high levels of inflammatory mediators traumatic brain injury (TBI). Among patients with those and appear to be at increased risk of significant hyponatremia. other illnesses, the evolving study of the influence of inflam- Interleukin effects on antidiuretic hormone release may matory mediators directly on the hypothalamus and indirectly contribute. on vasopressin secretion may further clarify which patients are 9,10 • Albumin infusions have been generally safe but may at most risk of clinically significant hyponatremia. introduce increased mortality risk in patients with traumatic Evidence for and against the use of colloids in specific brain injury. Those given albumin had increased intracranial groups of critical patients is accumulating. Intriguing but less 11-14 pressure, which may contribute to the apparent risk. than definitive studies suggest benefit in severe sepsis and • After septic patients achieve hemodynamic stabilization, possible harm in patients with TBI, perhaps associated with 15 avoiding or correcting excessive fluid volume overload will increased intracranial pressure. Consideration of albumin 16,17 assist in liberating patients from ventilators and the intensive use in selected patients remains appropriate. Albumin does care unit. appear useful in stabilizing patients with severe hepatic failure 18-20 • Proton pump inhibitors may cause hypomagnesemia, and in prevention of hepatorenal syndrome. particularly in patients on concurrent diuretics. Although Evidence for albumin use with or without diuresis among usually mild, this may be of significance in critically those with acute respiratory distress syndrome (ARDS) sug- 21 vulnerable patients. gests improved oxygenation but minimal effect on outcomes. In general, in patients with relatively intact vascular endothe- lium, 10 to 15 mL/kg of 4% or 5% albumin may be used for intravascular volume expansion with slower leakage into the ECF space compared to crystalloids. Albumin concentrate at Overview 25% may be useful in temporarily redistributing ECF volume Traditional fluid and electrolyte management in critical illness from the extravascular to the intravascular space to facilitate is being refined by science, observations of clinical experience, organ perfusion and spontaneous or drug-assisted diuresis and expert opinion. Particular attention is drawn to intrave- with minimal additional infused fluid volume. There are cur- nous fluid (IVF) composition, appropriate uses and choices rently no formulations of hydroxyethyl starch that can be of colloids, extracellular fluid (ECF) volume targets from recommended for use in critically ill patients.22,23 resuscitation to maintenance, and approaches to removal of Adult and pediatric studies have raised concern regarding excessive ECF volume using diuresis, continuous renal replace- damaging effects of fluid volume overload particularly in ment therapy (CRRT), and intermittent hemodialysis (IHD). patients with sepsis or ARDS.24,25 Patients with less fluid gain Fluid and electrolyte management often begins at resuscita- early in their illness have more ventilator-free days and shorter tion, but important choices are also made at anesthesia induc- ICU stays than those with greater than 10% to 15% early posi- tion and at initial postoperative maintenance. Resuscitative tive fluid balance. It remains unclear if mortality rates are normal saline imposes an acid load, largely related to the affected.26-29 chloride content.1 Although physiologically effective and This effect of fluid volume on morbidity and perhaps mor- cost effective in almost all circumstances,2 concerns regarding tality has led to proposals of a phased approach to fluid man- chloride toxicity warrant further clarification.3 Similarly, agement including aggressive resuscitation using appropriate 1007 Downloaded for Anonymous User (n/a) at Walter Reed National Military Medical Center from ClinicalKey.com by Elsevier on December 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 1008 Section V Renal, Fluids, Electrolytes fluids guided by careful clinical measurement and evaluation, severe hyponatremia, although gross feeding or iatrogenic prompt reduction of resuscitation fluid rates when hemody- misadventures also should be considered. Severe hyponatre- namically tolerated, gradual correction of volume excesses mia, which is variably defined as a serum sodium concentra- using fluid restriction, colloid dosing to adjust fluid space tion of either <125 mEq/L or <120 mEq/L, is uncommon distribution, continuous infusion diuresis, and CRRT or IHD and is usually associated with known risk factors such as pul- when needed.30-33 monary or CNS disease or injury or the use of certain drugs. As ICU patients progress from stabilization to maintenance, Mild hyponatremia is common among hospitalized pediatric ECF volume overload may spontaneously resolve, or it may patients and occurs predictably in postoperative patients. warrant active intervention due to the association of persisting Patients with renal, hepatic, or cardiac disease and those major overload with increased morbidity. Loop diuretics do exposed to prolonged general anesthesia are particularly at not prevent or ameliorate acute kidney injury34 but may be risk. Accurate identification of patients at risk will inform useful in mobilizing excess ECF volume.35 Studies of this decisions on frequency of laboratory monitoring and will measure are variable as to dosages, patient diagnoses, and allow an early evaluation of and response to evolving hypo- renal conditions. Carefully titrated continuous infusion of natremia, whether related to water retention or sodium loop diuretics may be superior to bolus dosing.36-39 In ARDS, excretion. continuous infusion plus albumin have enhanced fluid mobilization.40-42 Careful studies of approaches to fluid Pathophysiology and Etiology removal are needed. Accompanying loss of K+, Ca++, and Hyponatremia may occur in the presence of decreased, Mg++ should be anticipated and replaced appropriately. For increased, or normal amounts of total body sodium. patients unresponsive to diuresis, either CRRT or IHD can provide electrolyte management and gradual ECF fluid Decreased Total Body Sodium correction43-45 (see also Chapter 78). Loss of total body sodium results in hyponatremia if total body water is retained in relative excess of the sodium loss. Hypovolemic stimulation of antidiuretic hormone (ADH) Sodium release may overwhelm osmotic ADH control, maintaining Sodium distribution is 90% extracellular and, with its associ- water retention despite hyponatremia and hypoosmolality. A ated anions, largely determines the osmotic condition of the decrease of as little as 5% in circulating volume may be suf- extracellular fluid (ECF). Disturbance of ECF osmolality ficient to trigger this response.54 Sodium deficit and volume affects cell volume with critical clinical significance in the loss may occur through extrarenal or renal losses. In children, central nervous system (CNS). Neurologic symptoms, there- extrarenal losses most often occur from vomiting and diar- fore, dominate the clinical picture in both hyponatremia and rhea. In critically ill patients, large extrarenal losses may result hypernatremia. In pediatric patients in the intensive care unit from fluid sequestration that occurs with septicemia, perito- (ICU), young age, underlying neurologic conditions, develop- nitis, pancreatitis, ileus, rhabdomyolysis, ventriculostomy mental delay, cerebral hypoperfusion, and medication effects drains, and burns. Renal losses include diuretic use, osmotic may obscure subtle neurologic findings, and judicious labora- diuresis, various salt-losing renal diseases, CSW, and adrenal tory monitoring along with careful clinical assessment is insufficiency.55 essential. Emerging evidence in both adult and pediatric patients sug- Renal Sodium Losses gests an association between disturbances in sodium balance Renal salt-wasting states are generally identified by a urinary and adverse outcomes, including mortality, ICU length of stay sodium excretion in excess of 20 mEq/L and a fractional (LOS), use of both noninvasive and invasive mechanical ven- excretion (FENa) of more than 1%. The use of thiazide diuret- tilation,
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