BNF for Children 2011-2012

458 9.2.1 Oral preparations for fluid and electrolyte imbalance BNFC 2011–20129 Nutrition and bloodSando-K c (HK Pharma)Tablets, effervescent, potassium bicarbonate andchloride equivalent to potassium 470 mg (12 mmol ofK + ) and chloride 285 mg (8 mmol of Cl ), net price 20= £1.53. Label: 13, 21Modified-release preparationsAvoid unless effervescent tablets or liquid preparationsinappropriateSlow-K c (Alliance) UTablets, m/r, orange, s/c, potassium chloride 600 mg(8 mmol each of K + and Cl ), net price 100 = £2.14.Label: 25, 27, counselling, swallow whole with fluidduring meals while sitting or standingManagement of hyperkalaemiaAcute severe hyperkalaemia calls for urgent treatmentwith intravenous infusion of soluble insulin (0.3–0.6 units/kg/hour in neonates and 0.05–0.2 units/kg/hour in children over 1 month) with glucose 0.5–1 g/kg/hour (5–10 mL/kg of glucose 10%; 2.5–5 mL/kg ofglucose 20% via a central venous catheter may also beconsidered). If insulin cannot be used, salbutamol (section3.1.1.1) can be given by intravenous injection, but ithas a slower onset of action and may be less effective forreducing plasma-potassium concentration.Calcium gluconate (section 9.5.1.1) is given by slowintravenous injection to manage cardiac excitabilitycaused by hyperkalaemia.The correction of causal or compounding acidosis withsodium bicarbonate infusion (section 9.2.2.1) shouldbe considered (important: preparations of sodiumbicarbonate and calcium salts should not be administeredin the same line— risk of precipitation). Intravenousfurosemide can also be given but is less effectivein children with renal impairment. Drugsexacerbating hyperkalaemia should be reviewed andstopped as appropriate; dialysis may occasionally berequired.Ion-exchange resins may be used to remove excesspotassium in mild hyperkalaemia or in moderate hyperkalaemiawhen there are no ECG changes. Calciumpolystyrene sulphonate is preferred unless plasma-calciumconcentrations are high.POLYSTYRENE SULPHONATE RESINSCautions impaction of resin with excessive dosage orinadequate dilution; monitor for electrolyte disturbances(stop if plasma-potassium concentrationbelow 5 mmol/litre); sodium-containing resin incongestive heart failure, hypertension, and oedema;interactions: Appendix 1 (polystyrene sulphonateresins)Contra-indications obstructive bowel disease; neonateswith reduced gut motility; calcium-containingresin in hyperparathyroidism, multiple myeloma, sarcoidosis,or metastatic carcinomaRenal impairment use sodium-containing resin withcautionPregnancy manufacturers advise use only if potentialbenefit outweighs risk—no information availableBreast-feeding manufacturers advise use only ifpotential benefit outweighs risk—no informationavailableSide-effects faecal impaction following rectal administration,gastro-intestinal concretions following oraladministration, intestinal necrosis reported with concomitantuse of sorbitol, gastric irritation, anorexia,nausea, vomiting, constipation (discontinue treatment—avoidmagnesium-containing laxatives), diarrhoea,hypomagnesaemia; gastro-intestinal obstruction,ulceration, necrosis, and ischaemic colitis alsoreported; with calcium-containing resin, hypercalcaemia(including in dialysed patients and occasionallythose with renal impairment); with sodium containingresin, sodium retention, hypocalcaemiaIndication and doseHyperkalaemia associated with anuria orsevere oliguria, and in dialysis patients. By mouthChild 1 month–18 years 125–250 mg/kg (max.15 g) 3–4 times daily. By rectumNeonate 125–250 mg/kg repeated as necessaryevery 6–8 hours. Irrigate colon to remove resinafter 6–12 hoursChild 1 month—18 years 125–250 mg/kgrepeated as necessary every 6–8 hours. Irrigatecolon to remove resin after 6–12 hoursAdministration By mouth: administer in water or as apaste—do not give with fruit squash, which has a highpotassium content.By rectum: mix 1 g of resin with 5–10 mL of amethylcellulose solution. Water may be used butretention is more difficult.Calcium Resonium c (Sanofi-Aventis)Powder, buff, calcium polystyrene sulphonate, netprice 300 g = £68.47. Label: 13Resonium A c (Sanofi-Aventis)Powder, buff, sodium polystyrene sulphonate, netprice 454 g = £67.50. Label: 139.2.1.2 Oral sodium and waterSodium chloride is indicated in states of sodium depletion.In preterm neonates in the first few weeks of lifeand in chronic conditions associated with mild or moderatedegrees of sodium depletion, e.g. in salt-losingbowel or renal disease, oral supplements of sodiumchloride (section 9.2.1.3) may be sufficient. Sodiumchloride solutions suitable for use by mouth in neonatesare available from ‘special-order’ manufacturers or specialistimporting companies, see p. 809; they should beused with care because they are hypertonic. Supplementationwith sodium chloride may be required toreplace losses in children with cystic fibrosis particularlyin warm weather.SODIUM CHLORIDEIndication and doseSee also section 9.2.2