1Catecholamines (endogenous & exogenous) r/in reduction of ______ & ______ and stimulate production of ______ & _______, resulting in ______
- insulin secretion and peripheral insulin action
- glucagon and adrenocorticotropic hormone
- hyperglycemia, lipid intolerance, and protein catabolism in acutely and critically ill children.
2Hepatic protein synthesis changes during periods of inflammation, resulting in increased production of C-reactive protein (CRP) and reduced production of albumin and prealbumin
....
3Increased serum counterregulatory hormone concentrations induce insulin and growth hormone resistance, resulting in the catabolism of endogenous stores of protein, carbohydrate, and fat to provide essential substrate intermediates and energy necessary to support ongoing metabolic stress response
....
4______ & _____ compete with bilirubin for binding to albumin in neonatal patients. Increased concentrations of free bilirubin increase the risk for kernicterus; thus, these agents are avoided in neonates
- Ceftriaxone and sulfamethoxazole
5The revised Schwartz equation is used to
- estimate creatnine clearance
- CrCl = [k × height (cm)]/serum creatinine
(K typically= 0.413)
6The Holliday-Segar method is commonly used to calculate
maintenance fluid requirements for a 24-hr period in children
7Classification of Dehydration determined by ____. Isotonic= ______, Hypotonic= ______, Hypertonic= _____
- Serum Sodium Concentration
- Isotonic – Serum sodium 135 to 145
- Hypotonic/Hyponatremia- Serum sodium < 135
- Hypertonic/Hypernatremic- Serum sodium > 145
8Fluid Deficit Calculation
- Fluid Deficit (mL) = % dehydration x weight (kg) x 10
- % Dehydration = (pre-illness weight – illness weight)/illness weight x 100%
9Isotonic and Hyponatremic Dehydration tx:
- Replace 1/2 of the deficit + 1/3 of the MIVF over 8 hours, then the remaining 1/2 of the deficit & 2/3 of the MIVF over the next 16 hours
- or replace the whole deficit over 8 hours, then the whole day’s maintenance over 16 hours
10Hypernatremic Dehydration tx
- Combine the total volume deficit + the MIVF volume for 48 hours; administer this total volume divided over 48 hours.
- Prevents osmotic fluid shifts resulting in cerebral edema and seizures.
11Ensure serum sodium level is NOT corrected by greater than ____ mEq/L/day or ____ mEq/L/h to prevent risk of cerebral edema and seizures
- 10 -12
- 0.5-1
12Hypophosphatemia (P<2.7) caused by
malabsorption, antacid use, diuretic use,
decreased renal reabsorption, cellular uptake
(insulin administration).
13Hypophosphatemia (P<2.7) Sx
- Swollen &slow:
- GI: constipation
- GU:Stones(kidney)
- MSK: Bone pain, DTR decreased
- Muscle weakness
14Hypophosphatemia (P<2.7) management
- P>2.2 intake milk
- P<1.5 or symptomatic give 2.5- 5mg/kg IV phosphate over 6 hours.
15Hyperphosphatemia (P>4.5) caused by
Decreased renal excretion, redistribute from
extra to intracellular, Increased intake (uncommon)
16Hyperphosphatemia (P>4.5) Sx
- Neuro:+ Trousseau’s sign, +Chvostek’s sign, seizures, tetany
- GI: Diarrhea
- Circumoral tingling, Risk of fractures, bleeding
- Cardiac: arrhythmias, QT interval prolonged, Hypotension, bradycardia
17Hyperphosphatemia (P>4.5) management
- Improve renal fxn & excretion: vol. expansion w/ normal saline.
- Phosphate binders: Ca, Mag, or aluminum compounds, Sevelamer
- Dialysis
18Hypokalemia (K<3.5) caused by
Diuretics, GI losses (vomiting, NG tube suction),
diaphoresis, Cushing syndrome, metabolic
alkalosis.
19Hypokalemia, K<3.5 Sx:
Ascending muscle weakness, smooth muscle dysfunction: constipation, ileus, depressed T- wave, U-wave, ST depression
20Hypokalemia, K<3.5 management
- KCl oral 2-5mEq/kg/day divided doses, IV 0.5-1
mEq/kg :must be on cardiac monitor.
21Hyperkalemia K>5 caused by
Excessive intake, salt substitutes, DKA,
decreased excretion (renal failure, beta-blockers,
acidosis), tumor lysis, hemolyzed sample
22Hyperkalemia K>5 Sx
muscle weakness, flaccid paralysis, decreased DTR, numbness &tingling, N/V, Peaked T-wave, wide PR interval, wide QRS complex
23Hyperkalemia K>5 management
- Mild:remove all K+ sources (oral, IV)
- Severe:Stabilize the heart: CaCl (10%) 20mg/kg IV, CaGluc 60-100mg/kg (max 3 grams)
- Move K into the cells: Sodium Bicarb 1-2 mEq/kg IV, Gluc 0.5g/kg + insulin 0.1-0.3 units/kg IV
- Remove K from the blood: Kayexelate 1g/kg PR, Diuretics (Lasix) or albuterol for mild cases, Dialysis
24Hypocalcemia (Ca<8.4, Ical <1 mmol/L in infants, 1.2 mmol/L in kids/teens) caused by
Diarrhea, Vit D deficiency, hypoparathyroidism,
renal insufficiency, massive transfusion, ethylene
glycol
25Hypocalcemia (Ca<8.4, Ical <1 mmol/L in infants, 1.2 mmol/L in kids/teens) Sx
- Neuro:+ Trousseau’s sign, +Chvostek’s sign, seizures, tetany
- GI: Diarrhea
- Circumoral tingling, Risk of fractures, bleeding
- Cardiac: arrhythmias, QT interval prolonged, Hypotension, bradycardia
26Hypocalcemia (Ca<8.4, Ical <1 mmol/L in infants, 1.2 mmol/L in kids/teens) management
Ca supps, CaCl (10%) 20mg/kg IV, CaGluc 60-100mg/kg (max 3 grams)
Need central line for IV Ca
Low albumin: get corrected Ca level
Ca corrected = Ca measured + [0.8 (4.0 – albumin
measured mg/dL)]
27Hypercalcemia (Ca>10.5) caused by
Hyperparathyroidism, corticosteroids
28Hypercalcemia (Ca>10.5) Sx
Swollen &slow:
- GI: constipation
- GU:Stones(kidney)
- MSK: Bone pain, DTR decreased
- Muscle weakness
29Hypercalcemia (Ca>10.5) management
0.9 NaCl, calcitonin. severe: dialysis
30Hyponatremia (Na<135, severe <125) caused by
SIADH, adrenal insufficiency, hypervolemia/hypovolemia, excessive water
intake (Formula)
31Hyponatremia (Na<135, severe <125) Sx
- Neuro: decreased LOC, confusion, seizures, coma
- Cardiac: hypotension, tachycardia, weak thready pulses
- GI: nausea, vomiting
- Respiratory arrest
32Hyponatremia (Na<135, severe <125) management
- NS 20 ml/kg bolus, 3% NaCl 3-5 ml/kg if severe
- Slow correction, 0.5 mEq/L/hr, Rapid causes central pontine demyelination (now called osmotic demyelination syndrome, ODS)
33Hypernatremia (Na >145, severe >160) caused by
Fluid losses, dehydration, salt intake, DI
34Hypernatremia (Na >145, severe >160) Sx
Big & bloated.
Neuro: seizures, AMS
Cardiac: HTN, tachycardia
Skin: flush, edema, low-grade fever
GI: thirst, N/V
GU: low urine output, increased muscle tone
Late serious signs: swollen, dry tongue
35Hypernatremia (Na >145, severe >160) management
Free water
¼ NS, D5W, D10W
Slow correction, 0.5 mEq/L/hr, but not >10
mEq/L/day
Rapid correction causes seizures