Cesar Mella

Pediatric Critical Care

Introduction
Case #1
4 year old male presents to ER.
History of vomiting and diarrhea.
He has had 10 episodes of vomiting (clear then yellow
tinged)
8 episodes of diarrhea with some mucousy material in the
first few episodes. The diarrhea is now watery and the last
few episodes have been red in color. The diarrhea odor is
very foul.
He has had a fever T-max 101 degrees at home.
Case #1
His parents gave him a sports drink (red color), and
then they tried clear Pedialyte.
Continues to have vomiting and diarrhea.
He feels weak and tired and he looks slightly pale at
times.
He has only urinated twice in the last 15 hours.
Case #1
Exam: VS T 38.2 degrees (oral), P 110, R45, BP 90/65,
oxygen saturation 100% in room air. Weight 18 kg.
He is alert and cooperative, but not very active.
He is not toxic or irritable. His eyes are not sunken. Oral
mucosa is moist but he just vomited.
CVS/RS exams are normal except for tachycardia. His
abdomen is soft and non-tender. Bowel sounds are
normoactive. He has no inguinal hernias and his testes are
normal. His overall color is slightly pale, his capillary refill
time is 2 seconds over his chest, and his skin turgor feels
somewhat diminished.
Body Water Composition
Body composition is 60% to 75% water.
The 60% applies to adults and the 75% applies to
newborns.
Younger children have more water than adults.
 Out of this, about 60% is intracellular and 40% is
extracellular.
Of the extracellular fluid, 3/4 is interstitial and 1/4 is
circulating as plasma
There is also a small percentage known as trans-cellular
water (about 2%).
 Total Body Water
60%

Extracellular
water 20%
Intracellular Water 40%
Interstitial PV 5%
Fluid 15%
Total Body Water
However, total blood volume is actually 8% to 9% of body
weight for children and 7% of body weight for adults
This is because the red blood cell elements of blood are
not considered to be "body water".
Thus, if plasma consists of 5% of the body weight, a few
more percentage points would account for the circulating
blood volume (which is larger than the circulating plasma
volume).
Normal fluid losses
 Fluid losses occur routinely through urine, stools, respiratory vapor
and insensible skin losses. Perspiration can exaggerate skin losses.
 Illness and exercise can exaggerate respiratory fluid loss through
vapor. (Remember tachypneic patients)
 Other conditions such as burns, vomiting, diarrhea, hemorrhage,
diuretics, etc., can also exaggerate fluid losses.
 Normal fluid losses:

 Insensible 30-40 cc/kg (skin and lungs)

 Urine 60 cc/kg

 Stool 10-20 cc/kg

Osmolality of body fluids
Definition- Solute concentration per unit of solution
(i.e.. serum)
Normal: 280 -295 mOsm/l
Tightly regulated and equal between compartments
Fluid moves from one compartment to the other to
maintain osmolality.
Serum Osmolality

2Na + Bun + Blood Glucose

2.8 18
Renal Fluid Physiology
The postnatal shift in body fluids is principally
mediated through the kidneys' regulation of water
and sodium excretion.
Related to GFR and tubular function.
A term newborn's glomerular filtration rate (GFR) is
25% of an adult's.
Renal Electrolyte and Fluid
Physiology
Clinical states that can increase basal fluid
requirements in the infant include:
Hyperthermia
Increased evaporative losses from mechanical
ventilation
Altered transepithelial losses from premature
gestational age.
Renal Physiology
Simple maneuvers include increasing basal fluid
replacement in infants with hyperthermia or in
those placed under bilirubin heating lamps and
ensuring that all ventilator tubing is humidified.

The patient's state of hydration, renal function,

and osmolar load determine his or her urine
output and concentration.
Renal Physiology
Osmolar load consists of endogenous and exogenous
solutes that the kidney must clear to maintain
homeostasis.

The volume of renal water must be sufficient for the

kidney to clear the osmolar load given its
concentrating capacity.
 Maintenance Fluids
 BW ( kg ) Cal/kg/day

 2.5 - 10 100
 11 - 20 50 (+ 1000)
 20 + 20 (+ 1500)

 1 calorie = amount of heat necessary to

increase the temperature of 1g of water
from 14.5 to 15.5 degree Centigrade.
Maintenance Fluids II
100 cc/kg for the first 10 kg of body weight
50 cc/kg for the next 10 kg of body
20 cc/kg for every kilogram thereafter.

For example, 40kg patient would be:

10 x 100= 1000cc
10 x 50= 500cc
20x 20= 400cc
Total: 1900cc/ 24h
IVF
Normal Saline (0.9 %) = 154 mEq/L

½ N/S (0.45%) = 77 mEq/L

1/3 N/S (0.33%) = 51 mEq/L

¼ NS (0.2 %) = 39 mEq/L
Fluid Deficit States
Clinical
Mild Dehydration (5%)
Moderate Dehydration (10%)
Severe Dehydration (15% or more)
Body Weight
Clinical Dehydration Assessment
Examination Mild Moderate Severe
Percentage 5% 10% 15% or >
Older Child 3% 6% 9% or >
Skin turgor Normal Tenting None
Skin touch Normal Dry Clammy
Buccal Mucosa Moist Dry Cracked
Eyes Normal Deep Set Sunken
Tears Present Reduced None
Fontanelle Flat Soft Sunken
CNS Consolable Irritable Lethargic/Obtunded

Pulse Rate Normal Slightly Increased Increased

Pulse Quality Normal Weak Feeble/Impalpable

Capillary Refill Normal 2 secs >3secs

Urine Output Normal Decreased Anuric
ORS
Preferred
Cheaper
Less Invasive
Can be done at home
But… needs frequent assessments and is much slower
Contraindications
>10 % Dehydration
PO Intolerance
Intractable vomiting
Altered Mental status
Rapid ongoing losses
IV Hydration
NS or LR 20cc/kg is a common starting point
Severe dehydration -> infuse in < 10 mins
Moderate dehydration can be given 1 hr
NS or LR are “isotonic fluids”
Type of Fluids
Maintenance Electrolytes
Na is given as 3 meq/ 100 cc of IVF
K is given as 2 meq / 100 cc of IVF
Replaced evenly over time
Deficit Electrolytes
Rapid onset dehydration > ECF
Prolonged dehydration ECF and ICF
ECF  140 meq/L Na
ICF  140 meq/L K

Duration of symptoms
<3 days: 80% ECF, 20% ICF
> 3days: 60% ECF, 40% ICF
Other Factors
Bolus
Electrolyte Imbalances
Rapid Corrections
Correct Slowly
Reassess
Reassess
Numbers to Memorize
Maintenance Fluid Calculations
100/ 50/ 20
Maintenance Electrolytes
3 meq Na/ 100cc IVF 2 meq K/ 100 cc IVF
Bolus 20 cc/kg
Normal Osmolarity: 290 mOsm/ L
30 cc= 1 ounce
Duration of symptoms
<3 days: 80% ECF, 20% ICF
> 3days: 60% ECF, 40% ICF
Clinical Cases
Case Study #1
HPI:
A 3 month-old is in the PICU for shock following a two
day history of fever and irritability. Blood and CSF
cultures are positive for Streptococcus pneumoniae.
Hospital course:
The urine output had decreased (< 0.5 mL/kg/hr) over
the last 24 hours.
What is your differential diagnosis regarding the
cause of the oliguria?
Case Study #1
Differential Diagnosis
Oliguria
1) Pre-Renal (decreased effective renal blood flow)
 Diminished intravascular volume, cardiac dysfunction,
vasodilatation
2) Renal
 Acute tubular necrosis, acute renal failure, SIADH, ...
3) Post-Renal
 Outlet obstruction (intrinsic vs. extrinsic), Foley catheter
occlusion

 What laboratory studies would you order?

Case Study #1
Laboratory studies
Serum studies
Sodium 126 mEq/L BUN 4 mg/dL
Chloride 98 mEq/L Creatinine 0.4 mg/dL
Potassium 3.7 mEq/LGlucose 129 mg/dL
Bicarbonate 25 mEq/L Osmolality 260 mosm/kg

Urine studies
Specific gravity 1.025 Sodium 58 mEq/L
Osmolality 645 mosm/kg FeNa 2.4%

What are the primary abnormalities?

Case Study #1
Laboratory studies
Major abnormalities
 1) Hyponatremia
 2) Oliguria (inappropriately concentrated urine)

What is the most likely explanation for these findings?

Case Study #1
SIADH
Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) Variable etiology
Trauma Infection
Psychosis Malignancy
Medications Diabetic ketoacidosis
CNS disorders Positive pressure ventilation
“Stress”
Case Study #1
SIADH
 Manifestations
 By definition, “inappropriate” implies the exclusion of normal
physiologic reasons for release of ADH:
 1) In response to hypertonicity.
 2) In response to life threatening hypotension.
 Euvolemia with:
 1. Hyponatremia
 2. Oliguria
 3. Concentrated urine
 elevated urine specific gravity
 “inappropriately” high urine osmolality in face of hyponatremia
 4. Normal to high urine sodium excretion
Case Study #1
SIADH
 Diagnosis
 Critical level of suspicion.
 Demonstration of inappropriately concentrated urine in face of
hyponatremia
  urine osmolality
  SG
  urine sodium excretion ( FeNa)
 Be certain to exclude conditions with normal physiologic release of
ADH
 Frequently secondary to decreased perfusion
  Serum sodium,  urine osmolality,  urine sodium excretion (low
FeNa)  consistent with dehydration or diminished renal blood flow.
Look at patient more closely !!
Case Study #1
SIADH
Treatment
Fluid restriction.
 50-75% of maintenance requirements, be certain to include
oral intake.
Daily weights.
Case Study #1
The saga continues….
Hospital course:
Four hours after beginning fluid restriction, you are
called because the patient developed generalized
seizures. There is no response to two doses of IV
lorazepam (Ativan®) and a loading dose of fosphenytoin
(Cerebyx®)

What is the most likely explanation?

Case Study #1
The saga continues
Seizure
 1) Worsening hyponatremia
 2) Intracranial event
 3) Meningitis
 4) Other electrolyte disturbance
 5) Medication
 6) Hypertension
What diagnostic studies would you order?
Case Study #1
The saga continues
Stat labs: Sodium 117 mEq/L

What would you do now?

Case Study #1
Hyponatremic Seizures
 Treatment: Hypertonic saline (3% NaCl) infusion
 Because patient is symptomatic (seizures), immediately increase
serum sodium by 5 mEq/L
 mEq sodium = (0.6) (Wt in kg) (Desired Na in mEq) =
= (0.6) (8kg) (5 mEq increase) = 24 mEq
 3% NaCl = 0.5 mEq/L, therefore 24 mEq = 48 mL
 To correct sodium to 125 mEq/L, the deficit is equal to
 (0.6) (weight [kg]) (125- measured sodium)
 (0.6)(8)(125-117) = 38.4 mEq
 Follow the initial 24 mEq by slow infusion of remaining 14.4 mEq
(29 mL) over next several hours
 This equation can be estimated by (slight underestimate)
 1mL/kg of 3% NaCl will raise Na by 1 mEq
 If you want to raise Na by 5 mEq give 5 mL/kg
Case Study #2
 HPI:
 A 5 month-old girl presents with a one day history of irritability
and fever. Mother reports three days of “bad” vomiting and
diarrhea.
 Home meds:
 Acetaminophen and ibuprofen for fever
 PE:
 BP 70/40, HR 200, R 60, T38.3 C.
 Irritable, sunken eyes and fontanel, skin feels “doughy”
 No one can obtain IV access after 15 minutes,

What would you do now?

Case Study #2
Place intraosseous line
 Bolus 40 mL/kg of isotonic saline
 Reassessment (HR 170, RR 40, BP 75/40)

Serum studies
Sodium 164 mEq/L BUN 75 mg/dL
Chloride 139 mEq/L Creatinine 3.1 mg/dL
Potassium 5.5 mEq/L Glucose 101 mg/dL
Bicarbonate 12 mEq/L
VBG pH 7.07 pCO2 11 pO2 121 HCO3 8

What type of acid/base disorder does this patient have?

What is the most likely explanation of this patient’s
acidosis?
Case Study #2
Non-anion Gap Metabolic Acidosis
Anion Gap
Sodium - (chloride + bicarbonate)
Normal 12 +/- 2 mEq/L
Elevated anion gap consistent with excess acid
Normal anion gap consistent with excess loss of base
Patient’s Anion Gap: 164 - (139 + 12) = 13
 1. Normal 2. Increased gap
gap

1. Renal “HCO3” 2. GI “HCO3” 1.  Acid prod 2.  Acid elimination

losses losses

Methanol
Uremia Renal disease
Proximal RTA Diarrhea DKA
Distal RTA “Rectal Tubular Paraldhyde
IEM, Iron
Acidosis” Lactate
Ethylene Glycol
Salicylates
Case Study #3
HPI:
 A five year old (18 kg) boy was involved in a a motor vehicle crash
two days ago. He sustained an isolated head injury with
intraventricular hemorrhage and multiple large cerebral
contusions. Three hours ago, he had an episode of severe
intracranial hypertension (ICP 90 mmHg, MAP 50 mmHg,
requiring intravascular volume expansion and epinephrine
infusion for hypotension. Over the last two hours, his urine
output has increased to 130-150 mL/hour (~ 8mL/kg/hr).

What is your differential diagnosis?

What test would you order?
Case Study #3
Differential diagnosis
 Polyuria
1) Central diabetes insipidus
 Deficient ADH secretion (idiopathic, trauma, pituitary surgery, hypoxic
ischemic encephalopathy)
2) Nephrogenic diabetes insipidus
 Renal resistance to ADH (X-linked hereditary, chronic lithium,
hypercalcemia, ...)
3) Primary polydipsia (psychogenic)
 Primary increase in water intake (psychiatric), occasionally
hypothalamic lesion affecting thirst center
4) Solute diuresis
 Diuretics (lasix, mannitol,..), glucosuria, high protein diets, post-
obstructive uropathy, resolving ATN, ….
Case Study #3
Laboratory studies
Serum studies
Sodium 155 mEq/L BUN 13 mg/dL
Chloride 114 mEq/L Creatinine 0.6 mg/dL
Potassium 4.2 mEq/LGlucose 86 mg/dL
Bicarbonate 22 mEq/L Serum osmolality: 320 mosm/kg
Other
Urine specific gravity 1.005, no glucose.
Urine osmolality: 160 mosm/kg

What are the main abnormalities?

Case Study #3
Laboratory studies
Major abnormalities
 1) Hypernatremia
 2) Polyuria (inappropriately dilute urine)

What is the most likely explanation?

Case Study #3
Diabetes Insipidus
Diagnosis
Central Diabetes insipidus
1) Polyuria
2) Inappropriately dilute urine (urine osmolality < serum osmolality)
May be seen with midline CNS defects
Frequently observed in patients with severe
intracranial hypertension resulting in herniation and
loss of cerebral perfusion
What should you do to treat this child?
Case Study #3
Diabetes Insipidus
Treatment
Acute: Vasopressin infusion - begin with 0.5
milliunits/kg/hour, double every 15-30 minutes until
urine flow controlled
Chronic: DDAVP (desmopressin)
Warning
Closely monitor for development of hyponatremia
Case Study #4
 HPI:
 A six year old, 25 kg, boy with severe asthma (S/P ECMO for a
previous exacerbation) presents with a two day history of severe
vomiting and diarrhea to the Emergency Department.
 Home meds:
 Albuterol MDI two puffs QID, Salmeterol MDI two puffs BID,
Prednisone 10mg daily, Fluticasone 220 mcg two puffs BID
 PE:
 BP 70/40, HR 168, R 40, T39.0 C. He is very lethargic (GCS 11).
Poor perfusion with cool extremities, mottling, and delayed
capillary refill, otherwise no specific system abnormalities.

 What is your differential diagnosis?

 What diagnostic studies would you order?
Case Study #4
Differential diagnosis
Shock
1) Cardiogenic
 Myocarditis
 Pericardial effusion

2) Hypovolemic
 Hemorrhage, excessive GI losses, “3rd spacing” (burns,
sepsis)
3) Distributive
 Sepsis, anaphylaxis
Case Study #4
Laboratory studies
Serum studies
Sodium 130 mEq/L BUN 43 mg/dL
Chloride 99 mEq/L Creatinine 0.6 mg/dL
Potassium 5.7 mEq/L Glucose 48 mg/dL
Bicarbonate 12 mEq/L
Other
 WBC: 13k (60% P, 30% L), HCT 35%, PLT 223k
 Chest radiograph: no abnormalities

What are the electrolyte abnormalities?

Case Study #4
Diagnosis
Major abnormalities
 1) Hyponatremic dehydration
 2) Hypoglycemia
 3) Hyperkalemia, mild
 4) Acidosis
 5) Azotemia

What is the most likely explanation for these findings?

Case Study #4
Adrenal Insufficiency
1o adrenal insufficiency (Addison’s disease)
Adrenal gland destruction/dysfunction (ie.
autoimmune, hemorrhagic)
most common in infants 5-15 days old
Secondary adrenal insufficiency
ACTH deficiency (ie. panhypopituitarism or isolated
ACTH)
“Tertiary” or “iatrogenic”
Suppression of hypothalamic-pituitary-adrenal axis (ie.
chronic steroid use)
Case Study #4
Adrenal Insufficiency
Manifestations
Major hormonal factor precipitating crisis is
mineralocorticoid deficiency, not glucocorticoid.
Dehydration, hypotension, shock out of proportion to
severity of illness
Nausea, vomiting, abdominal pain, weakness, tiredness,
fatigue, anorexia
Unexplained fever
Hypoglycemia (more common in children and tertiary)
Hyponatremia, hyperkalemia, azotemia
Case Study #4
Adrenal Insufficiency
Diagnosis - critical level of suspicion in all patients with
shock
1) Demonstration of inappropriately low cortisol secretion
 Basal morning level vs. random “stress” level
 Significant controversy exists as to what level is adequate

2) Determine whether cortisol deficiency dependent or

independent of ACTH secretion.
  ACTH,  cortisol  1o adrenal insufficiency
  ACTH,  cortisol  2nd or tertiary insufficiency

3) Seek a treatable cause

 What should you do to treat this child?
Case Study #4
Adrenal Insufficiency
Treatment
Do not wait for confirmatory labs
Fluid resuscitation - isotonic crystalloid
Treat hypoglycemia
Glucocorticoid replacement - hydrocortisone in stress
doses - 25-50 mg/m2 (1-2 mg/kg) IV every 6 hours
Consider mineralocorticoid (Florinef®)
Case Study #5
HPI:
An eight month old infant with autosomal recessive
polycystic kidney disease presents with irritability. She
is on nightly peritoneal dialysis at home. The lab calls a
panic potassium value of 7.1 mEq/L. The tech states
that the sample did not have hemolysis.
What do you do now?
Case Study #5
Hyperkalemia
Treatment
Immediately recheck serum potassium.
Immediately check EKG and treat if EKG changes are
present
Anticipatory – discontinue all sources of potassium
including feeds
The Patient’s EKG Strip:

What is the immediate next step in treatment?

Case Study #5
Hyperkalemia
 Calcium chloride 10-20 mg/kg over 5 minutes; may repeat x2
 Antagonism of membrane actions of potassium
 First treatment!!!
 Avoid rapid IV push
 Shift potassium intracellularly
 Glucose 1 gm/kg plus 0.1 unit/kg regular insulin
 Alkalinize (increase ventilator rate; Sodium bicarbonate 1 mEq/kg
IV)
 Inhaled 2 adrenergic agonist (albuterol)
 Removal of potassium from the body
 Loop / thiazide diuretics
 Cation exchange resin: sodium polstyrene sulfonate (Kayexelate®) 1
gm/kg PO or PR (or both)
 Dialysis
Case Study #6
HPI:
 A three year old boy is recovering from septic shock. He received
150 mL/kg in fluid boluses in the first 24 hours of therapy and has
developed anasarca. You begin him on a bumetanide infusion
(Bumex®) for diuresis. He develops significant generalized
weakness and begins to hypoventilate. You notice unifocal
premature ventricular beats on his cardiac monitor.

What is your differential diagnosis?

What tests would you order?
Case Study #6
Laboratory studies
 Serum studies
Sodium 134 mEq/L BUN 11 mg/dL
Chloride 98 mEq/L Creatinine 0.4 mg/dL
Potassium 2.4 mEq/L Calcium 9.2 mg/dL
Bicarbonate 27 mEq/L Phosphorus 3.2 mg/dL
 Other
EKG: Unifocal PVC’s

 What is the main abnormality?

Case Study #6
Laboratory studies
Major abnormality
Hypokalemia

What would you do now?

Case Study #6
Hypokalemia
Treatment
Oral
 Safest, although solutions may cause diarrhea
IV
 Peripheral: do not exceed 40-50 mEq/L potassium - Avoid
temptation to administer potassium by rapid bolus
 Central: 0.5 -1 mEq/kg over 1-3 hours, depending on severity

Replace magnesium also if low

 (25-50 mg/kg MgSO4)
Questions? Comments?