Cesar Mella Pediatric Critical Care

Introduction Case #1
y 4 year old male presents to ER. y History of vomiting and diarrhea. y He has had 10 episodes of vomiting (clear then yellow tinged) y 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. y He has had a fever T-max 101 degrees at home.

Case #1
y His parents gave him a sports drink (red color), and

then they tried clear Pedialyte. y Continues to have vomiting and diarrhea. y He feels weak and tired and he looks slightly pale at times. y He has only urinated twice in the last 15 hours.

Case #1
y Exam: VS T 38.2 degrees (oral), P 110, R45, BP 90/65, oxygen saturation 100% in room air. Weight 18 kg. y He is alert and cooperative, but not very active. y He is not toxic or irritable. His eyes are not sunken. Oral mucosa is moist but he just vomited. y 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
y Body composition is 60% to 75% water. y The 60% applies to adults and the 75% applies to newborns. y Younger children have more water than adults. y Out of this, about 60% is intracellular and 40% is extracellular. y Of the extracellular fluid, 3/4 is interstitial and 1/4 is circulating as plasma y There is also a small percentage known as trans-cellular water (about 2%).

Total Body Water
Total Body Water 60% Extracellular water 20%

Intracellular Water 40%

Interstitial Fluid 15%

PV 5%

Total Body Water
y However, total blood volume is actually 8% to 9% of body weight for children and 7% of body weight for adults y This is because the red blood cell elements of blood are not considered to be "body water". y 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
y Fluid losses occur routinely through urine, stools, respiratory

vapor and insensible skin losses. Perspiration can exaggerate skin losses. y Illness and exercise can exaggerate respiratory fluid loss through vapor. (Remember tachypneic patients) y Other conditions such as burns, vomiting, diarrhea, hemorrhage, diuretics, etc., can also exaggerate fluid losses. y Normal fluid losses:
y Insensible 30-40 cc/kg (skin and lungs) y Urine 60 cc/kg y Stool 10-20 cc/kg

Osmolality of body fluids
y Definition- Solute concentration per unit of solution

(i.e.. serum) Normal: 280 -295 mOsm/l Tightly regulated and equal between compartments y Fluid moves from one compartment to the other to maintain osmolality.

Serum Osmolality
2Na + Bun + Blood Glucose 2.8 18

Renal Fluid Physiology
y The postnatal shift in body fluids is principally

mediated through the kidneys' regulation of water and sodium excretion. y Related to GFR and tubular function. y A term newborn's glomerular filtration rate (GFR) is 25% of an adult's.

Renal Electrolyte and Fluid Physiology
y Clinical states that can increase basal fluid

requirements in the infant include:
y Hyperthermia y Increased evaporative losses from mechanical

ventilation y Altered transepithelial losses from premature gestational age.

Renal Physiology
y 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.
y The patient's state of hydration, renal function, and

osmolar load determine his or her urine output and concentration.

Renal Physiology
y Osmolar load consists of endogenous and exogenous

solutes that the kidney must clear to maintain homeostasis.
y The volume of renal water must be sufficient for the

kidney to clear the osmolar load given its concentrating capacity.

Maintenance Fluids 
BW (

kg )  2.5 - 10  11 - 20  20 + 

Cal/kg/day 100 50 (+ 1000) 20 (+ 1500)

calorie = amount of heat necessary to increase the temperature of 1g of water from 14.5 to 15.5 degree Centigrade.

Maintenance Fluids II
y 100 cc/kg for the first 10 kg of body weight y 50 cc/kg for the next 10 kg of body y 20 cc/kg for every kilogram thereafter. y For example, 40kg patient would be:
y 10 x 100= 1000cc y 10 x 50= y 20x 20= y Total:

500cc 400cc 1900cc/ 24h

y Normal Saline (0.9 %) = 154 mEq/L

y½ N/S
y 1/3 N/S y ¼ NS

(0.45%) = 77 mEq/L (0.33%) = 51 mEq/L (0.2 %) = 39 mEq/L

Fluid Deficit States
y Clinical y Mild Dehydration (5%) y Moderate Dehydration (10%) y Severe Dehydration (15% or more) y Body Weight

Clinical Dehydration Assessment
Examination Percentage Older Child Skin turgor Skin touch Buccal Mucosa Eyes Tears Fontanelle CNS Pulse Rate Pulse Quality Capillary Refill Urine Output Mild 5% 3% Normal Normal Moist Normal Present Flat Consolable Normal Normal Normal Normal Moderate 10% 6% Tenting Dry Dry Deep Set Reduced Soft Irritable Severe 15% or > 9% or > None Clammy Cracked Sunken None Sunken

Slightly Increased Increased Weak 2 secs Decreased Feeble/Impalpable >3secs Anuric

y Preferred y Cheaper y Less Invasive y Can be done at home y But

needs frequent assessments and is much slower

y >10 % Dehydration y PO Intolerance y Intractable vomiting y Altered Mental status y Rapid ongoing losses

IV Hydration
y NS or LR 20cc/kg is a common starting point y Severe dehydration -> infuse in < 10 mins y Moderate dehydration can be given 1 hr y NS or LR are isotonic fluids

Type of Fluids
y Maintenance Electrolytes y Na is given as 3 meq/ 100 cc of IVF y K is given as 2 meq / 100 cc of IVF y Replaced evenly over time

Deficit Electrolytes
y y y y

Rapid onset dehydration > ECF Prolonged dehydration ECF and ICF ECF $ 140 meq/L Na ICF $ 140 meq/L K

y Duration of symptoms y <3 days: 80% ECF, 20% ICF y > 3days: 60% ECF, 40% ICF

Other Factors
y Bolus y Electrolyte Imbalances y Rapid Corrections y Correct Slowly y Reassess y Reassess

Numbers to Memorize
y Maintenance Fluid Calculations
y 100/ 50/ 20

y Maintenance Electrolytes
y 3 meq Na/ 100cc IVF

2 meq K/ 100 cc IVF

y Bolus 20 cc/kg y Normal Osmolarity: 290 mOsm/ L y 30 cc= 1 ounce y Duration of symptoms
y <3 days:

80% ECF, y > 3days: 60% ECF,

20% ICF 40% ICF

Clinical Cases

Case Study #1
y HPI: y 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. y Hospital course: y The urine output had decreased (< 0.5 mL/kg/hr) over the last 24 hours. y What is your differential diagnosis regarding the

cause of the oliguria?

Case Study #1 Differential Diagnosis
y Oliguria 1) Pre-Renal (decreased effective renal blood flow)

Diminished intravascular volume, cardiac dysfunction, vasodilatation Acute tubular necrosis, acute renal failure, SIADH, ... Outlet obstruction (intrinsic vs. extrinsic), Foley catheter occlusion

2) Renal

3) Post-Renal

y What laboratory studies would you order?

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

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

y What are the primary abnormalities?

Case Study #1 Laboratory studies
y Major abnormalities y y

1) Hyponatremia 2) Oliguria (inappropriately concentrated urine)

y What is the most likely explanation for these findings?

Case Study #1 SIADH
y Syndrome of Inappropriate Antidiuretic Hormone

(SIADH) Variable etiology
Trauma Psychosis Medications CNS disorders Stress Infection Malignancy Diabetic ketoacidosis Positive pressure ventilation

Case Study #1 SIADH
y Manifestations

By definition, inappropriate implies the exclusion of normal physiologic reasons for release of ADH:
y y

1) In response to hypertonicity. 2) In response to life threatening hypotension.

y Euvolemia with:

1. Hyponatremia y 2. Oliguria y 3. Concentrated urine
y y

elevated urine specific gravity inappropriately high urine osmolality in face of hyponatremia


4. Normal to high urine sodium excretion

Case Study #1 SIADH
y Diagnosis

Critical level of suspicion. y Demonstration of inappropriately concentrated urine in face of hyponatremia
y y y

o urine osmolality o SG o urine sodium excretion (o FeNa)


Be certain to exclude conditions with normal physiologic release of ADH
y y

Frequently secondary to decreased perfusion q Serum sodium, o urine osmolality, q urine sodium excretion (low FeNa)   consistent with dehydration or diminished renal blood flow. Look at patient more closely !!

Case Study #1 SIADH
y Treatment y Fluid restriction.

50-75% of maintenance requirements, be certain to include oral intake.

y Daily weights.

Case Study #1 The saga continues .
y Hospital course: y 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®) y What is the most likely explanation?

Case Study #1 The saga continues
y Seizure y y y y y y

1) Worsening hyponatremia 2) Intracranial event 3) Meningitis 4) Other electrolyte disturbance 5) Medication 6) Hypertension
y What diagnostic studies would you order?

Case Study #1 The saga continues
y Stat labs: Sodium 117 mEq/L y What would you do now?

Case Study #1 Hyponatremic Seizures
y 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 (0.6) (weight [kg]) (125- measured sodium) (0.6)(8)(125-117) = 38.4 mEq


To correct sodium to 125 mEq/L, the deficit is equal to
y y

Follow the initial 24 mEq by slow infusion of remaining 14.4 mEq (29 mL) over next several hours y This equation can be estimated by (slight underestimate)
y y

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
y 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. y Home meds: y Acetaminophen and ibuprofen for fever y PE: y BP 70/40, HR 200, R 60, T38.3 C. y Irritable, sunken eyes and fontanel, skin feels doughy y No one can obtain IV access after 15 minutes,

y What would you do now?

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

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

y What type of acid/base disorder does this patient have? y What is the most likely explanation of this patient s


Case Study #2
Non-anion Gap Metabolic Acidosis
y Anion Gap y Sodium - (chloride + bicarbonate) y Normal 12 +/- 2 mEq/L y Elevated anion gap consistent with excess acid y Normal anion gap consistent with excess loss of base y Patient s Anion Gap: 164 - (139 + 12) = 13

Case Study #2 Metabolic acidosis and the anion gap
1. Normal gap 2. Increased gap


Renal ´HCO3µ 2. GI ´HCO3µ losses losses

1. o Acid prod 2. q Acid elimination

Proximal RTA Diarrhea Distal RTA ´Rectal Tubular Acidosisµ

Methanol Uremia Renal disease DKA Paraldhyde IEM, Iron Lactate Ethylene Glycol Salicylates

Case Study #3
y 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).

y What is your differential diagnosis? y What test would you order?

Case Study #3 Differential diagnosis
y Polyuria

1) Central diabetes insipidus

Deficient ADH secretion (idiopathic, trauma, pituitary surgery, hypoxic ischemic encephalopathy) Renal resistance to ADH (X-linked hereditary, chronic lithium, hypercalcemia, ...) Primary increase in water intake (psychiatric), occasionally hypothalamic lesion affecting thirst center Diuretics (lasix, mannitol,..), glucosuria, high protein diets, postobstructive uropathy, resolving ATN, .

2) Nephrogenic diabetes insipidus

3) Primary polydipsia (psychogenic)

4) Solute diuresis

Case Study #3 Laboratory studies
y 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

y Other y Urine specific gravity 1.005, no glucose. y Urine osmolality: 160 mosm/kg y What are the main abnormalities?

Case Study #3 Laboratory studies
y Major abnormalities y y

1) Hypernatremia 2) Polyuria (inappropriately dilute urine)
y What is the most likely explanation?

Case Study #3 Diabetes Insipidus
y Diagnosis y Central Diabetes insipidus
1) Polyuria 2) Inappropriately dilute urine (urine osmolality < serum osmolality)

y May be seen with midline CNS defects y Frequently observed in patients with severe

intracranial hypertension resulting in herniation and loss of cerebral perfusion y What should you do to treat this child?

Case Study #3 Diabetes Insipidus
y Treatment y Acute: Vasopressin infusion - begin with 0.5 milliunits/kg/hour, double every 15-30 minutes until urine flow controlled y Chronic: DDAVP (desmopressin) y Warning y Closely monitor for development of hyponatremia

Case Study #4
HPI: y 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. y Home meds: y Albuterol MDI two puffs QID, Salmeterol MDI two puffs BID, Prednisone 10mg daily, Fluticasone 220 mcg two puffs BID y PE: y 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.

y What is your differential diagnosis? y What diagnostic studies would you order?

Case Study #4 Differential diagnosis
y Shock 1) Cardiogenic
y y

Myocarditis Pericardial effusion Hemorrhage, excessive GI losses, 3rd spacing (burns, sepsis) Sepsis, anaphylaxis

2) Hypovolemic

3) Distributive

Case Study #4 Laboratory studies
y Serum studies
Sodium 130 mEq/L Chloride 99 mEq/L Potassium 5.7 mEq/L Bicarbonate 12 mEq/L BUN 43 mg/dL Creatinine 0.6 mg/dL Glucose 48 mg/dL

y Other
WBC: 13k (60% P, 30% L), HCT 35%, PLT 223k y Chest radiograph: no abnormalities

y What are the electrolyte abnormalities?

Case Study #4 Diagnosis
y Major abnormalities y y y y y

1) Hyponatremic dehydration 2) Hypoglycemia 3) Hyperkalemia, mild 4) Acidosis 5) Azotemia

y What is the most likely explanation for these findings?

Case Study #4 Adrenal Insufficiency
y 1o adrenal insufficiency (Addison s disease) y Adrenal gland destruction/dysfunction (ie. autoimmune, hemorrhagic) y most common in infants 5-15 days old y Secondary adrenal insufficiency y ACTH deficiency (ie. panhypopituitarism or isolated ACTH) y Tertiary or iatrogenic y Suppression of hypothalamic-pituitary-adrenal axis (ie. chronic steroid use)

Case Study #4 Adrenal Insufficiency
y Manifestations y Major hormonal factor precipitating crisis is mineralocorticoid deficiency, not glucocorticoid. y Dehydration, hypotension, shock out of proportion to severity of illness y Nausea, vomiting, abdominal pain, weakness, tiredness, fatigue, anorexia y Unexplained fever y Hypoglycemia (more common in children and tertiary) y Hyponatremia, hyperkalemia, azotemia

Case Study #4 Adrenal Insufficiency
y Diagnosis - critical level of suspicion in all patients

with shock
1) Demonstration of inappropriately low cortisol secretion
y y

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.
y y

q ACTH, o cortisol   1o adrenal insufficiency q ACTH, q cortisol   2nd or tertiary insufficiency

3) Seek a treatable cause

y What should you do to treat this child?

Case Study #4 Adrenal Insufficiency
y Treatment y Do not wait for confirmatory labs y Fluid resuscitation - isotonic crystalloid y Treat hypoglycemia y Glucocorticoid replacement - hydrocortisone in stress doses - 25-50 mg/m2 (1-2 mg/kg) IV every 6 hours y Consider mineralocorticoid (Florinef®)

Case Study #5
y HPI: y 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. y What do you do now?

Case Study #5 Hyperkalemia
y Treatment y Immediately recheck serum potassium. y Immediately check EKG and treat if EKG changes are present y 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
y Calcium chloride 10-20 mg/kg over 5 minutes; may repeat x2

Antagonism of membrane actions of potassium First treatment!!! Avoid rapid IV push y Shift potassium intracellularly y Glucose 1 gm/kg plus 0.1 unit/kg regular insulin y Alkalinize (increase ventilator rate; Sodium bicarbonate 1 mEq/kg IV) y Inhaled F2 adrenergic agonist (albuterol) y Removal of potassium from the body y Loop / thiazide diuretics y Cation exchange resin: sodium polstyrene sulfonate (Kayexelate®) 1 gm/kg PO or PR (or both) y Dialysis
y y y

Case Study #6
y 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.

y What is your differential diagnosis? y What tests would you order?

Case Study #6 Laboratory studies
y Serum studies
Sodium 134 mEq/L Chloride 98 mEq/L Potassium 2.4 mEq/L Bicarbonate 27 mEq/L BUN 11 mg/dL Creatinine 0.4 mg/dL Calcium 9.2 mg/dL Phosphorus 3.2 mg/dL

y Other
EKG: Unifocal PVC s

y What is the main abnormality?

Case Study #6 Laboratory studies
y Major abnormality y Hypokalemia y What would you do now?

Case Study #6 Hypokalemia
y Treatment y Oral

Safest, although solutions may cause diarrhea 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 (25-50 mg/kg MgSO4)

y IV


y Replace magnesium also if low

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