Flashcards in Case 15 Deck (65)
What are the key history findings for acute gastroenteritis?
Diarrhea for two days, vomiting, tactile fever, children sick at child care.
What are the key findings from physical exam for acute gastroenteritis?
Weight loss, afebrile, mild dehydration, normal bp and abdominal exam.
What are the key history findings for pyloric stenosis?
Forceful vomiting, no fever, no diarrhea, increasing sleepiness.
What are the key physical exam diagnosis for pyloric stenosis?
Arousable, but excessively sleepy, weak cry, weight loss, tachycardia, sunken eyes and fontanel, dry mucous membranes, poor perfusion, no abdominal tenderness or masses, visible peristaltic waves.
What is on the differential diagnosis for pyloric stenosis?
Gastroenteritis, UTI, GERD, Intussusception, Lower GI obstruction, metabolic disorder, CNS disease
What are the key findings from testing for pyloric stenosis?
BMP: hypochloremic, hypokalemic metabolic alkalosis.
US: Pyloric stenosis
Rehydration therapy for children:
When fluid therapy is planned for patients (i.e. when their fluid and electrolyte intake will be controlled by means other than their normal oral intake), it is necessary to consider both their water and their electrolyte needs.
-Primary solutes (electrolytes) to consider are sodium, potassium, and chloride (chloride is usually coupled to the sodium and potassium to maintain electrical neutrality)
-For both water and electrolytes, consider:
--Daily maintenance needs
--Any fluid and/or electrolyte deficits
--Any unusual ongoing losses (eg diarrhea, fever)
Maintenance fluid definition:
Replacement of fluid and electrolytes lost through normal basal metabolic processes (eg, heat dissipation, growth, energy metabolism) and urine output.
-Heat is dissipated by insensible evaporation of water from the skin or by elimination of warm vapor from the upper respiratory tract during exhalation.
-Soluble waste products of metabolism are excreted in urine
How were fluid and electrolyte replacement for a child with dehydration calculated previously?
It involved calculating both the maintenance needs and the estimated fluid and electrolyte deficit, and administering these over a 24-48 hour time period (termed "deficit therapy")
How to treat children with mild-moderate (5-9 percent) dehydration?
Oral or enteral rehydration, using an appropriate oral rehydration solution (ORS) is recommended, using the following guidelines:
-50-100 mL/kg of oral rehydration solution (ORS) over 2-4 hours; begin with very small volumes - teaspoons - given very frequently
-Give 10 mL/kg ORS for each additional diarrheal stool and 2 mL/kg ORS for each additional emesis.
How to treat children with moderate-severe (10-15 percent dehydration)?
Initial rehydration should be via IV bolus therapy, using an isotonic, non-dextrose containing solution (normal saline or lactated Ringer's solution are common choices), as follows:
-20 mL/kg IV fluid bolus
-Repeat bolus after re-evaluation until patient is clinically improved:
--Awake, alert, well perfused
--Interested in and tolerating oral fluids
--Urine output present
-Often 60-100 mL/kg total (in 10-20 mL/kg increments) of bolus fluids are required, with repeated evaluation
-Depending on the clinical situation, rehydration can be completed with oral rehydration therapy, or with IV fluids at a rapid rate (eg, 1.5 maintenance fluids with D5 1/2 normal saline)
Maintenance fluid and electrolyte calculations:
Used to derive the appropriate amount of fluid administration in patients who cannot be allowed free access to oral fluids.
-These calculations assume that patient is in a normal situation (i.e. normal urine output, no abnormal fluid losses, etc.)
-Individuals with losses outside the norm (eg, due to renal failure, diabetes insipidus, increased evaporative fluid loss due to persistent high fever) require modifications of the formulas.
What are the two calculation methods for maintenance fluids?
Maintenance fluids can be calculated using either the (1) weight method or the (2) body surface area (BSA) method.
-BSA method is technically somewhat more accurate, but an accurate BSA is often not available
-Both methods provide an adequately accurate estimate of daily fluid and solute requirements.
What is the weight method of calculating maintenance fluids?
Water - 100 ml/kg/day (first 10 kg body weight) plus 50 ml/kg/day (next 10 kg body weight) plus 20 ml/kg/day (any additional body weight)
Sodium - 3-4 mEq per 100 mL fluid
Potassium - 2-3 mEq per 100 mL fluid
What is the body surface area (BSA) method?
Water - 1500-2000 mL/m2/day, Sodium - 45 mEq/m2/day, Potassium - 35-40 mEq/m2/day
What is the composition of D5W IV?
Glucose, 50 g/L solute concentration, 278 mOsm/L Total.
What is the composition of D10W IV?
Glucose, 100 g/L solute concentration, 556 mOsm/L Total.
What is the composition of 0.2 percent saline (1/4 NS)?
NaCl 2.0 g/L solute concentration. 34 mEq/L Na, 34 mEq/L Cl, 68 mOsm/L Total.
What is the composition of 0.4 percent saline (1/2 NS)?
NaCl 4.5 g/L solute concentration. 77 mEq/L Na, 77 mEq/L Cl, 154 mOsm/L Total.
What is the composition of 0.9 percent saline (NS)?
NaCl 9.0 g/L solute concentration. 154 mEq/L Na, 154 mEq/L Cl, 308 mOsm/L Total.
What is the composition of D5 0.2 percent saline?
Glucose 50 g/L and NaCl 2.0 g/L solute concentration. 34 mEq/L Na, 34 mEq/L Cl. 346 mOsm/L Total.
What is the composition of D5 0.45 percent saline?
Glucose 50 g/L and NaCl 4.5 g/L solute concentration. 77 mEq/L Na, 77 mEq/L Cl. 432 mOsm/L Total.
What is the composition of D5 NS?
Glucose 50 g/L and NaCl 9.0 g/L solute concentration. 154 mEq/L Na, 154 mEq/L Cl. 586 mOsm/L Total.
What is the composition of Lactated Ringer's (LR)?
NaCl (6.0), KCl (0.3), CaCl2 (0.2), Na lactate (3.1). 130 Na, 109 Cl. K (4.0), Ca (3.0), lactate (28). 272 mOsm/L Total.
What is the composition of Ringer's?
NaCl (8.6), KCl (0.3), CaCl2 (0.3). 147 Na, 156 Cl. K (4.0), Ca (3.0). 309 mOsm/L Total.
What is the composition of hypertonic saline?
3 percent NaCl. NaCl 30. 513 Na 513 Cl. 1026 mOsm/L Total.
What is the composition of Sodium bicarbonate 5 percent?
NaHCO3 50. Na 595. HCO3 (595), 1190 mOsm/L Total.
What is the composition of sodium bicarbonate 8.4 percent?
NaHCO3 84. Na 1000. HCO3 (1000), 2000 mOsm/L Total.
What is the composition of 5 percent albumin?
Albumin 50. Na 100-160. Less than 120 Cl.