Peds Fluid replacement

Question 1

Fluid Replacement Therapy

general

Answer 1

Children are particularly vulnerable to developing dehydration…WHY?
% of TBW
Higher insensible water loss
Elevated metabolic rates requiring more fluid
Inability to communicate their needs

Question 2

Dehydration

Answer 2

Defined as a decrease in total body water
Includes intracellular and extracellular water loss

Question 3

ped dehydration

Excessive water loss
Etiologies

Answer 3

Gastrointestinal:
Diarrhea
Most common cause worldwide
Most cases are infectious – Norovirus and Rotavirus are the most common in the United States
Vomiting

Urinary: excessive urination from hyperosmolar states (diabetes)

Increased insensitive loss from evaporation:
Febrile illnesses
Burns
Increased respiratory loss with respiratory illness (bronchiolitis)

Question 4

peds dehydration

Decreased intake
Etiology

Answer 4

Anorexiafrom illness
Lack of access to clean water
Neglect

Question 5

Phototherapy

Answer 5

Used to prevent the neurotoxic effects of high serum unconjugated bilirubin

The amount of phototherapy needed depends on the level of hyperbilirubinemia

Question 6

Phototherapy
Mechanism

Answer 6

Lowers the serum bilirubin level by transforming bilirubin into water-soluble isomers that can be eliminated in the urine without conjugation in the liver

Question 7

Phototherapy

Risks

Answer 7

Increases insensible water loss by 25-50% due to the warming effect

Body temperature and number of wet diapers should be closely monitored

Question 8

Peds dehydration

Answer 8

3 most sensitive exam findings for determining severe dehydration are prolonged capillary refill, abnormal respiratory pattern, and abnormal skin turgor

Children maintain cardiac output by raising their heart rate; hypotension is a late finding in children

ask about wet diapers

Question 9

Dehydration

Dx

Answer 9

History and physical exam are sufficient to diagnose dehydrationand its etiology
Laboratory testing is reserved for severe cases and to monitor rehydration
History

Fluid balance:
Number of wet diapers/urination per day
Increased drinking or asking for water

Recent illness:
Fever
Diarrheal episodes (quantity andqualityof stool loss can be estimated)
Vomiting

Question 10

dehydration

Behavioral changes

Answer 10

Lethargy
Irritability

Lethargy and irritability are terms that should never be taken lightly when used in children

Question 11

Lethargy

Answer 11

Apathological state of sleepiness or deep unresponsiveness and inactivity

Symptom of disease with varied levels of medical seriousness

True lethargy is a seconds to minutes emergency and could be due to:
Sepsis
Meningitis
Severe dehydration
Medication overdose

difficulty arousing the child. they fall asleep after waking up.

Question 12

Irritability

Answer 12

Inconsolability; fussiness or whining despite attempts to comfort and console

Patient looks well; not ill appearing

True irritability could be due to:
Fracture
Head trauma
Intussusception
Meningitis
Hair tourniquet

Question 13

peds dehydration

Laboratory testing

Answer 13

Basic metabolic panel(CHEM-7) is indicated in cases of severe dehydration
Can show:
↓glucose
↑blood urea nitrogen(BUN)
↑sodiumandchloride
↓bicarbonate
↑ creatinine

Glucose drops quickly in kids, BUN/creat will increase, K is most stable. Bicarb will brop.

Question 14

Question 15

Mild dehydration

Labs

Answer 15

Mild dehydration → slight increase in BUN and decrease in glucose

Question 16

Moderate dehydration

Labs

Answer 16

Moderate dehydration → increased sodium, chloride and BUN; decreased bicarbonate and glucose…patient is becoming ???
Calculation of anion gap

Question 17

Severe dehydration

BMP Labs

Answer 17

Severe dehydration → increased sodium, chloride, BUN, and creatinine, while bicarbonate and glucose have decreased sharply

Question 18

Answer 18

Question 19

Mild-Moderate Dehydration

Tx

Answer 19

1st-line therapy:oralrehydrationtherapy (ORT)
Give solutions with similar electrolyte contents to fluid lost
Pedialyte or Enfalyte
Breastfed infants should continue to nurse
Fluids with high sugar content should be avoided as they may worsendiarrhea

Provide 50–100 cc/kg of fluids over 2–4 hours
Route of administration depends on patient age and frailty
Syringe or spoon-feeding
Nasogastric (NG) tube

+/-ondansetron (Zofran)to preventvomiting
Clinical hydration status should be monitored frequently

Failure to improve with ORT → intravenous hydration

Question 20

Severe Dehydration Tx

Acute resuscitation phase

Answer 20

Medical emergency due to hypoperfusion of the brain and vital organs

Acute resuscitation phase
Goal: correct or prevent hypovolemicshock
Rapid volume expansion through fluid boluses:
10-20 cc/kg given over 20 minutes
Can be repeated up to 3x (to a total of 1 liter)- no more than a L
Monitor vital signs between each bolus
Choice of replacement fluid:
Isotonicfluids only
Lactated Ringer’s or0.9% normal saline

Question 21

Severe Dehydration Tx

Glucosemonitoring

Acute resuscitation phase

Answer 21

Point of care (POC) monitoring forhypoglycemia
IVglucoseshould be administered
5–10 ml/kg of D10 NSOR2-4ml/kg of D25 NS

Question 22

Severe Dehydration

Resuscitationphase

Answer 22

Slower replacement of lost fluids over 24 hours

Total fluid ofresuscitationphase = maintenance fluids + (rehydration– bolus already given)

Rehydrationis divided in 2 phases:
50% over the first 8 hours
50% over the next 16 hours

After 24 hours if clinically stable→ continue maintenance fluids

Question 23

Answer 23

can use this for adults as well for maintenace

Question 24

Question 25

maintenance fluids

Question 26

Calculate acute resuscitation phase (use 20 cc/kg)

Question 27

how much for maintenance for a 25kg kid in a day

Answer 27

1560 cc per day

Question 28

Monitoring Response to Fluids

Answer 28

Urine output: optimal> 1 cc/kg/hr

Clinical improvement of signs of dehydration:
Increasedskin turgor
Improved pulse
Improved capillary refill
Improved mental status
Able to cry tears

Question 29

A 2-year-old boy presents with a refusal to drink liquids. He has a heart rate of 130bpm with otherwise normal vitals. He weighs 12 kg. Initial observationshows a tired appearing crying child who is producing tears. HEENT exam shows moist mucosa with erythematous papulovesicular eruptions on the buccal mucosa. What is the most appropriate rehydration strategy for this patient?

A. D5 normal saline 120 mL IV over 30 minutes
B. Water 500 mL over 2 hours
C. Commercial drink with low carbohydrates and no sodium 750 mL over 2-4 hours
D. Compounded oral solution with 1:1 glucose/sodium content 600 mL over 4 hours

Answer 29

D

Question 30