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Pediatrics Paper Chase 12/04/02 8-9:30AM Dra. Alvarez Fluids and Electrolytes

Pediatrics Paper Chase

12/04/02 8-9:30AM

Dra. Alvarez

Fluids and Electrolytes

  1. Electrolyte 48, travot 4: maintenance fluid
  2. Maintenance fluid
  3. per 100kcal metabolized need to replace 100ml fluid
  4. lungs 15ml
  5. skin 30ml
  6. kidney 50ml
  7. GI 5ml
  8. CHO 10-15g
  9. In 100ml fluid, have the following electrolytes
  10. K 2-2.5 (add 20 to 1L)
  11. Na 2.5-3
  12. Cl 5 (its Na and K summed)
  13. CHO 5g (this is where we get 5% glucose)
  14. If use 1L liquid, multiply the electrolyte values by 10 to get their quantities for travot 4 maintenance fluid
  15. 0.2%Nacl/5%glucose
  16. 100, 50, 20 rule
  17. up to 10kg weight use 100kcal/kg
  18. 11-20kg 1000kcal + 50kcal/kg above 10kg
  19. >20kg 1500kcal +20kcal/kg above 10kg
  20. 4, 2, 1 rule, useful up to 80kg
  21. modifications of maintenance
  22. anuria: HUS most common, don’t give kidney and GI, so give only 45ml from lungs and skin, give 45% of 1000ml, so give 450ml of maintenance liquids of glucose and water D5W (not electrolytes because they are retaining electrolytes)
  23. fever 10% mas por cada grado de fiebre arriba de 38C, so give 1200ml (Nelson says 12%)
  24. if bronchilitis, if asthma: hyperventilating, add 10% more to the liquids
  25. hypothyroidism: decreased metabolism, so give less liquids, according to the level of hypothyroidism can decrease 10-20
  26. phototherapy, produces loss through skin and diarrhea
  27. meningitis, encephalitis: produces SIADH, do water restriction 20%, have high specific gravity >1.025, Na <125, prevent cerebral edema, seizures, coma
  28. Review
  29. Travot 4, electrolito 48: 25 Na, 20K, 50Cl, lactate 23, maintenance
  30. Travot 2, electorlito 75: 40 Na, 35K, replacement
  31. 0.2% NaCl 5glucose: 34Na, 34Cl, no potassium so add 20mEq/L, maintenance
  32. pedialyte from WHO has 90meq/l Na for diarrhea and we don’t use because its excess sodium
  33. dehydrated
  34. vomits, diarrhea
  35. viral rash and diarrhea: rotavirus, vaccine was suspended because intussusception
  36. bandemia: etiologia bacteriana shigella, diarrhea disenterica, vibrio cholera secretory, osmotic acumula de azucar en GI, cytotoxic rotavirus, dysenteric shig, salm, campylobacter
  37. find out if vomit, estudiante de medicina con salmonella y diarrhea, hay que darle liquidos, no antibioticos because provokes carrier state, don’t give immodium
  38. grade of dehydration
  39. volume lost: estado de ion sodio, isonatremica most common, 130-150mEq/L, 85% cases
  40. hyponatremica: <130mEq/L
  41. hypernatremica: >150mEq/L
  42. signs: lethargic, responsive to stimuli, sensorio is the first, then check the eyes, are they hundido, cry without tears, oral mucosa, no skin turgor changes in isonatremica, but tongue is wrinkled, capillary refill <2seconds can lose 50ml/kg, 2-3sec 50-100ml/kg, 3-4 100-120ml/kg, >4seconds severely dehydrated in coma and have 150ml/kg loss
  43. tachycardia first sign, pressure not lost at first, pulse is weak but fast
  44. ideal weights to compare to actual dehydrated weights
  45. weight is meses (age) + 11 (16libras if 5 months old)
  46. 2-6years, 5age + 17 (if 3 years old has 32 pounds)
  47. 7-12 years, 7 age + 5
  48. leve 3-5%: thirsty, irritable, no changes in pulse, mom says that for the last 6 hours hasn’t urinated, but looks hydrated, must replace the loss by weight, older we get the less water we have in our body, replace by mouth, 50cc/kg, if more than 15kg then use 3%, if less than 15 use 5% (because newborn has 85% TBW while older children with more weight have 60% TBW)
  49. moderado: 6-10%, lethargic, rapid weak pulse, sunken fontanelle, elasticity of skin, mucosa membranes dry, urine is oscura, capillary refill >2sec
  50. severo: 10-15% of weight, give 100cc/kg
  51. must replace deficit plus maintenance, if patient is 1 year old, weight 10kg, 10% lost, 3-4sec capillary refill, Na 135 isonatremic dehydration, must replace the volumen intravascular porque quiero evitar shock, tengo que dar una cantidad de liquido que permanence circulando en espacio intravascular, give 1000ml deficit because 10kg x 100ml/kg, and give 1000ml maintenance. give 20cc/kg in ER which is 200ml of 0.9% with 20meq/l K without glucose because don’t want glucose overload, still need 800ml in 8 hours using less sodium such as 0.45% NaCl/D5W with 16K (80% of 20meq/l), order it as 1L with 20meq/l K and drop it at 100ml/hour and stop it at 8 hours, first 8 hours to replace the deficit, then the second 16 hours to replace maintenance 1L with 20meq/l Kcl added, then give 1000ml in 16 hours which is 63ml/hour of 0.2% NaCl/D5W
  52. pyloric stneosis use 0.9%, we like 0.9% more than the surgeons
  53. during the IV push 20cc/kg can’t use K because don’t know if kidneys are working, but then when giving the next load of liquid 800ml can give the K only if see that he is urinating
  54. commercial to replace deficit is electrolyte 75
  55. 40 Na, 35K (pedialyte from WHO has 90meq/l Na for diarrhea and we don’t use because its excess sodium), this electrolyte 75 would be used in deficit replacement in the case above for 800ml instead of 0.45% Nacl/D5W, and this elec 75 can be used as maintenance because it has so little Na (40 compared to 0.2% maintenance which has 34 Na)
  56. 4kg boy projectile vomiting
  57. can have indirect bilirubin because immature glucoronyl transferase associated with pyloric stenosis
  58. Ph will be alkalotico
  59. Mass in the RUQ, do US, see the thickness of the muscle and the length of the pyloric canal
  60. Weights 4kg, deficit is 400ml because 100cc/kg x 4kg, and maintenance is 400cc, so give 20cc/kg or 80ml of 0.9, then give 320 of 0.45%, if this patient had potassium of 3meq/kg, then can give more K than usually, can add more than 20, but only per liter give 20, but need to give 40 because its hypokalemic, so give 12meqkcl, and the total infusion rate of 320 is at 40ml/hour all in 8 hours, then in 16 hours give 400ml of 0.2% NaCl/D5W so give 25cc/hour, once potassium is corrected from 8 hours, don’t ened to continue 40meq/l, but can use 20meq/l if the K is controlled
  61. To go to sala for pyloric stenosis, need >2.8K, <7.5ph, <30HCO3