Pediatric Cases LEC Flashcards
What should the urine output in a newborn be?
•Urine output-1-3 ml/kg/hr
What are the sodium levels associated with hypo and hypernatremia in the newborn?
- Hypernatremia- Sodium > 150mmol/L
- Hyponatremia-Sodium < 130mmol/l
What are the signs of Excessive water loss in the newborn?
- –Excessive wt loss
- –Dry oral mucosa
- –Sunken anterior fontanelle
- –Capillary refill > 3seconds
- –Tachycardia
- –Decreased BP
- –Metabolic acidosis
What determines the volume of the ECF in the newborn?
Total sodium content, so renal sodium handling is a critical component in maintaining proper volume
•A 10 day old male infant presents to the ED with lethargy, poor feeding and decreased urine output.
What are your initial thoughts/concerns?
- Sepsis
- Metabolic defect (IEM)
- Intracranial bleed
- Hypoxic/ischemic encephalopathy
- Feeding difficulties/Dehydration
- Renal malformations
- Renal vein thrombosis
•A 10 day old male infant presents to the ED with lethargy, poor feeding and decreased urine output.
Infant was born at 41 weeks gestation and weighted 3.18 Kg (10-25th percentile) to a 43 y/o multiparous mother
The pregnancy was complicated by hyperemesis gravidarum requiring 4 admissions for rehydration. She received escitalopram (Lexapro) for depression and low molecular weight heparin throughout pregnancy.
Risk factors based on this?
Age of mother = more defects and more difficult birth
Hyperemesis with 4 admission
Depression Lexapro = SSNRI
Clotting disease - Low molecular weight heparin
•A 10 day old male infant presents to the ED with lethargy, poor feeding and decreased urine output.
Infant was born at 41 weeks gestation and weighted 3.18 Kg (10-25th percentile) to a 43 y/o multiparous mother
The pregnancy was complicated by hyperemesis gravidarum requiring 4 admissions for rehydration. She received escitalopram (Lexapro) for depression and low molecular weight heparin throughout pregnancy.
Delivery was via vacuum extraction for fetal distress and meconium staining of the amniotic fluid, however, the infant transitioned well to post natal life.
What are your thoughts now?
Baby has been breathing in the meconium laced amnion which causes difficulty with respiration.
•A 10 day old male infant presents to the ED with lethargy, poor feeding and decreased urine output.
Infant was born at 41 weeks gestation and weighted 3.18 Kg (10-25th percentile) to a 43 y/o multiparous mother
The pregnancy was complicated by hyperemesis gravidarum requiring 4 admissions for rehydration. She received escitalopram (Lexapro) for depression and low molecular weight heparin throughout pregnancy.
Delivery was via vacuum extraction for fetal distress and meconium staining of the amniotic fluid, however, the infant transitioned well to post natal life.
The infant displayed poor feeding with a low maternal milk supply.
Physical exam showed very dry and coarse skin. No other comments were made in the record concerning the physical exam
The infant was discharged to home on day 3 with a weight of 2.8 kg (12% loss from birth) with plans for follow-up with the family practitioner. The Mother’s history of depression was not addressed at discharge.
What is the significance of the dry course skin?
Skin is a key point of moisture loss, may lead to volume issues.
During the first week at home the mother’s milk supply increased and there was a transient improvement in feeding. However, the infant fed only 10 minutes at the breast per feeding. No supplement formulas were given.
On day 9 the baby became increasingly lethargic and uninterested in feeding. The infant vomited once (non-billious) and one loose stool. The infant was brought to the ED where on arrival it was noted he had absent urine output for over 12 hours.
How concerned are you about this infant?
Quite concerned
What is the definition of ARF in the newborn based on?
•a rapid elevation in the concentration in the blood of BUN, creatinine and other cellular waste products resulting from diminished GFR
At what level of creatinine can you make the ARF call in a newborn.
You can’t, due to the fact that the newborns levels reflect the mother’s levels
Output of urine can be used as an indicator of ARF, what is the key value?
Less than
•0.5 ml/kg/hour
What are the prerenal causes of ARF in the newborn? (7)
–Sepsis
–Hypovolemia
–Hemorrhage
–Hypoxia Ischemia
–Cardiac Failure
–Hypotension
–Hyperviscosity
What are the Renal (intrinsic) causes of ARF?
•ATN
–Hypoxia-ischemia
–Toxins
•Drugs
–Aminoglycosides
–Contrast Agents
•ACE inhibitors
•Vascular
–Renal vein or artery thrombosis
•Congenital parenchymal disease
•Maternal drugs
•Transient acute renal failure of the newborn
What are the post renal causes of ARF in the newborn?
•Congenital obstruction
–Ureteral
–Urethral
–Bladder
–Pelvic mass
•Calculi
Patient is hypernatremic, hyperkalemic, hyperchloric, hyperuremic, excessive creatinine, very low bicarb, and has venous pH of 7.04. Fibrinogen is low, and platelets are insanely high.
Head CT attached.
- Fluid resuscitation with 0.9% saline was initiated
- Calcium chloride and salmutabol were given for hyperkalemia
- Over the first 12 hours improvement was noted with improved electrolyte status and decreasing BUN and creatinine
However neurological status continued to deteriorate with loss of spontaneous movement and absent reaction to painful stimuli. The infant was pronounced dead 24 hours after admission.
- Was this baby managed appropriately?
- What were the errors in management?
- No
- •Lack of attention to the infant’s skin condition
•Lack of attention to the Infant’s weight loss prior to discharge
•Failure to adequately educate mother as to potential feeding problems
•Failure to recognize that escitalopram (Lexapro) use in pregnancy has been associated with feeding difficulties and increased sodium content in breast milk
•Failure to follow-up with the mother in 1-2 days after discharge
