Pediatric GI cases and IV administration

Question 1

Isonatremic/Isotonic

Answer 1

Na 130-150
Proportional loss of Na and water

often seen with gastroenteritis

Question 2

Crystalloids

Answer 2

Saline - use for kids

D5W (5% dextrose in water)

Lactated ringers (NaCl, KCl, CaCl, & Na lactate in water)

Question 3

Colloids

Answer 3

Albumin 5%
Fresh frozen plasma
Synthetics (hetastarch & dextran)

Question 4

5 steps in approach to fluid replacement in dehydration?

Answer 4

1. Restore intravascular volume for hemodynamic stability: the boluses!

• Bolus therapy:
• Rapid infusion of relatively isotonic fluid
• 20 ml/kg (consider 10 ml/kg for cardiac pts)
• Normal saline or Lactated ringers

2. Calculate 24 hr water requirements
   Maintenance – given at constant rate over 24 hrs
   Deficit – divided so that ½ is given over first 8 hrs, then ½ over the next 16 hrs.
3. Calculate 24 hr electrolyte requirements
   Maintenance Na+ and K+
   Deficit Na+ and K+ (especially important in hypo/hypernatremic dehydration)
4. Select appropriate fluids
5. Replace ongoing losses

Question 5

level of dehydration

Answer 5

child: 3,6,9%
infant: 5.10,15%
(mild, moderate, severe)

mild: consolable and normal appearance
moderate: skin tenting, dry skin/mucosa, deep set eyes soft fontanelle, irritable, increased pulse rate thats weak, 2 sec. capillary refill, decreased urine
severe: no skin tenting, clammy, parched skin w/ sunken eyes/fontanelle, lethargic, increased pulse thats feeble, >3 sec cap. refill, anuric

Question 6

what is bolus?

Answer 6

give normal saline (isotonic fluid)

20ml/kg given

this restores the intravascular volume and is the first step in rehydration

Question 7

how to calculate maintenance reqs? 24 hour water reqs?

Answer 7

given at constant rate over 24 hrs

Maintenance = daily water needed based on energy expenditure

Daily calculation:
0-10kg = 100 ml/kg/day
11-20 kg = 50 ml
21+ kg = 20 ml

ex: 12 kg child needs
10(100) = 1000
2(50)= 100
Total: 1100 ml/day

Hourly calculation:
(0-10): 4 ml/hr
(11-20): 2 ml/hr
(21+): 1 ml/hr

ex: 12 kg child
10(4)= 40
2(2)= 4
Total: 44 ml/hr

Question 8

how to calculate deficit? how much child is down?

Answer 8

divided so that ½ is given over first 8 hrs, then ½ over the next 16 hrs.

Fluid deficit (ml) 
= 	%dehydration of pre-illness wt.(kg) X 1000 ml/kg

Ex: infant w/ weak pulses, tenting of skin and irritability = 10% dehydration
10% of 12 kg child is 1.2 kg
1.2 kg X 1000 = 1200 ml fluid deficit

Question 9

at what rate do we replinish deficits?

Answer 9

first 8 hours: 1/3 maintenance, 1/2 deficit volume

2nd 8 hours: 1/3 maintenance, 1/4 deficit volume

3rd 8 hours: 1/3 maintenance, 1/4 deficit volume

Question 10

which type of saline to use?

Answer 10

In general, for isonatremic dehydration as a quick reference

20 kg given 0.5 NS

Question 11

if fussy but not consolable?

Answer 11

then check for meningitis!!!

Question 12

rooting?

Answer 12

stroking side of lips, goes looking for food

Question 13

morro

Answer 13

baby makes scene and arms go up and they cry when they are dropped

Question 14

double bubble

Answer 14

duodenal atresia - needs intervention

Congenital obstruction of 2nd portion duodenum

Usually occurs below the ampulla of Vater - thus bilious vomiting

accounts for 1/3 of all atresias

assoc:
Polyhydramnios
Down syndrome 25% of patients
CHD in 20%

most common: type I = mucosal web

Question 15

viral diarrhea?

Answer 15

Low-grade fevers
Vomiting followed by copious watery diarrhea (up to 10-20 per day)
Persists for 3-8 days

Question 16

bacterial diarrhea

Answer 16

High fevers
Shaking chills
Bloody bowel movements
Abdominal cramping
Fecal leukocytes

Question 17

GERD

Answer 17

the most common esophageal disorder in children of all ages.

• • see recurrent regurgitation with or w/out vomiting
• • cough

Sx usually in first few months
Peak 4 months of age
Resolve in the majority by 12 months of age

** occur most often during transient relaxations of the lower esophageal sphincter (LES) unaccompanied by swallowing

Question 18

pyloric stenosis

Answer 18

Typical nonbilious vomiting that is forceful immediately after feeding, while the infant remains hungry. – “projectile vomiting” every time

A firm “olive-like” mass may be palpable in the right upper quadrant of the abdomen

hypochloremic metabolic alkalosis