资源描述
,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Fluid and Electrolyte Emergencies in Critically Ill Children,Richard T.Blaszak,M.D.,Stephen M.Schexnayder,M.D.,Fluid and Electrolyte Emergenc,1,Objectives,At the end of this presentation learners will be able to:,1)Recognize common fluid and electrolyte disorders in critically ill children,2)List a diagnostic strategy for these disorders,3)Apply appropriate management principles,ObjectivesAt the end of this,2,Case Study#1,HPI:,A 3 month-old is in the PICU for shock following a two day history of fever and irritability.Blood and CSF cultures are positive for,Streptococcus pneumoniae,.,Hospital course:,Decreasing urine output(0.5 ml/kg/hr)over the last 24 hours.,Case Study#1HPI:,3,Case Study#1,What is your differential diagnosis?What diagnostic studies would you order?,Case Study#1What is your dif,4,Case Study#1,Differential diagnosis,Oliguria,1)Pre-Renal(decreased effective renal blood flow),Diminished intravascular volume,cardiac dysfunction,vasodilitation,2)Post-Renal,Outlet obstruction(intrinsic vs.extrinsic),foley catheter occlusion,3)Renal,Acute tubular necrosis,acute renal failure,SIADH,.,Case Study#1Differential dia,5,Case Study#1,Laboratory studies,Serum studies,Sodium 126 mEq/LBUN 4 mg/dL,Chloride 98 mEq/LCreatinine 0.4 mg/dL,Potassium 3.7 mEq/LGlucose 129 mg/dL,Bicarbonate 25 mEq/LOsmolality 260 mosmol/kg,Urine studies,Specific gravity 1.025Sodium 58 mEq/L,Osmolality 645 mosmol/kgFeNa 2.4%,What are the primary abnormalities?,Case Study#1Laboratory studi,6,Case Study#1,Laboratory studies,Major abnormalities,1)Hyponatremia,2)Oliguria(inappropriately concentrated urine),What is the most likely explanation for these findings?,Case Study#1Laboratory studi,7,Case Study#1,Syndrome of Inappropriate Antidiuretic Hormone(SIADH),Variable etiology,Trauma,Infection,Psychosis,Malignancy,Medications,Diabetic ketoacidosis,CNS disorders,Positive pressure ventilation,“Stress”,Case Study#1 Syndrome of Ina,8,Case Study#1,SIADH,Manifestations,By definition,“inappropriate”implies having excluded normal physiologic reasons for release of ADH:,1)In response to hypertonicity.,2)In response to life threatening hypotension.,Hyponatremia,Oliguria,Concentrated urine,elevated urine specific gravity,“inappropriately”high urine osmolality in face of hyponatremia,Normal to high urine sodium excretion,Case Study#1 SIADHManifestat,9,Case Study#1,SIADH,Diagnosis,Critical level of suspicion.,Demonstration of inappropriately concentrated urine in face of hyponatremia,urine osmolality,SG,urine sodium excretion(FeNa),Be certain to exclude normal physiologic release of ADH,Frequently secondary to decreased perfusion,Serum sodium,urine osmolality,urine sodium excretion(,low FeNa,),consistent with dehydration or diminished renal blood flow.Look at patient more closely!,Case Study#1 SIADHDiagnosis,10,Case Study#1,SIADH,Treatment,Fluid restriction.,50-75%of maintenance requirements,be certain to include oral intake.,Daily weights.,Case Study#1 SIADHTreatment,11,Case Study#1,The saga continues.,Hospital course:,Four hours after beginning fluid restriction,you are called because the patient is having a generalized seizure.There is no response to two doses of IV lorazepam(Ativan)and a loading dose of fosphenytoin(Cerebyx),What is the most likely explanation?,Case Study#1The saga continu,12,Case Study#1,The saga continues,Seizure,1)Worsening hyponatremia,2)Intracranial event,3)Meningitis,4)Other electrolyte disturbance,5)Medication,6)Hypertension,What diagnostic studies would you order?,Case Study#1The saga continu,13,Case Study#1,The saga continues,Stat labs:,Sodium 117 mEq/L,What would you do now?,Case Study#1The saga continu,14,Case Study#1,Hyponatremic seizure,Treatment,Hypertonic saline(3%NaCl)infusion,To correct sodium to 125 mEq/L,the deficit is equal to,(0.6)(weightkg)(125-measured sodium),(0.6)(8)(125-117),=38.4 mEq,Because patient is symptomatic with seizures,immediately increase serum sodium by 5 mEq/L,mEq sodium=(0.6)(8 kg)(5),=24 mEq,3%NaCl=0.5 mEq/L,therefore 24 mEq bolus=48 mls,followed by slow infusion of remaining 14.4 mEq(29 mls)over next several hours,Case Study#1 Hyponatremic se,15,Case Study#2,HPI:,A 5 month-old girl presents with a one day history of irritability and fever.Mother reports three days of“bad”vomiting and diarrhea.,Home meds:,Acetaminophen and ibuprofen for fever,PE:,BP 70/40,HR 200,R 60,T38.3 C.Irritable,sunken eyes and fontanelle,skin feels like Pillsbury Dough Boy,Case Study#2HPI:,16,Case Study#2,No one can obtain IV access after 15 minutes,what would you do now?,Case Study#2No one can obtai,17,Case Study#2,Place intraosseous line,Bolus 40 ml/kg of isotonic saline,Reassessment(HR 170,RR 40,BP 75/40),Serum studies,Sodium 164 mEq/LBUN 75 mg/dL,Chloride 139 mEq/LCreatinine 3.1 mg/dL,Potassium 5.5 mEq/LGlucose 101 mg/dL,Bicarbonate 12 mEq/L,pH 7.07 pCO,2,11,pO,2,121 HCO,3,8,Case Study#2Place intr
展开阅读全文