ࡱ> ` “bjbj ߈%D$$$Hcv"222xczczczczczczc$oehgcO c223cv22xcxcdK 4O2 `I>f$LNPO|c0cNYh0YhOYhO\nk'dcc^c$$$ Pediatric Acute Care Guide PEDIATRIC INTUBATION ET TUBE SIZES (ID=mm): After one year, then tube size can be estimated by using the following formula: age in years/4 + 4 Term Newborn: 3.0-3.5 mm 3 mo-1 yr: 3.5-4.0 mm 1 yr 2 yr: 4.0 - 4.5 mm 2 yr - 15 yr: mm = 4 + (age (yr)/4) Adult Female: 7.0 - 8.0 mm Adult Male: 8.0 - 9.0 mm (Note-uncuffed tubes used until 8 yr. of age, for children > 8 yr., use cuffed ET tubes) TUBE DEPTH: Age in years/2 + 12 or Size of the tube (ID in mm) x 3 LARYNGOSCOPE BLADES: Newborn: Miller #0; 1 mo-18 mo: Miller #1; 18 mo-8 yr: Miller/MAC#2; > 8 yr: Miller/MAC#3 Intubation Tips: Think of the pneumonic MS MAID Monitors: pulse ox (turn volume on), CR monitor Suction Machine: make sure the ventilator is in the room and ready to go Airway: ETT with stylet, good to have a size larger & smaller available IV access Drugs: vagolytic, lidocaine in (ICP, sedation, paralytic Preoxygenate with 100% O2 and monitor with pulse oximeter. Have suction device (Yankauer) present. Proper positioning is mandatory (supine, minimal reverse Trendelenberg, head extended - neck flexed [sniffing position], Note - keep head and neck immobilized with possible spinal injury). Open jaw with scissors motion using thumb and 1st finger in opposite directions. Insert tip of laryngoscope blade into the vallecula advancing along right side of tongue and sweep to left to midline. Have assistant apply cricoid pressure. Observe cords & insert ETT under direct visualization. (Use new stylet and insert in ETT beforehand with tip not protruding. Bend stylet at adapter site to maintain position.) Post Intubation Checks See ETT go past vocal cords Check for bilateral breath sounds and abdominal gurgling Watch chest rise with positive pressure Monitor pulse oximeter and ETCO2 Check post intubation CXR. If the position of the ET is in doubt or the patient is not responding, remove the ET and bag the patient with 100% oxygen. Intubation Medications Sedation/Amnesia Midazolam 0.1 mg/kg Lorazepam 0.1 mg/kg Thiopental 5 mg/kg IV (cardiac and respiratory depressant, not with asthma) Etomidate 0.2-0.4 mg/kg (good with low BP, can cause myoclonus, increased respiratory rate) Ketamine 1-2 mg/kg IV, 6-10 mg/kg PO, 3-7 mg/kg IM (sedative and general anesthetic, minimal cardiac and respiratory depressant, increases ICP, releases catecholamines) Fentanyl 1-2 mcg/kg Paralyzing Agents Succinylcholine 1-2 mg/kg IV (complications - hyperkalemia, malignant hyperthermia - contraindicated; onset in 30 seconds - 1 min., with 5 min. duration), needs concurrent defasiculating dose of other paralytic, not used in Egleston PICU Atracurium 0.5 mg/kg IV (histamine release leads to decreased BP, takes 1-2 minutes for good paralysis); then 0.1 mg/kg q 15-30 min Mivacurium 0.1-0.3 mg/kg IV (onset 2-3 min, lasts 15-20 min) Pancuronium 0.1-0.2 mg/kg IV (onset 90 seconds, lasts 45 minutes to 1 hour, vagolytic) Rocuronium 0.61.2 mg/kg IV (onset 30-90 sec, lasts up to 30 min) Vecuronium 0.1 mg/kg IV (onset 1-3 min, lasts up to 30 min) Give Atropine 0.01-0.02 mg/kg (( with neonate) with Succinylcholine to prevent bradycardia - Minimum dose 0.15 mg, Max dose child - 0.5 mg/adolescent - 1.0 mg. Rapid Sequence Induction, RSI (esp. child with head injury) GIVE RAPIDLY!! Lidocaine 1-2 mg/kg (if head injury, should wait 3 minutes) ( Atropine 0.01-0.03 mg/kg (minimum dose - 0.1 mg) ( Thiopental 4-6 mg/kg (consider Midazolam 0.2 mg/kg or Etomidate 0.3 mg/kg) ( Rocuronium 1 mg/kg PEDIATRIC EMERGENCY MEDICATIONS Analgesics Demerol: 1 mg/kg/dose IM, IV q 2 hr PRN Fentanyl: 1-2 mcg/kg IV, IM q 1-2 hrs PRN (Analgesia) Morphine: 0.1-0.2 mg/kg IV, IM, SC q 2-4 hrs PRN Lidocaine 0.5-1.0% local - max dose 4 mg/kg or 7 mg/kg with Epinephrine (avoid Epi with end arteries- fingers-toes-nose-ears-penis). Sedatives Chloral Hydrate: 20-50 mg/kg/dose PO/PR q 4-6 hrs Diphenhydramine (Benadryl): 5 mg/kg/day - q 6 hrs PO/IM (max total dose 400 mg/day) (may give 1-2 mg/kg/dose slow IV for anaphylaxis or Phenothiazine overdose q 4-6 hrs) Midazolam (Versed): 0.1 mg/kg IV/IM; 0.2 mg/kg sublingual, 0.4-0.5 mg/kg PO, 0.5 mg/kg PR Lorazepam (Ativan): 0.1 mg/kg IV Diazepam (Valium): 0.1 mg/kg/dose IV Pentobarbital: 2-4 mg/kg IV/IM (potent sedative hypnotic, onset-1 min, duration-30 min) Methohexital (Brevital): 1-2 mg/kg IV, 10 mg/kg IM (ultra short acting, onset 30-60 sec, duration 5-10 min) Ketamine (really a dissociative anesthetic) 0.5-1.5 mg/kg IV, 3-7 mg/kg IM, 6-10 mg/kg PO (causes increased secretions, laryngospasm, increased BP, increased ICP) Antihypertensives Diazoxide: 3.0-5.0 mg/kg rapid IV push (10 mg/kg max total dose) Hydralazine: 0.1-0.2 mg/kg IM, IV q 4-6 hrs prn not greater than 20 mg; Labetolol (not with asthma): 0.25-1.0 mg/kg IV q 1-2 hrs, or 0.4 mg/kg/hr IV infusion Nitroprusside: 0.2-8 mcg/kg/min (light sensitive: bag & tubing must be wrapped, can cause CN toxicity, should be given with sodium thiosulfate). Minoxidil: 0.25-1.0 mg/kg/day PO given QD or BID, with max dose 50 mg/day Nitroglycerin 1-6 mcg/kg/min Nicardipine: 0.5 mcg/kg/min with range of 0.5-2.0 mcg/kg/min Esmolol: 500 mcg/kg load then 50-250 mcg/kg/min Cardiac (PALS) Adenosine 0.1 mg/kg IVP, may double second dose with max first dose of 6 mg and max 2nd dose of 12 mg Calcium Chloride (10%): 25 mg/kg or 0.2-0.3 cc/kg IV; Use caution in digitalized patients Calcium Gluconate (10%): 60-120 mg/kg (0.6-1.2 ml/kg) IV over 5-10 min Digoxin: Digitalizing: 20-40 mcg/kg PO to be given over 24 hrs = Total Digitalizing Dose (Adult Dose = 1 mg); Give TDD Stat, then TDD q 8 hrs x 2; Maintenance: 10-20 mcg/kg/day PO BID; Note: IV dose = 2/3 PO dose (For SVT or CHF) Heparin: 50-100 U/kg IV Bolus, then IV Drip at 10-20 U/kg/hr Lidocaine 1 mg/kg IVP, then 20-50 mcg/kg/min prone Propranolol: Arrhythmias- 0.05-0.15 mg/kg IV slow push, may repeat q 6-8 hrs. (Max single dose = 1 mg/dose); Tet Spells- 0.15-0.25 mg/kg/dose IV slowly Synchronized cardioversion: 0.5-1.0 J/kg Verapamil 0.1 mg/kg IV (> 1 yr old) Diuretics Spironolactone: 1.0-3.5 mg/kg/day + q 6-8 hrs PO Chlorothiazide: 20-40 mg/kg/day t q 12 hrs PO Hydrochlorothiazide 2-4 mg/kg/day PO + BID Furosemide (Lasix): 1.0 mg/kg/dose IV slow push, PO (CHF/Diuresis) Mannitol: 0.25-1.0 gm/kg/dose IV Ethacrynic Acid IV 0.6-2.0 mg/kg. Vasoactive Drips (Use standard concentrations when available) Milrinone: Dose: 50 mcg/kg IV Load over 15 min., 0.5-1 mcg/kg/min; Dopamine & Dobutamine: Dose: 2-20 mcg/kg/min Epinephrine & Isoproterenol: Dose: 0.05 - 0.5 mcg/kg/min PGE-I: Dose: 0.05-0.1 mcg/kg/min Reversal Antidotes Naloxone: Opioid induced respiratory depression in patients with pain or to reverse opioid effects in conscious sedation: 0.001 mg/kg (maximum: 0.05 mg) every 1-2 minutes until respirations are adequate Respiratory arrest: children <5 years or <20 kg: 0.1 mg/kg; children >5 years or 20 kg: 2 mg/dose Opiate intoxication: <5 years or <20 kg: 0.1 mg/kg; repeat every 2-3 minutes if needed; may need to repeat doses every 20-60 minutes; >5 years or 20 kg: 2 mg/dose; if no response, repeat every 2-3 minutes; may need to repeat doses every 20-60 minutes Continuous infusion: titrate dose to 0.04-0.16 mg/kg/hour for 2-5 days in children Flumazenil: Conscious sedation reversal: initial dose: 0.01 mg/kg (max dose: 0.2 mg) give over 15 sec; may repeat 0.01 mg/kg (max dose: 0.2 mg) after 45 sec, then every min to max total dose of 0.05 mg/kg or 1 mg, whichever is lower Overdose: initial dose: 0.01 mg/kg (max dose: 0.2 mg) with repeat dose of 0.01 mg/kg (max dose: 0.2 mg) given every min to max total dose of 1 mg Continuous infusions: 0.005-0.01 mg/kg/hour Neostigmine: 0.05-0.07 mg/kg/dose IV (with anticholinergic) Physostiomine: 0.01 mg/kg slow IV (adult dose = 2 mg...consider anticholinergic). Activated Charcoal - 1-2 g/kg/dose. Pediatric Emergencies Hyperkalemia Calcium Gluconate 10%: 0.5-1.0 cc/kg IV over 5-10 min with CR monitor or give Calcium Chloride 10%: 20 mg/kg IV over 5-10 minutes (kept in code cart!!) NaHCO3, 1-2 mEq/kg over 5-10 min. Dextrose (50%): 1-2 cc/kg IV or Dextrose (25%): 2-4 cc/kg over 15 min with 0.15-0.3 units/kg of Regular Insulin Sodium Polystyrene Sulfonate (Kayexalate): 25% in Sorbitol Solution, 1 g/kg/dose q 6 hrs PO or q 2-6 hrs PR Albuterol nebs 2 unit doses (5 mg neb) stat Dialysis Hypoglycemia Neonates - D10, 1-2 cc/kg IV Toddlers & Children - D25 (0.25 g/cc), dose- 2-4 cc/kg Older Children & Adolescents - D50, dose- 1-2 cc/kg Work Up (before Dextrose given if able) - consider glucose, Insulin level, Glucagon, C-peptide, ketones, GH, Cortisol, lytes (?AG), lactate, urine ketones Adrenal Crisis D5NS 20 ml/kg IV bolus Hydrocortisone 1-2 mg/kg IVBP, then [1000 mL D5NS + 100 mg Hydrocortisone] IV at maintenance -or- Hydrocortisone 50 mg/m2 IV q 6 hours; if in shock give 50 mg/kg q24-48 or as needed Clinical - shock, altered mental status, weak, nausea, vomit, abdominal pain, body aches, hyponatremia, hyperkalemia, metabolic acidosis, decreased serum cortisol Respiratory Issues Asthma Medications Albuterol (Ventolin, Proventil, racemic albuterol): continuous nebulizer 0.5 mg/kg/hr (max 10 mg/hr) Xoponex (Levalbuterol): 0.63-1.25 mg neb per treatment, continuous xoponex not well studied in PICU Epinephrine 0.01 mg/kg SC (up to 0.3-0.5 mg)q 20 min x 3 doses prn Terbutaline 0.01 mg/kg SC q 20 min x 3 doses, then q 2-6 hours prn, may be given continuously if needed Ipratroprium bromide nebulizer 500 mcg neb q4 hours, try to coordinate with albuterol nebs Methylprednisolone (Solumedrol) 2 mg/kg load then 1 mg/kg IV q 6 hours for 48 hours Prednisone 1-2 mg/kg/day PO (max 60 mg/day) for 3-10 days Magnesioum Sulfate: 40 mg/kg/dose (max 2 grams) x one, give over 20 min and watch for hypotension (have NS bolus available and slow down drip rate if blood pressure changes) Stridor Medications Racemic Epinephrine nebulizer 0.25-0.5 cc in 2.5 cc NS q 2-4 hrs Dexamethasone (Decadron) 0.5 mg/kg IV q6 x 6 does Anaphylaxis Tx NS/ RL/ 5% Albumin 10-20 ml/kg IV Epinephrine 0.01 mg/kg SC (0.01 ml/kg 1:1000 soln) and repeat in 15 min prn. IV infusion: 0.1-1.0 mcg/kg/min.; Diphenhydramine (Benadryl) 1-2 mg/kg IV over 5-10 min.; Methylprednisolone 2 mg/kg IV LD followed by 1 mg/kg q 6 hours; Ranitidine (Zantac) 1-2 mg/kg IVBP q 6-8 hours. Fluid Maintenance, Deficits, and Dehydration Bolus: 20 ml/kg RL or NS for significant dehydration or volume deficit, repeat if no significant clinical improvement Maintenance Fluids: 1st 10 kg - 100 ml/kg/24 hrs (or roughly 4 ml/kg/hr) + 2nd 10 kg 50 ml/kg/24 hrs (or roughly 2 ml/kg/hr) + wt. > 20 kg 20 ml/kg124 hrs (or about 1 ml/kg/hr) Dehydration and Deficits Mild (<2-3 years old - 5% or 50 ml/kg deficit, >2-3 years old - 3% or 30 ml/kg deficit) Clinical - thirsty, ?dry mucous membranes, tears present, ? tachycardia, normal urine output(>l ml/kg/hr), normal BP and respirations Moderate (< 2-3 years old - 10% or 100 ml/kg deficit, >2-3 years old - 6% or 60 ml/kg deficit) Clinical - thirsty, irritable, dry mucous membranes, no tears, delayed capillary refill (> 2 sec), decreased turgor, skin tenting, sunken eyeballs and anterior fontanel, oliguria, tachycardia, weak pulse, normal BP Severe (< 2-3 years old 15% or 150 ml/kg deficit, > 2-3 years old - 9% or 90 ml/kg deficit) Clinical - shock, cold mottled skin, altered mental status, non-palpable or very weak and thready pulse, significant oliguria or anuria, tachypnea, very sunken eyeballs and/or anterior fontanel, significant delayed capillary refill (>3-4 sec), no tears, very dry mucous membranes Management of Fluid Deficits Isonatremic/Isotonic - Bolus with NS or LR. Replace [Deficit - Boluses] - 50% over 1st 8 hours, then 50% over next 16 hours. Add maintenance. Use D5NS or D5NS. Replace K with adequate urine output Hyponatremic/Hypotonic (Na < 130 mEq/l) - Bolus with NS or LR. Use D5NS or NS with maintenance and deficits. Use 3% NaCl if Na < 115-120 mEq/l or symptomatic (i.e. seizures...). Ask the fellow or attending!!! Hypernatremic/Hypertonic (Na > 150 mEq/l) - Replace fluid deficit evenly during a 48-72 hour period. Bolus with NS prn. Add maintenance. Replace K with adequate urine output. Use D5NS or D5NS. Serum Na reduction should be < 10-14 mEq/l/day. Ask the fellow or attending!!! Estimates of Continuing Losses (mEg/L) SourceNaKClHCO3Saliva60201550Gastric601090-Jejunum100510010Ileum120510020Bile150510050Pancreatic15058070Sweat50540-Urine603040-Diarrhea120158050 ELECTROLYTE DISORDERS Hyponatremia (Na+ < 136 mEq/l) Hypovolemic (ECF, Extra-renal - UNa < 20 mEq/l, Renal UNa > 20 mEq/l) Losses from GI (vomit, diarrhea), skin (sweating), lungs, third spacing (peritonitis...), bums; Renal (diuretics, RTA, diuretic phase of ATN, adrenal insufficiency - Addisons disease, hypoaldosteronism, ketonuria) Tx Seizures, use 3% saline, 5 cc/kg will (Na by 4 mEq/L Asymptomatic; see below Hypervolemic (ECF) - CHF, cirrhosis, nephrosis, renal failure, liver failure Tx water restriction, consider diuresis, treat underlying cause Isovolemic H2O intoxication (UNa < 10 mEq/l), SIADH (UNa > 20 mEq/l; pulmonary-TB, pneumonia...; CNS- trauma, infection, CA; Meds- Chlorpropamide, Vincristine, Clofibrate, Cytoxan, Narcotics, NSAIDs, Barbiturates, Tegretol, Tricyclics); hypothyroidism- myxedema, adrenal insufficiency; Sheehans, stress (pain, physical, psychological) Tx - initially restrict water and consider replace losses with NS, consider hypertonic saline if symptomatic. Others - Pseudohyponatremia (hyperlipidemia, hyperproteinemia- MM, hyperglycemia [100 mg/dl glucose 1.6 mEq/l Na+]); infusions (Glucose, Mannitol, Glycine), Ethanol, Methanol, Ethylene glycol, Isopropyl alcohol - check osmols Tx - if asymptomatic, treat underlying cause Dx - weakness, anorexia, nausea, vomiting, confusion, lethargy, seizures, coma Hypernatremia (Na+ > 148 mEq/l) Excess Free H2O Loss - Renal (DI - central or nephrogenic, osmotic diuresis - hyperglycemia, Mannitol); GI, Skin, and Respiratory losses; fevers, thyrotoxicosis, significant burns Inadequate Free H2O Intake - reset osmostat, poor PO intake, AMS, coma Excess Na+ Gain - Iatrogenic (NaHCO3, hypertonic saline, exogenous steroids), hyperaldosteronism, Cushings, congenital adrenal hyperplasia Dx - thirst, dehydration, confusion, muscle irritability, seizures, rasp. paralysis, coma Tx - Correct free H2O deficit slowly with one half of calculated amount and reassess. If correction is too rapid, CNS edema may result. Isotonic fluids for hemodynamic resuscitation. Calculated free H2O deficit = (Na+ - 140) x 0.6 (wt in kg)/l40 Managing Hypo/Hypernatremia and Characteristics of InfusatesFormulaClinical Use( Na+=(infusate Na+ + infusate K+) serum Na+Estimate the effect of 1 L of infusate containing Na+ and K+ on serum Na+[ 0.6 x Wt (kg)] + 1InfusateInfusate Na+ECF Distribution %5% saline in water8551003% saline in water5131000.9% saline in water154100Ringers lactate130970.45% saline77730.2% saline in 5% dextrose in water34555% dextrose in water040 Removes ICF as a consequence N Engl J Med 2000; 342:1581-1589, May 25, 2000 N Engl J Med 2000; 342:1493-1499, May 18, 2000 SIADH vs. DIDI Excessive water loss secondary to decreased ADH Polyuria and polydipsia Urine SG < 1.005 Serum Osm > 286 Dehydration ensues with hypernatrenmia Tx: DDAVP & Vasopressin SIADH Excessive water retention Serum Osm <280 Increased ECF volume excessive water retention by kidneys and Na < 130 Tx: Fluid restriction, ( LasixLab valueSIADHDIUOPdecreasesincreasesSpecific GravityincreasesdecreasesSerum NadecreasesincreasesSerum OSMdecreasesincreasesUrine NaincreasesdecreasesUrine OSMincerasesdecreases Hypokalemia Redistribution (alkalosis NaHCO3 or contraction, Insulin - Glucose, anabolism, B12 therapy, (2 Agonists, Periodic Paralysis) Renal losses (diuretics, low Mg+2, RTA - type I, vomiting, gluco/mineralocorticoid excess, hyperaldosteronism, Bartters, Liddles) GI losses (gastric - vomit, NG suction - GI obstruction, diarrhea, bile, fistula) (PO intake, lab error Dx - weakness, paresthesias, ileus; ECG - flat Ts, PVCs, U wave, (ST, wide QRS, arrhythmias Tx if K+ is 3.0-3.4(0.3 mEq/kg IV over 1( (20 mEq max all doses)2.5-2.9(0.5 mEq/kg IV over 1( & ( maintainence rate<2.5(1 mEq/kg IV over 2( (over 1( if symptoms) & ( maintainence rate Hyperkalemia Causes - acidosis, tissue necrosis - crush, hemolysis, blood transfusions, GI bleed, renal failure, pseudohyperkalemia (leukocytosis, thrombocytosis), (mineralocorticoid activity (Addisons, hypoaldosteronism), Spironolactone, Triamterene, Amiloride, excess PO K+, high dose PCN, Succinylcholine, (-Blockers, Captopril, Digoxin, Heparin, catabolism, RTA IV, lab error Dx - weakness, paresthesias, paralysis, confusion, arrhythmias; ECG - peaked T waves, ST depression, diminished P and R waves, prolonged PR and QT intervals, small P waves, wide QRS, sine waves (fusion of QRS and T waves) ( cardiac arrest Tx (see emergency section) EKG monitoring Correct acidosis or hypovolemia Calcium Gluconate 10%: 0.5-1.0 cc/kg IV over 5-10 min with CR monitor or give CaCl2 10%: 20 mg/kg over 15-20 min (kept in code cart!!!) Dextrose (50%): 1-2 cc/kg IV or Dextrose (25%): 2-4 cc/kg over 15 min with 0.15-0.3 units/kg of Regular Insulin Sodium Polystyrene Sulfonate (Kayexalate): 25% in Sorbitol Solution, 1 g/kg/dose q 6 hrs PO or q 2-6 hrs PR NaHCO3, 1-2 mEq/kg over 5-10 min. Albuterol nebs 2 unit doses (5 mg neb) stat Dialysis Hypocalcemia [< 8.0 mg/dl, ionized < 2.0 mEq/l or < 1.0 mmol/l] Causes - hypoparathyroidism (s/p para or thyroidectomy, RT, infiltration, hungry bone syndrome, pseudo-), Vit D def (malabsorption, hepatic or renal failure...), pancreatitis, (PO4, (Mg+2, alkalosis, CRF, loop diuretics, hypoalbuminemia, rhabdomyolysis, tumor lysis syndrome, Heparin, sepsis - shock, multiple blood transfusion, osteoblastic mets Dx - hyperactive tendon reflexes, paresthesias (circumoral, fingertips), carpopedal spasm, laryngospasm, tetany, seizures, Chevosteks or Trousseaus sign, weakness, confusion, irritability, hyperpigmentation, card. failure; ECG -prolonged OT intervals without U waves Tx Calcium Gluconate 10% 60-100 mg/kg IV over 1 hour (Ca+2 may potentiate Digoxin) CaCl2 10%: 20 mg/kg over 15-20 min; ( for (Mg+2 & (K+ Calcium gluceptate: 200-500 mg/kg/day IV divided every 6 hours Hypercalcemia Causes - 1( hyperparathyroidism (adenoma, hyperplasia, CA), cancer (bone mets, paraneoplastic syndrome, PTH like hormone), thyrotoxicosis, adrenal insufficiency, immobility, pheochromocytoma, meds (Thiazides, Vit A or D intoxication, Lithium), granulomatous disease (sarcoid, TB, fungal...), S/P ARF, Pagets, CRF, PO calcium, milk alkali syndrome, MM, acromegaly Dx - anorexia, nausea, vomit, dehydration, abdominal pain, PUD, pancreatitis, nephrolithiasis, restless, delirium, depression, lethargy, coma, hyporeflexia, fractures; ECG - short QT, wide T Tx - if symptomatic NS 10-20 cc/kg IV over 1 hour and keep urine output ~ 2-3 cc/kg/hr (Na excretion causes Ca excretion) Lasix 0.5-1 mg/kg IV q 2-4 hrs for diuresis Hydrocortisone 1-2 mg/kg IV QD and taper if sarcoidosis, Vit A & D intoxication, leukemia Mitramycin 25 mcg/kg/day IV over 3-4 days Calcitonin (dosage not established in children) 4 units/kg IM/SQ q12; may increase up to 8 units/kg q12 to max of q6 hrs Etidronate 7.5 mg/kg/day IV over 2 hours for 3-7 days Gallium nitrate 200 mg/m2 per liter NS over 5 days Dialysis Hypomagnesmia Causes - Alcoholism, cirrhosis, diuretics, chronic diarrhea and fistulas, pancreatitis, malabsorption, malnutrition, NG drainage, vomiting, Amphoterecin B, Cisplatin, Aminoglycosides, S/P ATN, DKA Tx, sepsis, post-parathyroidectomy, hyperaldosteronism, with (K and (PO4, bums Dx - Weakness, muscle fasciculation, tremor, tetany, seizures, AMS, coma, anorexia, nausea, vomiting, ileus, arrhythmias; ECG - (PR and QT interval, (ST, flipped Ts, wide QRS Tx Magnesium sulfate: 20-50 mg/kg/dose IV/IM q4-6 for 3-4 doses; max single dose: 2000 mg (16 mEq) or for acute symptoms 5-10 mg/kg IV over 20 min Magnesium chloride: 0.2-0.4 mEq/kg/dose IV/IM q4-6 hours for 3-4 doses; max single dose 16 mEq Magnesium chloride, gluconate, lactate, carbonate, oxide, or sulfate salts: 10-20 mg/kg/dose PO of elemental magnesium 4 times per day Hypermagnesmia Causes - Renal failure, rhabdomyolysis, tumor lysis, bums, tissue trauma, DKA, severe acidosis, hypothyroidism, cathartic abuse, antacids, eclampsia Tx, adrenal insufficiency. Dx - Lethargy, come, nausea, vomiting, areflexia, muscle weakness, respiratory depression, (BP, arrhythmias and conduction defects, vasodilatation; ECG - like hyperkalemia Tx Volume expansion with NS Lasix IV if renal function adequate Ca Gluconate 10% 0.5-1.0 cc/kg IV over 5-10 min with CR monitor Tx acidosis Dialysis if renal function severely impaired Hypophosphatemia Causes - DKA Tx, alcoholism, TPN, glucose infusions, refeeding syndrome, bums, alkalosis (respiratory or metabolic), PO4 - binding in gut, sepsis, malabsorption, diarrhea, Vit D def, hyperparathyroidism, (Mg+2, (K+, (Ca+2, renal tubular defects, anabolism, anabolic steroids Dx - CNS dysfunction (irritability, weakness, paresthesias, confusion, seizures, coma), RBC hemolysis, (2,3 DPG, cardiomyopathy, osteomalacia, platelet dysfunction, respiratory failure Tx - Replace either IV phosphorus (sodium phosphate or potassium phosphate), NEVER replace by IM route. Avoid metastatic calcification. Consider PO phosphate. Hyperphosphatemia Causes - Laxative/enema abuse, PO4 salts for hypercalcemia Tx, hypoparathyroidism, renal insufficiency, acidosis (respiratory, lactic), sepsis, rhabdomyolysis, tumor lysis, chemo, tissue necrosis, hemolysis, (GH, Vit D intoxication Dx - Similar features as seen with hypocalcemia. Ectopic calcification may occur. Tx May include volume expansion (NS) if renal function normal Aluminum Hydroxide: 50-150 mg/kg/day divided every q4-6, Dialysis ACID BASE DISORDERS Metabolic Acidosis pH < 7.35, (HCO3 (acute) Compensation: a fall of 1 mEq HCO3 will lead to a fall of 1.2 mmHg PaCO2 Elevated Anion Gap (Na+ - Cl HCO3 > 12 mEq/l) ( MUD PILES Methanol, Uremia, Diabetic Ketoacidosis, Paraldehyde & Phenformin, Iron & INH, Lactate, Ethanol & Ethylene Glycol, Salicylates Normal Anion Gap (hyperchloremic, loosing bicarbonate) - RTA, diarrhea, pancreatic or small bowel fistula, ileostomy, loss of small bowel fluid, ureterosigmoidostomy, ileal loop bladder, drugs (Acetazolamide - carbonic anhydrase inhibitor, Sulfamylon, Cholestyramine, Spironolactone), TPN, Arginine, Lysine, NH,CI, posthypocapnia, adrenal insufficiency, hypoaldosteronism, dilutional Tx - review current indications for bicarbonate replacement therapy HCO3 deficit (mEq)=(24 HCO3) (0.4) (wt (kg)) Metabolic Alkalosis pH > 7.45, ( HCO3 (acute) Compensation: a rise of 1 mEq HCO3 will lead to a rise of 0.6 mmHg PaCO2 NaCl Responsive - contraction alkalosis - volume depletion, vomiting, NG suction, diuretics (loss of urine K*), villous adenoma, PCN and Carbenicillin (large doses), rapid correction of chronic hypercapnia Tx - NaCl (0.9%) NaCl Resistant - excess mineralocorticoids (Cushings, hyperaldosteronism, Bartters), severe (K+, alkali administration (lactate - RL, citrate - banked blood, acetate, NaHCO3), milk alkali syndrome, licorice excess Respiratory Acidosis pH < 7.35, (PaCO2, (acute), ( HCO3 (compensation) Acute: a rise of 10 mmHg PaCO2 will lead to a fall of 0.08 in pH a rise of 1 mEq/l HCO3 will lead to a rise of 10 mmHg PaCO2 Chronic: a rise of 3.5 mEq/l HCO3 will lead to a rise of 10 mmHg PaCO2 Dx - acute airway obstruction (asthma), lung disease, hypoventilation (narcotics - MS..., sedatives, tranquilizers, CVA, paralysis, neuropathy), thoracic cage abnormalities (flail chest, rib fractures, kyphoscoliosis, scleroderma), pleural effusions, PTX, hypokalemia, hypophosphatemia, hypomagnesemia, muscular dystrophy Respiratory Alkalosis pH > 7.45, ( PaCO2 (acute), ( HCO3 (compensation) Acute: a fall of 10 mmHg PaCO2 will lead to a rise of 0.08 in pH a fall of 2 mEq/l HCO3 will lead to a fall of 10 mmHg PaCO2 Chronic: a fall of 5 mEq/l HCO3 will lead to a fall of 10 mmHg PaCO2 Dx - hyperventilation, anxiety, pain, CNS (CVA, head trauma, meningitis, (ICP), early sepsis, fevers, PE, CHF, pneumonia, ASA toxicity, interstitial lung disease, hepatic insufficiency, pregnancy, thyrotoxicosis, hypoxia, ventilator induced, pericardial effusion tamponade Seizure Disorders Febrile Seizures Simple (< 5-15 min., general, only 1 in 24 hours) Complex (> 5-15 min., focal, multiple); Associated with URIs, OM, UTI, pneumonia, pharyngitis, viral illness, DDx - hypoglycemia, electrolyte abnormalities, CNS pathology (head trauma, meningitis, encephalitis, tumor), hypoxia, toxins Work-up - CBC, lytes, glucose, U/A and C/S...; Strongly consider LP with first febrile seizure and < 12 months. If > 18 months, do LP with meningeal signs or possible CNS infection by Hx or PE. With prior antibiotics Tx, strongly consider LP with ? masked symptoms. May not need Head CT or EEG with first simple febrile seizure Increased risk of Meningitis: complex febrile seizure, MD visit within 2 days, extended post-ictal state, suspicious Neuro exam/PE, seizures in ER, first seizure after 3 years old; Consider Tx (Phenobarbital, Diazepam, Valproic Acid) with febrile seizure and abnormal baseline Neuro exam, seizure > 15 min., focal seizure with Neuro deficit (temporary or permanent), + family Hx of non-febrile seizures Anti-pyretics: Acetaminophen or Ibuprofen. Afebrile Seizures DDx Neonatal: Metabolic (hypoxic, hypo/hyperglycemia, hypocalcemia, hypo/hypernatremia, hypomagnesemia, inborn error of metabolism, pyridoxine deficiency or dependency, kernicterus), Infectious (meningitis, encephalitis, sepsis, post-TORCH infections), CNS (intracranial hemorrhage, cerebral-congenital malformation, mass), Drug withdrawal (opiates...), familial, hereditary (tuberous sclerosis), idiopathic 1-6 months: above, Shaken Baby Syndrome abuse 6 months - 3 years +: Toxins (ASA, CO, Theophyline, Pb, Amphetamine, Cocaine...), Trauma (abuse, CNS hemorrhage [subdural...], CNS injury...), Infectious, Metabolic or degenerative disorder, Sub-therapeutic anticonvulsant - withdrawal, idiopathic Tx Maintain airway (adequate oxygenation, may need oral or nasal airway, suction oral secretions, ?bag valve mask ventilation, ?intubation-RSI...) Check vital signs Check STAT glucose Obtain IV access (consider I0 if < 6 years and unstable) Meds STOP THE SEIZURE!!! Lorazepam (may last up to 24-48 hours) 0.1 mg/kg IV q 10-15 min to max of 4 mg/dose Diazepam 0.2-0.5 mg/kg IV. Repeat q 10-15 min. prn Max total dose (< 5years - 5 mg, > 5 years 10 mg). Rectal Diazepam 0.5 mg/kg pr (max - 20 mg, onset of activity 6-10 min). ~51~a~ 005 - 0.20 mg/kg IV, maximum dose - 5 mg Phenytoin 18-20 mg/kg IV LD (max - 1 g) in NS given slowly at 0.5-1.0 mg/kg/min. Complications - hypotension, arrhythmias, CHF. Maintenance Dose- 4-8 mg/kg/day div QD or BID IV or PO, consider Fosphenytoin if no access or small vein Fosphenytoin 18-20 mg/kg IV LD (infuse 1-1.5 mg/kg/min) or IM (30-50 min onset, use 1 or 2 sites), expensive, can use phenytoin in giving through CVL Phenobarbital 10-20 mg/kg IV LD (max dose - 1 g). Infuse ~ 100 mg/min. Can repeat 5-10 mg/kg IV q 20 min prn (total maximum dose - 40 mg/kg). Maintenance Dose = 3-5 mg/kg day IV or PO - q 12 hrs Pentobarbital for induced coma with refractory case. May need pressors. Sample dosing - 8 mg/kg IV bolus, then 3-4 mg/kg/hr Work Up CBC with diff., electrolytes, glucose, Mg, Ca, Phos, LP, Tox screen, LFTs, NH3, PT/PTT, anticonvulsant levels, Head CT, EEG...) Hematological Issues DIC Treatment [From A Practical Guide to Pediatric Intensive Care, by Jeffrey L. Blumer, 3rd edition (January 1991), ISBN: 0801628547] Treat underlying problem If Hgb < 7 ( PRBCs (10 cc/kg will (Hct by 3%) If Plt < 20 ( Give Plt to 60,000 If Plt >50 & bleeding ( give FFP (10cc/kg) If fibrinogen < 75 g/dL; give cryoprecipitate (one bag per 10 kg ( ( fibrinogen by 50 g/dL or 0.5 units/kg) If after 6-8 hours of aggressive treatment still bleeding ( double exchange transfusion with heparinized fresh blood or FFP & PRBCs Once stable, consider 10-20 units/kg/hr of heparin with 50 units/kg load FFP contains all clotting factors except platelets Cryoprecipitate is enriched for factor VII, vWF, and fibrinogen Blood Products PRBCs - 10 ml/kg (( Hct by 3%) Leukodepleted: donor WBC removed to prevent febrile, non-hemolytic transfusion reactions & delays formation of antibodies Irradiated: inactivates WBC that may slip by during leukodepletion, decreases chance of GVHD and transmission of CMV FFP: 10-15 ml/kg IV over 30-120 min. Platelets pheresis for infants, pheresis for < 20 kg, 1 pheresis for > 20 kg Cryoprecipitate - 0.5 units/kg IV Types of BMT MUD: matched, unrelated donor Haplo: bone marrow with 3 out of 6 match, usually a parent Cord: cord blood with active stem cells Sibling: marrow from a matched sibling Autologous: patient receives his/her own harvested stem cells Tandem: autologous transplant performed a 2nd time after recovery from the r 1st autologous transplant; typically seen in neuroblastoma T cell depleted: MUD transplant with special prep to remove T cells, patients at high risk for infections Fluid Analysis Pleural Effusions FindingsTransudate (CHF, Nephrosis, Cirrhosis)Exudate (infection, cancer)AppearanceClear/straw+++/-White/milky++( chylothorax)Reddish++ (see below)Turbid++ (lipid/WBCs)Purulent++ (empyema)Foul Smell++ (anaerobic infxn)Hemorrhagic/Viscous++ (mesothelioma)Anchovy Paste++ (amebiasis)Specific Gravity< 1.016> 1.016Total Protein (g/dL)< 3.0> 3.0Pleural Protein/Serum Protein< 0.5> 0.5LDH (IU)< 200> 200LDH pleural/LDH Serum< 0.6> 0.6Glucose< 30 mg/dL: rheumatoid < 0-60 mg/dL: cancer, TB, empyemaAmylase> 2x serum amylase: acute pancreatitis pancreatic psuedocyst esophageal rupture lung cancerpH~ 7.4< 7.3LipidsSudan (+), TRIG (+) = chylous Sudan (-), TRIG (+) = chyliformCytology++ malignancyWBCs< 1000/mm3> 1000/mm3RBCs< 10,000/mm3> 10,000/mm3 CSF Fluid DiseasePressure (cm H2O)Total WBCPredominate Cell TypeGlucose (mg/dL)Protein (mg/dL)Normal7-180-10mononuclear45-8015-45Acute Bacterial Meningitis(/nl> 5 to 1000sPMNs0-4550-1500Brain Abscess(/nl> 5 to 1000slymphs & PMNsnl/(highAseptic Meningitisnl/occ (>5-2000lymphsnl/(20-200+TB Meningitis(/nl>5-500lymphs10-4545-500Fungal Meningitisnl/(>5-800lymphsnl/(nl/(Crypto>5-800lypmhsmod (up to 500 in 90%Coccidio, Histo, Blasto>5-200lymphsfreq ((Syphilisnl/(>5-1500lymphsnl/(25-300Amebic(/nl>400-20,000PMNs with RBC(/nl(Carcino-matous Meningitisnl/(>5-1000mononuclearnlup to 500Solitary Brain Tumor(/nl>5-150mononuclearnlup to 500Chemical Meningitisnl/(>5-1000sPMNsnl(Cerebral Thrombosisnl/(>5-50nlnl/up to 100+Cerebral Hemorrhage(/nlsame as bloodsame as bloodnlup to 2000Tips for bloody taps P=RBCCSF x (WBCblood/RBCblood) & O=WBCCSF then O:P > 10 is 93% sensitive & 97% specific to detect meningitis (J Infect Dis 1990 Jul;162(1):251-4) Allow 1 mg protein per 1000 RBC;s in traumatic tap, i.e. 74,000 RBC & Protein 160 ( 160 74 = 86 corrected Miscellaneous PICU Stuff Golytely Bowel Cleanout Regimen Regular breakfast only on the day before the procedure. Clear liquids only from breakfast until midnight. Start Golytely around 4 p.m. < 10 kg3 ozevery10 20 minto equal1 liter10-20 kg4 oz20 min1.5 liter20-30 kg5 oz20 min2 liter30-40 kg6 oz20 min2.5 liter40-50 kg7 oz20 min3 liter> 50 kg8 oz20 min4 literGive a dose metoclopromide 30 minutes prior to starting Golytely and repeat in 4 hours Most kids will not drink unless chilled or flavored Can only give NG, not post pyloric GOAL is to have clear BMs, may give more if needed Parameters Used to Monitor Acute Respiratory Failure ParameterHow to determineAlveolar O2 tension (PAO2) Normal = 102 torrPAO2 = PiO2 (PACO2/R) Where PiO2 = (P(-PH2O)(FiO2) Assume PAO2 = PaO2, R = 0.8, & PH2O = 47Blood O2 Content Arterial (CaO2) Normal = 20 vol % Venous (CvO2) Normal = 15 vol %CaO2 = (1.34*)(Hgb^)(SxO2) + 0.0031(PaO2) Where SxO2 is in fractions *1.32 for neonates, 1.36 for adults in ml/g ^ in g/dL Alveolar-arterial O2 gradient (A-aDO2) Normal = 30 to 50 torrA-aDO2 = PAO2 PaO2Intrapulmonary shunt (Qs/Qt) Normal = 3 to 7 vol %Qs/Qt = CCO2 CaO2CCO2 - CvO2Arteriovenous O2 Content Difference Normal = 5 vol %avDO2 = CaO2 - CvO2Mixed venous O2 tension (PvO2) Normal = 40 torrMeasured by means of pulmonary artery catheterMixed venous O2 saturation Nomral 75% (or 25% extraction)SvO2 = SaO2 - PvO2(Hgb x 13.8 x CI)Cardiac output (CO) Normal (adult) = 4-8 L/minFick: CO =VO2x 10C(a-v)O2Cardiac Index (CI) Normal = 3.5 5.5 L/min/m2CI = CO/Body surface areaLeft Cardiac Work Index Normal = 4.0 ( 0.4 kg m/m2CI x MAP x 0.0136Left Ventricular Stroke Work Index Normal = 56 ( 6 gm m/m2SI x MAP x 0.0136Right Cardiac Work Index Normal = 0.5 ( 0.06 kg m/m2CI x MPAP x 0.0136Right Ventricular Stroke Work Index Normal = 6 ( 0.9 gm m/m2SI x MPAP x 0.0136Oxygen delivery (DO2) Normal = 520 to 720 mL/min/m2DO2 = CaO2 x CI x 10 or ( SV x HR x CaO2Oxygen consumption (VO2) Normal = 100 to 180 mL/min/m2 Infants = 6 to 8 mL/kg/minVO2 = CI x avDO2 x 10O2 extraction ratio (O2ER) Normal = 22 % to 30 %CaO2 - CvO2x 100 or VO2/DO2CaO2PVR Normal 80 240 dyne-sec/cm5/m279.92 (MPAP PCWP)CISVR Normal 800 1600 dyne-sec/cm5/m279.92 x (MAP CVP)CIStroke Index (SI) Normal = 30 60 ml/m2CI/HRStatic compliance of the respiratory system (Crs)Crs = Exhaled tidal volumePlateau pressure - PEEPOther ParametersPaO2< 200 is ARDS and < 300 is ALI (Normal is 100/0.21 = 476)FiO2O2 index = FiO2 x Paw x 100where > 30 would need ECMO interventionPaO2CVP =4 10 mm HgPAP=25/10 (15) mm HgPCWP=8 15 mm HgSerum Osm=2[Na] +Glc+BUN+EtOH+Mannitol182.84.618Corrected Na=Measured Na +1.5 x (Glc 150)Or 1.6 mmol/L per 100 mg/dl of Glc100Corrected retic = Observed retic x (obs Hct/nml Hct)FENa=100 x Na urine x Cr serum< 1 is prerenal failure > 3 renal failureNa erum x Cr urineGlucose Load #g Glc/kg/day (D10W = 10g / 100cc & D12.5W = 12.5g / 100cc ( #g / 100cc = X / (cc/kg/day) Divide X by 1440 to get Y Multiple Y by 1000 to get mg/kg/minDead space ventilation VD/VT = PaCO2 ETCO2 / PaCO2      PAGE  PAGE 6 Clotting Cascade ( Heparin ATIII inactive Inactive Antithrombin III Protein C, S Inactive 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