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PedsPeds
Hyper/Hypoglycemia/FluidsHyper/Hypoglycemia/Fluids
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Type I diabetes-most common pedsType I diabetes-most common pedsendocrine disorderendocrine disorder
DKA leading cause of death in peds DMDKA leading cause of death in peds DMOverall mortality of peds DKA 3%Overall mortality of peds DKA 3%Equal male:femaleEqual male:femaleOnset 11-12 y.oOnset 11-12 y.oGenetic predispositionGenetic predisposition
Most common cause poor compilanceMost common cause poor compilance
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ClinicalClinical
Usually history of polyuria, polydipsia,Usually history of polyuria, polydipsia,
weight loss.weight loss.
N/V and abd. PainN/V and abd. PainMay mimic acute abd.May mimic acute abd.
New onset of abd. Pain and enuresis thinkNew onset of abd. Pain and enuresis think
DMDMBS>300, Ph
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ManagementManagement
0.9% NS at 20ml/kg/hr until stable0.9% NS at 20ml/kg/hr until stable Then 0.45 NS at 1.5 maintanance in EDThen 0.45 NS at 1.5 maintanance in ED
0.1 u/kg/hr of R insulin drip0.1 u/kg/hr of R insulin drip Decrease glucose at 50-100 mg/dl/hrDecrease glucose at 50-100 mg/dl/hr
Avoid HCO3 if possibleAvoid HCO3 if possible
Monitor K+ and replace as neededMonitor K+ and replace as neededAdd dextrose when BS in
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Monitor for hypokalemia and cerebralMonitor for hypokalemia and cerebral
edemaedema
Cerebral edema 6-12hrs after therapy: treatCerebral edema 6-12hrs after therapy: treat
with mannitol/intubationwith mannitol/intubation
PICUPICU
Bedside glucose q hourBedside glucose q hourElectrolyte panel and VBG q two hoursElectrolyte panel and VBG q two hours
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HypoglycemiaHypoglycemia
Serum glucose
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The most common cause in NIDDM childrenThe most common cause in NIDDM children
older than 1 yr in idiopathic ketoticolder than 1 yr in idiopathic ketotic
hypoglycemia.hypoglycemia.
Presents after a fasting period (afterPresents after a fasting period (after
sleeping)sleeping)
Return to normal after glucose loadReturn to normal after glucose load
Suspect with ketonemia & ketonuriaSuspect with ketonemia & ketonuria
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TreatmentTreatment
Oral replacement is preferredOral replacement is preferred
D10 at 5 ml/kg bolus in infants thenD10 at 5 ml/kg bolus in infants then
4ml/kg/hr4ml/kg/hr
D25 at 2.0 ml/kg bolus in children then 3D25 at 2.0 ml/kg bolus in children then 3
ml/kg/hrml/kg/hr
D50 IV too caustic for neonatal and infantsD50 IV too caustic for neonatal and infantsMaintenance fluids for neonates D10:Maintenance fluids for neonates D10:
infants and children D5infants and children D5
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Fluids and ElectrolytesFluids and Electrolytes
Abnormalities are primarily due toAbnormalities are primarily due to
gastroenteritis.gastroenteritis.
Infants have a high metabolic rate andInfants have a high metabolic rate and
require a large amount of waterrequire a large amount of water
Fluid requirements:Fluid requirements: For the first 10 kg: 100/ml/kg/dayFor the first 10 kg: 100/ml/kg/day
For the second 10 kg: 50ml/kg/dayFor the second 10 kg: 50ml/kg/day
For more than 20 kg: 20ml/kg/dayFor more than 20 kg: 20ml/kg/day
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Hyper metabolic states such as feverHyper metabolic states such as fever
increase the need for free water.increase the need for free water.
Electrolyte requirements for children isElectrolyte requirements for children is
3meq/kg/day for sodium and 2 meq/kg/day3meq/kg/day for sodium and 2 meq/kg/day
for potassium.for potassium.
Isotonic dehydration ofter occurs fromIsotonic dehydration ofter occurs from
diarrhea. If lost over time, it is welldiarrhea. If lost over time, it is well
tolerated. If rapid loss, it can be fatal.tolerated. If rapid loss, it can be fatal.
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Physical exam is helpful in determiningPhysical exam is helpful in determining
degree of dehydration.degree of dehydration. Normal mental status-mildNormal mental status-mild
Irritability-moderateIrritability-moderate
Lethargy-severeLethargy-severe
Decreased skin turgor/sunken eyes/fontanel-Decreased skin turgor/sunken eyes/fontanel-
moderate to severemoderate to severe
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Treatment for mildly dehydrated pts-oralTreatment for mildly dehydrated pts-oral
fluidsfluids
Moderately dehydrated- IV or oralModerately dehydrated- IV or oral
replacementreplacement
Severly dehydrated children-IV boluses ofSeverly dehydrated children-IV boluses of
NS or LR 20 ml/kg until improved. MayNS or LR 20 ml/kg until improved. May
require 60-80ml/kgrequire 60-80ml/kg
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Rehydrating solutions in infants:Rehydrating solutions in infants: Infants are D5 .25 NS or D5 .45 NSInfants are D5 .25 NS or D5 .45 NS
D5.20 NS is used for maintenanceD5.20 NS is used for maintenancerehydration in infants in isotonicrehydration in infants in isotonic
dehydrationdehydration
D5 .45NS can be used for maintanenceD5 .45NS can be used for maintanence
rehydration in children in isotonicrehydration in children in isotonic
dehydrationdehydration
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Hypernatremic dehydration sodium >Hypernatremic dehydration sodium >
150meq/L150meq/L
Presents with gastro pts. who are treatedPresents with gastro pts. who are treated
with salt rich solutionswith salt rich solutions
Replace free water with D .45 NS so thatReplace free water with D .45 NS so that
sodium falls slowly over days(max of 10-15sodium falls slowly over days(max of 10-15
meq/L/Day) so that cerebral edema doesmeq/L/Day) so that cerebral edema does
not occurnot occur
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Hyponatremic dehydration-sodium less thanHyponatremic dehydration-sodium less than
130meq/L130meq/L
Occurs with vomiting and diarrhea and fluidOccurs with vomiting and diarrhea and fluid
replacement with water.replacement with water.
In extreme cases seizures can occur. MostIn extreme cases seizures can occur. Most
common with Na
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Correction needs to take place over at leastCorrection needs to take place over at least
24 hrs.24 hrs.
Rapid correction can lead to central pontineRapid correction can lead to central pontine
demyelinization.demyelinization.
With severe hyponatremia 3% NS may beWith severe hyponatremia 3% NS may be
needed.needed.
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Hypokalemia- serum level
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Hyperkalemia-potassium >5.5Hyperkalemia-potassium >5.5Most common due to hemolysis in bloodMost common due to hemolysis in blood
draws.draws.Cardiac conduction delays most commonCardiac conduction delays most common
problems and life threateningproblems and life threateningEKG manifestationsEKG manifestations
First-peaked TsFirst-peaked Ts Prolonged PR intervalProlonged PR interval
Wide QRSWide QRS