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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