ALLERGY and IMMUNOLOGY ALLERGY and IMMUNOLOGY
IMMUNODEFICIENCY IMMUNODEFICIENCY
10 Warning signs of Immunodeficiency 10 Warning signs of Immunodeficiency
•• 8 ear infect8 ear infections or more ions or more within a yeawithin a yearr
•• 2 sinus 2 sinus infections infections within a within a yearyear
•• 2 months anti2 months antibiotics with littbiotics with little effectle effect
•• 2 pneumonias 2 pneumonias within 1 within 1 yearyear
•• failure gain failure gain weight; grow weight; grow normallynormally
•• Recurrent Recurrent abscessessabscessess
•• Thrush in Thrush in mouth or mouth or skinskin
•• IV antIV antibiotics fibiotics for infectior infectionsons
•• 2 d2 deep-seated eep-seated infectionsinfections
•• family history family history of primary of primary immunodeficiencyimmunodeficiency
General Screening of Immunity General Screening of Immunity
•• CBC, CBC, differential, differential, plateletsplatelets
•• IgG,IgA,IgM,IgE IgG,IgA,IgM,IgE levelslevels
•• Baseline Baseline Antibody Antibody TitersTiters
Phagocytic Defect Phagocytic Defect
•• NBT NBT testtest
•• Rebuck Rebuck skin skin windowwindow
•• Chemotaxis Chemotaxis
•• Bacterial Bacterial assayassay
Complement Defect Complement Defect
•• CH50 CH50
•• C3C3
•• C4 C4 assayassay
HIV Screening (ELISA) HIV Screening (ELISA)
Positive- Probable AIDS Positive- Probable AIDS Verify diagnosis by: Verify diagnosis by:
•• repeat Erepeat ELISA HILISA HIV testV test
•• Western Western blot blot analysisanalysis
•• CD4 CD4 T cell T cell countcount
Negative- Non-AIDS T cell defect Negative- Non-AIDS T cell defect
•• CMI skin tCMI skin test (PPD, est (PPD, Candida antigen, Candida antigen, etc.)etc.)
•• CD4, CD4, CD8 CD8 assay assay ratioratio
•• Lymphocyte Lymphocyte blastogenic blastogenic assayassay
•• T T cell cell enumerationenumeration
ANAPHYLAXIS ANAPHYLAXIS Criteria for rapid
Criteria for rapid recognitiorecognition of n of AnaphylaAnaphylaxisxis
1. Exposure to an allergen within 1 hour & 1 s
1. Exposure to an allergen within 1 hour & 1 systemic signystemic sign 2. Urticaria or angioedema & 1 systemic sign
2. Urticaria or angioedema & 1 systemic sign Systemic signs: Systemic signs: hypotension hypotension bronchospasm or dyspnea bronchospasm or dyspnea
laryngeal/pharyngeal edema, stridor or dysphonia laryngeal/pharyngeal edema, stridor or dysphonia increased gastrointestinal tract motility
increased gastrointestinal tract motility
Patterns Patterns
Acute – explosive onset within seconds to minutes of exposure to Acute – explosive onset within seconds to minutes of exposure to triggering event
triggering event
Biphasic – followed by a reaction
Biphasic – followed by a reaction 3 to 8 hours after initial reaction (53 to 8 hours after initial reaction (5-20%-20% of cases)
of cases)
Protracted – lasts 3 to 21 days from onset of acute reaction Protracted – lasts 3 to 21 days from onset of acute reaction
Laboratory findings Laboratory findings
Elevated plasma histamine Elevated plasma histamine
Elevated serum tryptase - longer half-life Elevated serum tryptase - longer half-life
Treatment Treatment
EPINEPHRIN
EPINEPHRINE IS THE E IS THE DRUG OF DRUG OF CHOICE!CHOICE! potent cathecholamine with both
potent cathecholamine with bothαα and andββ adrenergic properties adrenergic properties Reverses all pathophysiologic features of anaphylaxis
Reverses all pathophysiologic features of anaphylaxis
α
α-hypotension,peripheral vasodilation, increased vasopermeability,-hypotension,peripheral vasodilation, increased vasopermeability, urticaria, angioedema
urticaria, angioedema
β
β-positive inotropic & chronotropic effects, bronchodilation, increase-positive inotropic & chronotropic effects, bronchodilation, increase cAMP
cAMP Epinephrine
Epinephrine 1:1000 1:1000 0.01 ml/kg 0.01 ml/kg SC/ IM SC/ IM (ped) or (ped) or 0.3 to 0.3 to 0.5 ml 0.5 ml (adult)(adult) given q 20 mins prn
given q 20 mins prn Px on
Px onββ blockers may be resistant to epinephrine so higher does may be blockers may be resistant to epinephrine so higher does may be required or glucagon given
required or glucagon given
insect sting or injected drug: infiltrate 0.1 - 0.2 ml locally to retard insect sting or injected drug: infiltrate 0.1 - 0.2 ml locally to retard absorption of the residual allergen
absorption of the residual allergen
tourniquet applied proximally if injection or sting is on an extremity tourniquet applied proximally if injection or sting is on an extremity Immediate Therapy
Immediate Therapy
Rapid ABC’s of resuscitation Rapid ABC’s of resuscitation
Epinephrine IV (1:100,000) = 0.01 mg/kg or continuous drip 0.1-0.2 Epinephrine IV (1:100,000) = 0.01 mg/kg or continuous drip 0.1-0.2
µ
µg/kg/min titrated q 0.1g/kg/min titrated q 0.1 µµg/kg/min to max of 1.5g/kg/min to max of 1.5µµg/kg/ming/kg/min Separate IV line no HCO3 infusion
Separate IV line no HCO3 infusion
Continuous monitoring of CVS status and O2 Continuous monitoring of CVS status and O2
Rapid HX of triggering event, current medications, HX of asthma, Rapid HX of triggering event, current medications, HX of asthma, allergies and concomitant medical conditions
allergies and concomitant medical conditions Subacute
Subacute
H1 blocker – Diphenhydramine 1-2
H1 blocker – Diphenhydramine 1-2 mg/kg PO,IM,IVmg/kg PO,IM,IV Chlorpheniramine 10-20 mg IV,IM
Chlorpheniramine 10-20 mg IV,IM
Corticosteroids – Hydrocortisone 4-8 mg/kg/dose or methylprednisolone Corticosteroids – Hydrocortisone 4-8 mg/kg/dose or methylprednisolone 1-2 mg/kg Iv q 6 h
1-2 mg/kg Iv q 6 h
Β
Β2 agonist nebulization q 20 mins 2 agonist nebulization q 20 mins of continuousof continuous Secondary
Secondary
H2 blocker – Ranitidine IV or PO 2-4 mg/kg/day q 8 h H2 blocker – Ranitidine IV or PO 2-4 mg/kg/day q 8 h Glucagon 0.1 mg/kg IV if refractory to initial TX Glucagon 0.1 mg/kg IV if refractory to initial TX Observe at least 4 hours
Observe at least 4 hours for biphasic anaphylaxisfor biphasic anaphylaxis
Fluids – Loss of up to 50% intravascular volume may occur resulting in Fluids – Loss of up to 50% intravascular volume may occur resulting in profound hypotension not responsive to epinephrine
profound hypotension not responsive to epinephrine
Antihistamines are not appropriate monotherapy for the Tx of acute Antihistamines are not appropriate monotherapy for the Tx of acute anaphylaxis
anaphylaxis
Corticosteroids are used to prevent the biphasic response and to control Corticosteroids are used to prevent the biphasic response and to control bronchospasm
bronchospasm
Bronchodilators are useful adjuncts in TX esp in those with asthma Bronchodilators are useful adjuncts in TX esp in those with asthma
CARDIOLOGY CARDIOLOGY Heart Rate
Heart Rate Age
Age Awake Awake Mean Mean SleepingSleeping NB-3mos NB-3mos 85-205 85-205 140 140 80-16080-160 3mos-2yrs 3mos-2yrs 100-190 100-190 130 130 75-16075-160 2-10yrs 2-10yrs 60-140 60-140 80 80 60-9060-90 >10yrs >10yrs 60-100 60-100 75 75 50-9050-90 Prob SVT (nQRS) >220 infants, >180children
Prob SVT (nQRS) >220 infants, >180children Cardioversion/ Defibrillat
Cardioversion/ Defibrillation: ion: 0.5-1J/kg (VT); 2-4J/kg (V0.5-1J/kg (VT); 2-4J/kg (VF/ Pulseless VT)F/ Pulseless VT) ECG
Normal Axis Normal Axis Newborn Newborn 0- 0- (+)180(+)180 1- 1- 6 6 m0 m0 (+)10- (+)10- (+)125(+)125 6mo-
6mo- 3yr 3yr (+)10- (+)10- (+)110(+)110 >3yr >3yr 0- 0- (+)90(+)90 PR 0.12-0.20sec PR 0.12-0.20sec QRS 0.08-0.12sec QRS 0.08-0.12sec ST
ST not not >1mm >1mm in in limb limb leads; leads; not not >2mm >2mm in in precordialprecordial QTc
QTc 0.44sec 3-4days;0.44sec 3-4days;≤≤0.45 <6mos;0.45 <6mos;≤≤0.44 children0.44 children Q
Q <0.04sec; <0.04sec; <25% <25% of of QRSQRS <5mm in L precordial & aVF;
<5mm in L precordial & aVF; ≤≤8mm in LII for <3yo8mm in LII for <3yo T
T (+) (+) in in I, I, II II & & V6V6
>48hrs abn if >7mm in LL or 10m
>48hrs abn if >7mm in LL or 10m m in precordialm in precordial P
P <2.5mm <2.5mm amp; amp; <3yo <3yo 0.03-0.09sec; 0.03-0.09sec; >3yo >3yo 0.05-0.1sec0.05-0.1sec Chamber Enlargements:
Chamber Enlargements: RAE
RAE Steeple; Steeple; Peaked Peaked P >3 P >3 mm mm in L2 in L2 & & V1V1 LAE
LAE Wide, Wide, notched, notched, biphasic biphasic P P >2.5 >2.5 mm mm in in L2 L2 & & V1V1 RVH RVH RVH RVH in in NewbornNewborn •• SL1 SL1≥≥12mm12mm •• Pure Pure RV1 RV1 >10mm,>10mm, •• RV1 RV1 >25>25 •• qR qR in in V1V1
•• upright upright T in T in V1 >V1 >3day3day
•• R R in in avRavR≥≥8mm8mm RVH in Children RVH in Children
•• RV1 RV1 >20, >20, SV6 SV6 >7>7
•• qR qR in in chest lchest leadseads
•• upright upright T T >3yo>3yo
•• RV1RV1≤≤10mm10mm
•• T wave T wave inversion in inversion in avFavF
•• R/S R/S ratio in ratio in V1 V1 >1>1
•• RsR’ RsR’ in in V1V1
•• RAD RAD >3mos>3mos LVH
LVH SV1 SV1 >20, >20, RV6 RV6 >25>25
Asymmetric T wave inversion inV5 & V6 Asymmetric T wave inversion inV5 & V6 SV1 + RV6 >50mm
SV1 + RV6 >50mm
Qwave >30mm in II, III, aVF, V5-6 Qwave >30mm in II, III, aVF, V5-6 CVH
CVH Direct Direct signs signs of of RVH RVH & & LVHLVH LVH + RAD & tall R in V1 LVH + RAD & tall R in V1 RVH + q
RVH + q≥≥2 mm in V5 & V6, 2 mm in V5 & V6, tall R in V6, & inverted T tall R in V6, & inverted T in V6in V6 Large equiphasic QRS in V2- V4, R + S >60 mm- Large equiphasic QRS in V2- V4, R + S >60 mm- Katz-Wachtel phenomenon
Wachtel phenomenon QTc (corrected QT) -
QTc (corrected QT) - Bazett’s Formula:Bazett’s Formula: ____QTa______
____QTa______
√√RR intervalRR interval
where RR interval = # of small squares between R-R x 0.04 sec where RR interval = # of small squares between R-R x 0.04 sec First Degree AV Block
First Degree AV Block There must be P waves There must be P waves
There must be one P wave to each QRS com There must be one P wave to each QRS complexplex P waves have morphology and axis usual for the subject P waves have morphology and axis usual for the subject
QRS complex must have morphology and axis usual for the subject QRS complex must have morphology and axis usual for the subject P-R interval is constant
P-R interval is constant
P-R interval is prolonged (i.e. >0.20 P-R interval is prolonged (i.e. >0.20 sec.)sec.)
Second degree AV block Second degree AV block
Mobitz type 1- Wenkebach phenomenon Mobitz type 1- Wenkebach phenomenon
•• there there must be must be P wP wavesaves
•• there must be QRS there must be QRS complexescomplexes
•• P waves must P waves must have morphology have morphology and axis usual and axis usual for the for the subjectsubject
•• Progressive prolongation of P-R interval with each succeeding beatProgressive prolongation of P-R interval with each succeeding beat until there is a dropped beat
until there is a dropped beat
Second degree AV block Second degree AV block Mobitz type 2
Mobitz type 2
•• there must be P wthere must be P waves & QRS aves & QRS complexescomplexes
•• P waves have morphology and axis uP waves have morphology and axis usual for the subsual for the subjectject
•• QRS complex must have morphology axiQRS complex must have morphology axis usual for the subjects usual for the subject
•• P-R interval of conducted beats may be normal or long but fiP-R interval of conducted beats may be normal or long but fixed, thenxed, then there is a dropped beat
there is a dropped beat
High Grade AV Block High Grade AV Block
•• Some P waves are followed by QRS Some P waves are followed by QRS complexes and some are notcomplexes and some are not
•• Atrio-ventricular conduction Atrio-ventricular conduction ratio is 3:ratio is 3:1 or higher1 or higher
•• P-R interval of beats in which a QRS complex fP-R interval of beats in which a QRS complex follows a P wave mayollows a P wave may be normal or long but must be constant
be normal or long but must be constant
Third degree AV block Third degree AV block
•• Any form of atrial activity may be seen or there may be no atrialAny form of atrial activity may be seen or there may be no atrial activity
activity
•• no consistent or meaningful relationship betno consistent or meaningful relationship between atrial and ventricularween atrial and ventricular activity.
activity. Variable PR and Variable PR and RP intervals.RP intervals.
•• QRS may be normal in shape, QRS may be normal in shape, duration and axis but more oftduration and axis but more often areen are abnormal and are of constant morphology
abnormal and are of constant morphology
•• QRS rate is usually constant and lies within the range of 15-70 QRS rate is usually constant and lies within the range of 15-70 beats/min.
CHEST XRAY ABNORMAL PATTERN
RAE – AP: >1/3 of the right RVE
AP: apex upturned / rounded
Lateral: obliteration of the retrosternal space; ½ filled only normally. Displacement of LV posteriorly. Behind shadow of IVC
LAE
AP: increased distance between the right wall of the left atrium and left main stem bronchus (double density); ≥3.5cm for infants, ≥4.5cm for children; Prominence of left atrial appendage or so called disappearance of cardiac waistline; elevation of left main stem bronchus.
Lateral: elevation of left main stem bronchus; discrete bulge in the region of the left atrium which pushes the esophagus posteriorly LVE – AP: prominent left heart border and mid-left heart concavity with
apex displaced posteriorly and meets IVC at the diaphragm level
MYOCARIDAL INFARCTION IN CHILDREN
ECG Findings
• New onset wide Q waves (>0.035 sec) seen within first few hours and persistent over several years
• ST-segment elevation (>2mm) seen within the first few hours
• Diphasic T waves seen within first few days (beginning sharply inverted) then normalizing over time
• Prolonged QT interval (>0.44 sec) with accompanying abnormal Q waves
• Deep wide Q waves in Leads I, avL, or V6 contrast Q waves in II, III, avF
Other criteria
• Elevated creatinine kinase / MB although this is not specific for detection of acute MI in children
• Cardiac Troponin I is a more sensitive indicator of early myocardial damage in children – elevated within hours of cardiac injury, persists for 4-7 days, specific for cardiac injury
CARDIOVASCULAR MEDICATIONS
• Inotropes: agents that improve myocardial contractility and enhance stroke volume
• Pressors: agents that increase systemic vascular resistance and increase blood pressure
• Chronotropic: Increase heart rate
• Lusotropic: improve relaxation during diastole and decrease EDP in the ventricles
ALPHA-ADRENERGIC MEDICATIONS
• Alpha1-adrenergic effects: Vascular smooth muscle contraction
• Alpha2-adrenergic effects: Vascular smooth muscle relaxation--this is a very mild effect only at low doses of an alpha-adrenergic agent like epinephrine.
BETA-ADRENERGIC MEDICATIONS
• Beta1-adrenergic effects:Direct cardiac effects: (a) Inotropy (improved cardiac contractility) (b) Chronotropy (increased heart rate)
• Beta2-adrenergic effects: (a) Vasodilation (b) Bronchodilation CARDIAC MEDS VIA CONTINUOUS INFUSION
EPINEPHRINE
• Both an alpha- and beta-adrenergic agent
• Indications for its use as a continuous infusion are:
o low cardiac output state
beta effects will improve cardiac function
alpha effects may increase afterload and decrease cardiac output
septic shock - useful for both inotropy and vasoconstriction
• Actions are dose dependent (mcg/kg/min):
o 0.02-0.08 = mostly beta1 and beta2stimulation.
increased cardiac output
mild vasodilation
o 0.1-2.0 = mix of beta1and alpha1
increase cardiac output
increase SVR = vasoconstriction
o > 2.0 = mostly alpha1
increase SVR, and may decrease CO by increasing afterload
• Side effects include:
• Anxiety, tremors,palpitations
• Tachycardia and tachyarrhythmias
• Increased myocardial oxygen requirements and potential to cause ischemia
• Decreased splanchnic and hepatic circulation (↑AST, ALT)
• Anti-Insulin effects: lactic acidosis, hyperglycemia
NOREPINEPHRINE
• Employed primarily for its alpha agonist effect - increases SVR (and B.P.) without significantly increasing C.O.
• Used in cases of low SVR and hypotension such as profound “warm shock” with a normal or high C.O. state
• Infusion rates titrated between 0.05 to 1 mcg/kg/min
o In general, norepinephrine differs from epinephrine in that at doses
used in clinical practice, the vasoconstriction outweighs any increase in cardiac output. i.e. norepinephrine usually increases blood pressure and SVR, often without increasing cardiac output.
• Side Effects:
• Similar to those of Epinephrine
• Can compromise perfusion in extremities and may need to be combined with a vasodilator e.g. Dobutamine or Nipride
• More profound effect on sphlancnic circulation and myocardial oxygen consumption
DOPAMINE
• Intermediate product in the enzymatic pathway leading to the production of norepinephrine; thus, it indirectly acts by releasing norepinephrine.
• Directly has alpha, beta and dopaminergic actions (dose-dependent)
• Indications are based on the adrenergic actions desired.
• Improve renal perfusion 2-5 mcg/kg/min
• Improve C.O. in mild to moderate Cardiogenic or Distributive Shock 5-10mcg/kg/min
• Post-resuscitation stabilization in patients with hypotension (in conjuction with fluid therapy) 10-20mcg/kg/min
DOBUTAMINE
• Synthetic catecholamine with inotropic effect (increases stroke volume) and peripheral vasodilation (decreases afterload)
• Positive chronotropic effect (increases HR)
• Some lusotropic effect
• Overall, improves Cardiac Output by above beta-agonist acitivity
o Major metabolite is 3-O -methyldobutamine, a potent inhibitor of
alpha-adrenoceptors.Therefore, vasodilation is possible secondary to this metabolite.
• Usual starting infusion rate is: 5 mcg/kg/min, with the dose being titrated to effect up to 20 mcg/kg/min.
• Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy, myocardial infarction
• If BP adequate, can be combined with afterload reducer (Nipride or ACE inhibitor)
• In combination with Epi/Norepi in profound shock states to improve Cardiac Output and provide some peripheral vasodilatation
MILRINONE/AMRINONE
• Belong to new class of agents “Bipyridines”
• Non-receptor mediated activity based on selective inhibition of Phosphodiesterase Type III enzyme resulting in cAMP ac cumulation in myocardium
• cAMP increases force of contraction and rate and extent of relaxation of myocardium
• Inotropic, vasodilator and lusotropic effect
• AMRINONE
• First generation agent - limited use now
• Long half-life (4.4 hours) with potential for prolonged hypotension after loading dose
• Associated with thrombocytopenia
• Dosage: Load with 0.75 mg/kg with infusion rate of 5-10 mcg/kg/min
• Milrinone is preferred drug from this group
• MILRINONE
• Increases CO by improving contractility, decreased SVR, PVR (?), lusotropic effect; decreased preload due to vasodilatation
• Unique in beneficial effects on RV function
• Half-life is 1-2 hours
• Load with 50 mcg/kg over 30 mins followed by 0.3 to 0.75 mcg/kg/min
VASODILATORS
Classified by site of action
• Venodilators: reduce preload - Nitroglycerin
• Arteriolar dilators: reduce afterload Minoxidil and Hydralazine
• Combined: act on both arterial and venous beds and reduce both pre- and afterload Sodium Nitroprusside (Nipride)
• NITROPRUSSIDE
• Vasodilator that acts directly on arterial and venous vascular smooth muscle.
• Indicated in hypertension and low cardiac output states with increased SVR.
• Also used in post-operative cardiac surgery to decrease afterload on an injured heart.
• Action is immediate; half-life is short; titratable action.
• Toxicity is with cyanide, one of the metabolites of the breakdown of nipride.
• Severe, unexplained metabolic acidosis might suggest cyanide toxicity.
• Dose starts at 0.5 mcg/kg/min and titrate to 5 mcg/kg/min to desired effect. May go higher (up to 10 mcg/kg/min) for short periods of time.
• NITROGLYCERIN
• Direct vasodilator as well, but the major effect is as a venodilator with lesser effect on arterioles.
• Not as effective as nitroprusside in lowering blood pressure.
• Another potential benefit is relaxation of the coronary arteries, thus improving myocardial regional blood flow and myocardial oxygen demand.
• Used to improve myocardial perfusion following cardiac surgery
• Dose ranges from 0.5 to 8 mcg/kg/min. Typical dose is 2 mcg/kg/min for 24 to 48 hours post-operatively
• Methemoglobinemia is potential side effect
• ISOPROTERENOL
• Synthetic catecholamine
• Non-specific beta agonist with minimal alpha-adrenergic effects.
• Causes inotropy, chronotropy, and systemic and pulmonary vasodilatation.
• Indications: bradycardia, decreased cardiac output, bronchospasm (bronchodilator).
• No longer available in some markets
• Occasionally used to maintain heart rate following heart transplantation.
• Dose starts at 0.01 mcg/kg/min and is increased to 1.0 mcg/kg/min for desired effect.
• INHALED NITRIC OXIDE
• Selective Pulmonary vasodilator
• Dilates only pulmonary capillaries to alveoli participating in gas exchange
• Decreases intrapulmonary shunt and improves V/Q matching
• Rapidly inactivated by Hgb in pulm. cap. so no systemic side effects (eg hypotension)
• Potential for use in ARDS and Pulmonary Hypertension
• Currently only approved for use in neonatal Pulmonary Hypertension
• Expensive
• Special monitoring equipment required
• Dose: Concentration of 0.5-60 ppm in inhaled gas
CARDIAC ARREST MEDICATIONS EPINEPHRINE
• Both an alpha- and beta-adrenergic agent
• During an cardiac arrest, most think it has the greatest benefit by alpha-adrenergic actions, increasing afterload and thus diastolic blood pressure, leading to improved coronary artery perfusion.
• Indications: o Cardiac arrest o Severe bronchospasm o Anaphylactic reactions • Route of Administration o IV or IO o SQ or IM (for bronchospasm)
o ET (cardiac arrest without IV or IO access)
• Dosage:
o initial (low) dose: 0.01 mg/kg o = 0.1 cc/kg of 1:10,000
o subsequent (high) doses: 0.1 mg/kg o = (0.1 cc/kg of 1:1,000)
ATROPINE
• Parasympathetic (not an alpha- or beta-adrenergic) agent--acts by blocking cholinergic stimulation of the muscarinic receptors of the heart.
• Results in an increase in the sinus rate of the heart.
• Little effect on systemic vascular resistance or myocardial contractility.
• Indications:
o Bradycardia
o Second or third degree heart block o Asystole
o Pulseless electrical activity (electrical mechanical dissociation) o Route of Administration: IV, IO, ET, SQ, IM, nebulization
• Dosage:
o 10 to 20 mcg/kg
o minimum dose is 0.1 mg--smaller doses may cause reflex
bradycardia (central stimulatory effect on the medullary vagal nuclei)
o maximum (adult) dose is 2 mg
SODIUM BICARBONATE
• Use during CPR remains a controversial issue due to lack of evidence showing benefit from receiving bicarbonate.
• Elevates blood pH by binding with hydrogen to form water and CO2
• HCO
-3 + H+ => H2CO3 => H2O + CO2
• Must have adequate ventilation to remove CO2 or respiratory acidosis will worsen
• Adverse effects of acidosis:
o Cardiac
Decrease contractility
Lower threshold for ventricular fibrillation
Decrease responsiveness to catecholamines
o Vascular
Decrease systemic vascular resistance
Decrease systemic vascular responsiveness to catecholamines Increase pulmonary vascular resistance
• Indications:
o Pre-existing acidosis
o Prolonged CPR (after 10 minutes) o Pulmonary hypertensive crisis o Hyperkalemia
• Route of administration: IV, IO
o Dosage: 1-2 meq/kg/dose (1 meq/cc or 0.5 meq/cc)
CALCIUM
• Current recommendations for the use of calcium during CPR are restricted to a few specific situations.
• Intracellular calcium plays an important role in the process of cell death, but no studies have shown that transient hypercalcemia worsens outcome after cardiac arrest.
• Adverse Effects of Hypocalcemia
o Decreased myocardial contractility o Decreased systemic vascular resistance o Decreased catecholamine release
o Decreased cardiovascular response to catecholamines • Indications:
o Hypocalcemia
Ionized hypocalcemia may result from severe alkalosis or after large transfusions of citrated blood products.
o Hyperkalemia o Hypermagnesemia
o Calcium channel blocker overdose • Route of administration:
o IV, IO only
o Calcium chloride--central venous line o Calcium gluconate--peripheral venous line • Dosage:
o Calcium chloride = 10-20 mg/kg o Calcium gluconate = 100-200 mg/kg
LIDOCAINE
• Class 1B antiarrhythmic
• Decreases automaticity threshold and ventricular fibrillation threshold.
• Effective in terminating PVCs.
• Rarely used in pediatric arrests as ventricular tachycardia and ventricular fibrillation are not commonplace.
• Indications:
o Ventricular Tachycardia o Ventricular Fibrillation o Frequent PVCs
• Route of Administration: IV, IO, ET
o Dosage: 1 mg/kg/dose (may need up to 2.5 mg/kg ET)
ENDOTRACHEAL MEDICATIONS (LEAN)
o Lidocaine o Epinephrine o Atropine
o Naloxone (Narcan)
CONGENITAL HEART DISEASE
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Pulmonary valve stenosis Atrial septal defect
Pulmonary ejection murmur (innocent)
Pulmonary flow murmur -PA stenosis
-Aortic stenosis -PDA, PAPVR, TAPVR
Mitral Regurgitation Vibratory innocent murmur
MVP syndrome Aortic stenosis
IHSS Aortic Valve Stenosis
-Supravalvar AS -Subvalvar AS
Ventricular Septal Defect Endocardial Cushion Defect Vibratory Innocent Murmur
-HOCM (IHSS) -Tricuspid regurgitation -TOF ACYANOTIC DEFECTS INC.PBF L to R Shunts NORMAL PBF Obstructive Lesions LVH or CVH RVH - VSD - PDA - ECD - ASD - PAPVR LVH - AS or AR - CoA - MR RVH - PS - CoA(infants) - MS CYANOTIC DEFECTS PBF PBF LVH or CVH RVH - PTA - SV - TGA-VSD - TGA-IVS - TAPVR - HLHS LVH - TGA-PS - PTA w/ hypopl. PAs - SV w/PS RVH - TOF - Ebstein’sa. - PVOD CVH - TVA - PVA-IVS RHEUMATIC FEVER
Guidelines for the Diagnosis of Initial Attack of Rheumatic Fever (Jones Criteria, Updated 1992)
MAJOR MANIFESTATIONS MINOR MANIFESTATIONS SUPPORTING EVIDENCE OF ANTECEDENT GROUP A STREPTOCOCCAL INFECTION
Carditis Clinical features: Positive throat culture
or rapid streptococcal antigen test
Polyarthritis Arthralgia
Fever Elevated or increasing
streptococcal antibody titer Erythema marginatum Laboratory features:
Subcutaneous
nodules Elevated acute phasereactants: Erythrocyte
sedimentation rate C-reactive protein Prolonged PR interval Chorea
• intended only for the diagnosis of the initial attack of acute rheumatic fever and not for recurrences
• 5 major and 4 minor criteria and an absolute requirement for evidence (microbiologic or serologic) of recent GAS infection.
• Diagnosis of acute rheumatic fever: 2 major criteria or 1 major and 2 minor criteria and meets the absolute requirement.
• Chorea may occur as the only manifestation of acute rheumatic fever.
• Indolent carditis may be the only manifestation in patients who 1st come to medical attention months after the onset of acute rheumatic fever
Criteria for determining activity:
• joint symptoms
• new significant murmur
• increasing heart size
• congestive heart failure in the absence of old valvular disease
• subcutaneous nodules
• rectal temperature >100.4 F for at least 3 consecutive days
• sleeping pulse of >100/min
• positive C-reactive protein
*considered active if any one of the following findings is present
RHEUMATIC HEART DISEASE
MR/MS is appreciated on PE LVH/RVH on ECG
irregular cardiac borders on CXR
*In RF there is also cardiomegaly but with normal ECG findings Rheumatic Carditis
• Mild carditis – no cardiomegaly & no CHF • Moderate carditis – cardiomegaly & CHF
• Severe carditis – severe CHF & pulmonary edema • Valvulitis
• Apical systolic murmur (Mitral regurgitation) • Apical mid-diastolic murmur (Carey-Coomb’s) • Basal diastolic murmur (Aortic regurgitation) • Basal systolic murmur (Tricuspid regurgitation) • Resting tachycardia
• Muffled heart sounds • Gallop rhythm • Pericardial friction rub • Congestive heart failure Treatment
1. Mild carditis
ASA 80-100mg/kg/day X 2 weeks then 60mg/kg/day X 2 weeks 2. Moderate to severe carditis
Prednisone 2mg/kg/day X 2 weeks, Tapering until discontinued
On the last week of prednisone, start ASA 80-100mg/kg/day X 2 weeks then 60mg/kg/day X 2 weeks
INFECTIVE ENDOCARDITIS (Duke criteria) Major criteria
(1) positive blood cultures (two separate cultures for a usual pathogen, two or more for less typical pathogens) and
(2) evidence of endocarditis on echocardiography (intracardiac mass on a valve or other site, regurgitant flow near a prosthesis, abscess, partial dehiscence of prosthetic valves, or new valve regurgitant flow)
Minor criteria
(1) predisposing conditions (2) fever
(3) embolic-vascular signs
(4) immune complex phenomena (glomerulonephritis, arthritis, rheumatoid factor, Osler nodes, Roth spots)
(5) a single positive blood culture or serologic evidence of infection (6) echocardiographic signs not meeting the major criteria.
Definite Endocarditis: Two major criteria, one major and three minor, or five minor criteria
KAWASAKI DISEASE
Clinical and Laboratory Features
EPIDEMIOLOGIC CASE DEFINITION (CLASSIC CLINICAL CRITERIA) Fever persisting at least 5 days
Presence of at least 4 principal features:
• Changes in extremities
• Acute: Erythema of palms, soles; edema of hands, feet
• Subacute: Periungual peeling of fingers, toes in weeks 2 and 3
• Polymorphous exanthema
• Bilateral bulbar conjunctival injection without exudates
• Changes in lips and oral cavity: Erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosae
• Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral Exclusion of other diseases with similar findings
3 Clinical phases:
Acute Febrile Phase ( 1-2 weeks ) fever, conjuctivitis, erythema, rash Subacute Phase ( 2-4 weeks )
begins when the fever stops
desquamation, thrombocytosis, coronary aneurysms Convalescent Phase ( 4-6 Weeks )
resolution of all sign & symptoms labs return to normal
coronary aneurysms persists Coronary Aneurysms
Classification of CAA
Small - <5mm internal diameter Medim - 5-8 mm internal diameter Large - >8 mm internal diameter
Treatment
Acute Stage
Intravenous Immunoglobulin: 2g/kg over 10-12 hours
With Aspirin (80-100 mkd) q6, until day 14 of illness and afebrile for 48 to 72 hrs
This therapy should be instituted within the 1st 10 days of illness and if possible within 7 days of illness.
Convalescent Stage
Aspirin (3-5 mkd) OD, until the patient shows no evidence of CA changes by 6-8 weeks after the onset of illness.
IVIG also should be administered to children presenting after the 10th day of illness
Long Term: Coronary Abnormalities
Aspirin (3-5 mkd) divided dosed, continued indefinitely High dose intravenous gammaglobulin (IVIG)
• effective in preventing the occurrence of coronary artery abnormalities in KD.
• Patients treated with IVGG have a significant increase in T suppressor cells, a decrease in circulating activated T helper cells, and a decrease in spontaneous IgG and IgM synthesis.
• suggest that IVGG reduces the vasculitis in KD by suppressing the marked immune activation associated with this disease.
• Measles and Varicella immunization should be deferred for 11 months after child receives high-dose of IVIG
• Even when treated with high-dose of IVIG within the 1st 10 days of illness, 5% of children develop at the least transient coronary artery dilation and 1% develop giant aneurysms.
• Careful monitoring is necessary during the administration of gamma globulin because it rarely can cause an allergic-like reaction.
DEVELOPMENT Anterior fontanelles – closed at 7-19 months Posterior fontanelle – closed at 3 months
ANTHROPOMETRICS
Length/Height
Average Birth Length: 50cm Length: 9-8-5-3cm
Height: agex5+80 Weight
Average BW: 3000
1-6mos= age in mos x 600 + BW 7-12mos= age in mos x 500 + BW 1-6yrs=agex2+8
7-12yrs=agex7-5/2
BSA: square root of (wt x ht / 3600)
Head Circumference Average 13-14in 0-4 mos – 2in 5-12mos – 2in 1-2 yrs – 2 in 2-5 yrs – 2 in 5-20 yrs – 2 in OR Average: 35cm 0-3mos 2cm/mo 3-6 1cm/mo 6-9 0.5cm/mo 9-12 0.5cm/mo 1-3yrs 0.25cm/mo 4-6yrs 1cm/yr
Height age – age points on the growth curve where the child’s height falls on the 50th percentile
Weight age – age point on the weight curve where the child’s weight falls on the 50th percentile
Midparental height – 7 (for girls) ± 10 Midparental height + 7 (for boys) ± 10 OR
For Males:
(mother’s height + 13cm + father’s height) ± 5 2
For Females:
(Father’s height - 13cm + mother’s height) ± 5 2
Growth Velocity (cm/yr)
Ht (cm) measured at Time 2 - Ht (cm) measured at Time 1 X 12 (mos/yr) Number of months between time 2 and time 1
Age Rate (cm/yr)
1-2 month 38 4 months 28 1 year 12 2 years 10 3-4 years 7 5-6 years 6 7-puberty 5 Arm Span
Age Arm Span
Boys: <10-11 years <height Girls: <11-14 years <height
Adult Male >Height by 5.3cm
Adult Female >Height by 1.2cm
Body Mass Index (BMI) Wt (kg) / ht2 (m2)
Overweight: >85th percentile Obesity: >95th percentile Body proportions
Upper segment – sitting height (measure using Harpenden sitting table) Lower segment – measure from upper border of symphysis pubis to floor in standing position
Sexual Maturity Rating Girls
Stage Breast Pubic Hair
1 Preadolescent Preadolescent
2 Breast and papilla elevated as small mound, diameter of areola is increased
Sparse, lightly pigmented, straight, medial border of labia
3 Breast and areola enlarged, no
contour separation Darker, beginning to curl,increased amount 4 Areola and papilla form
secondary mound Coarse, curly, abundant butless than in adult 5 Mature nipple projects, areola
part of general breast contour Adult feminine triangle,spread to medial surface of thighs
Boys
Stage Penis Testes Pubic Hair
1 Preadolescent Preadolescent None
2 Minimal change
/ Enlargement Enlargedscrotum, pink texture altered
Scanty, long, slightly
pigmented
3 Lengthens Larger Darker,
beginning to curl, small amount 4 Larger; Glans and breadth increase in size Larger, scrotum
dark Resemblesadult type, but less quantity; coarse, curly
5 Adult size Adult size Adult
distribution, spread to medial surface of thighs RED FLAGS Motor Delay
poor head control by 3 months hands still fisted by 4 months unable to hold objects by 7 months does not sit independently by 10 months cannot stand on one leg by 3 years
Language Delay
does not turn to sound by 6 months
does not babble or use gestures by 12 months no single word utterances by 16 months No 2-word phrases by 2 years
No 3-word sentences by 3 years
Psychosocial Delay
No social smile by 3 months
Not laughing in playful situation by 6 months
Hard to console, stiffens when approached by 1 year In constant motion, resists discipline
Does not play with other children at 3 years
Cognitive delay
- 2 months Not alert to mother
-6 months Not searching for dropped objects - 12 months No object permanence
- 18 months No interest in cause-and-effect games - 2 years Does not categorize similarities - 3 years Does not know full name -4 ½ years Cannot count sequentially - 5 years Does not know letters or colors -5 ½ years Does not know birthday or address
ENDOCRINOLOGY
IDF definition of Metabolic Syndrome in children and adolescents Age 6 to <10 years
Obesity≥ 90th percentile as assed by WC. MS cannot be diagnosed but further measurements should be made if family history of MS, T2DM, dyslipidemia, CVD, hypertension, or obesity
Age 10 to <16 years
Obesity≥ 90th percentile as assessed by WC Triglyceride≥ 1.7mmol/L (150mg/dL)
HDL – Cholesterol < 1.03 mmol/L (40mg/dL) BP≥ 130mmHg systolic or≥ 85mmHg diastolic
Glucose ≥5.6 mmol/L = 100mg/dL (OGTT recommended) or known T2DM
Age >!6 yo
Use existing IDF criteria for MS
DIABETES MELLITUS
Positive findings from any two of the ff. tests on different days:
Symptoms of DM plus casual plasma glucose≥ 200 mg/dl (11.1 mmol/l) or
Fasting plasma glucose≥ 126 mg/dl (7 mmol/l) or
2hrsPPG≥ 200 mg/dl (11.1 mmol/l) after a 75g glucose load Clinical manifestation HYPERGLYCEMIA Osmotic diuresis Dehydration Electrolyte losses ↓ Na, K, PO4 Volume contraction Azotemia KETOSISACIDOSIS Hyperventilation Hypocapnia
Dec. cerebral blood flow Circulatory depression Ileus
Gastric dilatation
DIABETIC KETOACIDOSIS
hyperglycemia (BG >200 mg/dl (11.1 mmol/l) heavy glycosuria (>55 mmol/l)
ketonuria
acidosis (pH < 7.3) ( HCO3 < 15 mmol/l) 5% or more dehydrated
± vomiting / drowsy
Principle 1:Restoration of vascular volume
In shock with poor peripheral perfusion or coma: give 10 cc/kg x 10-30 min
Repeat if poor pulses remain Fluid of choice: 0.9 NSS
Fluid input > 4li/m2 : incrd risk for cerebral edema IV therapy
MODEL 1
Req’ts = Deficit + Maintenance Maintenance: 3 – 9 kg 80 cc/kg/d 10-19 kg 70 cc/kg/d 20-30 kg 60 cc/kg/d 30-50 kg 50 cc/kg/d >50kg 35 cc/kg/d
MODEL 2
Covers maintenance + 10% deficit, give evenly for 48 hrs. 3 – 9 kg 6 cc/kg/hr
10 – 19 kg 5 cc/kg/hr
20 kg 4 cc/kg/hr
(max 250 cc/hr)
Compute for the fluid requirement of VJ ( BW=35 kg) Deficit: 35 x 60cc= 2100 ml
(assume mod dehydration unless shocky) Maintenance: (35 x 50) x 2=35000 Total fluid for 48h: 5600 ml
Monitor urine output especially during the first 4-6 hours of therapy Replace urine losses volume per volume
Entails frequent changing rate of infusion Potassium supplementation
Start as early as the 3rd hour or even earlier as long as the patient is voiding
Shift to a glucose containing solution when the blood glucose is down to 200 mgs%
Principle 2:Inhibition of lipolysis and correction of hyperglycemia Insulin therapy
• Only short-acting insulin is used ( Humulin R, Actrapid )
• Should not be started until shock has been reversed
• IV route only
• Target fall in blood glucose: 50-100 mg per hour Low dose continuous Insulin Infusion 0.1 u/kg/hr (consider 0.05 u/kg/hr for a young child)
↓
Hourly blood glucose, fluid input and output Neurological status at least hourly
Electrolyte 2 hrs after start of IV therapy Monitor ECG for T wave changes How to prepare insulin infusion?
Mix 10 ‘U’ SA insulin in 100 cc plain NSS – 0.1 ‘u’/ml Flush tubings with solution
For VJ: 35 kg x .1’u’/kg/hr= 3.5 ‘u’ 35 ml/hr
So, always prepare a solution as above so that infusion rate is equal to the weight of the patient
When do you stop insulin infusion?
• acidosis is resolved
• patient is awake
How to shift to subcutaneous route?
• Compute at .15-.25 ‘u’/kg/dose q6h to be given 30 min pre-meals and at MN
• D/C infusion 30 min after 1st SQ dose Do not increase insulin levels >100% Dosing Schedule
AM 2/3 HR 1/3HN 2/3
PM 1/3 HR 1/3HN 2/3
Principle 3:Correction of acidosis Sodium Bicarbonate therapy
• pH < 7.0
• HCO3 < 5meq/li
Half-correction over 30 minutes - 1 hour
THYROID STORM
Precipitating factors for thyroid storm Infection
Surgery (thyroidal and nonthyroidal) Therapy with radioactive iodine
Administration of iodinated contrast dyes or ingestion of large, stable iodine loads
Withdrawal of antithyroid medication Amiodarone therapy
Ingestion of excessive amounts of exogenous thyroid hormone Diabetic ketoacidosis
Congestive cardiac failure Hypoglycemia
Toxemia of pregnancy
Parturition and the immediate postpartum state Severe emotional stress
Acute manic crisis Pulmonary embolism Cerebral vascular accident Bowel infarction
Acute trauma Tooth extraction
Vigorous palpation of thyroid gland
The predictive clinical scale for thyroid storm (Burch and Wartofsky)
Parameter taken into consideration Scoringpoints Thermoregulatory dysfunction, Temperature (oral)
99-99.9°F 37.2-37.7°C 5 100-100.9°F 37.8-38.2°C 10 101-101.9 °F 38.3-38.8 °C 15 102-102.9°F 38.9â39.3°C 20 103-103.9°F 39.4-39.9°C 25 >104 °F >40 °C 30 CNS effects Absent 0 Mild (agitation) 10
Moderate (delirium, psychosis, extreme
lethargy) 20
Severe (seizures, coma) 30
GI-hepatic dysfunction
Absent 0
Moderate (diarrhea, nausea/vomiting,
abdominal pain) 10
Severe (unexplained jaundice) 20
Tachycardia (beats/min) 99-109 5 110-119 10 120-129 15 130-139 20 >40 25
Congestive cardiac failure
Absent 0
Mild (pedal edema) 5
Moderate (bibasal rales) 10
Severe (pulmonary edema) 15
Atrial fibrillation Absent 0 Present 10 Precipitating event Absent 0 Present 10
A cumulative score of >45 is highly suggestive of thyroid storm, 25-44 is suggestive of impeding storm, and <25 is unlikely to represent thyroid storm.
From Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003;4:129-36. Treatment
1.Phenobarbital - may be used for sedation because it stimulates metabolic clearance of thyroid hormone by the liver
2. PTU - 600-1000 mg (12-20 mg/kg) loading dose, followed by 200-300 mg (4-6 mg/kg) every 4-6 hrs orally. The drug of choice because of its inhibition of peripheral conversion of T4 to T3 in addition to its inhibition of synthesis of thyroid hormone
3. Methimazole (alternative) - given as a loading dose of 60-100 mg (1.2-2 mg/kg), followed by (1.2-20-30 mg (0.4-0.7 mg/kg) every 6-8 hrs orally 4. Inorganic iodine -Ideally, iodine therapy should be administered 2 hrs after initial thiourea dosing, to allow for initial blockade of iodine organification. Saturated solution of potassium iodide (children, 5 drops, 250 mg, 2-4 times/day, infants 2 drops 4 times/day) and Lugol solution (4-8 drops 3 times/day)
5. Lithium therapy - (300 mg or 6 mg/kg every 6 hrs) may be used in addition to iodine to block thyroid hormone release
6.High-dose corticosteroids - Hydrocortisone 50-100 mg, IV, every 6-8 hrs or 25-50 mg/m2 body surface
- effective in blocking peripheral conversion of T4 to T3
7.β-adrenergic blocking agent - β-blockers (e.g., propranolol, 40-80 mg, 0.5 mg/kg, orally, or 1-3 mg/dose IV, every 4-8 hrs; Given in the absence of cardiac failure, effective in reducing tachycardia, hypertension, and adrenergic symptoms associated with thyrotoxicosis
* medical therapy should be used for weeks to months before definitive treatment with radioactive iodine or thyroidectomy
Indications for t hyroidectomy
Thyroid cancer
Prophylactic thyroidectomy in children with MEN-2 A large multinodular goiter
Graves disease (including young children, not responding to antithyroid drugs, in whom radioactive iodine is contraindicated)
Steroids
Hydrocortisone 50-100mg/m2 as loading dose then 50-100mg/m2 in divided doses q6
4 Hydrocortisone = 1 Prednisone 25 Hydrocortisone = 1 Dexamethasone Taper 25% every week
Glucocorticoid Comparison Chart
Name Equivale nt Dose (mg) Relative Anti-inflammator y Potency Relative Mineralocorticoi d Potency Plasm a Half-life Biologi c Half-life Short-acting Cortisone 25 0.8 2 0.5 8-12 Hydrocortisone 20 1 2 1.5-2 8-12 Intermediate-acting Methylprednisolo ne 4 5 0 1.5-3 18-36 Prednisone 5 4 1 1 18-36 Prednisolone 5 4 1 2-3.5 18-36 Triamcinolone 4 5 0 3.5-4 18-36 Long-acting Betamethasone 0.6 20-30 0 5.5 36-54 Dexamethasone 0.75 20-30 0 2-3.5 36-54 β-HCG : 3000mg/BSA
FLUIDS & ELECTROLYTES
Daily Water Loss
Area ml/100 cal expended
obligatory urine volume 50-55
stool water 0-5
Skin 30
Lungs 15
Holliday-Segar Method
Weight Daily Requirements 3-10 kg 100 ml/kg
11-20 kg 1000 ml + 50 ml/kg for each kg > 10 kg > 20 kg 1500 ml + 20 ml/kg for each kg > 20 kg
Body Surface Method
Requirements
Water 1500 ml/m2/day
Na+ 30-50 meq/m2/day
K+ 20-40 meq/m2/day
Factors Modifying Fluid Requirements Additional Fluids Needed
fever 12% for each ºC > 37.5ºC
sustained hyperventilation or excessive
muscular activity 25-50%
hypermetabolic states 25-75%
for burns: 2% increase per 1% BSA with burns
diarrhea and vomiting volume per volume
sweating 10-25%
room temperature > 31ºC 30% per ºC rise > 31ºC newborn under radiant warmer or
phototherapy 25%
Less Fluids needed
hypothermia 12% per ºC fall below 37.5ºC very high humidity 30%
humidified inspired air 25%
oliguria or anuria Individualized sedated or paralyzed 40%
Electrolyte Daily Requirement (meq/kg/day)
Na+ 2.5-3.0
K+ 2.0-2.5
Determine the fluid deficit
Severity of Dehydration Infant Child (>10 kg)
mild 50 cc/kg 30 cc/kg
moderate 100 cc/kg 60 cc/kg
severe 150 cc/kg 90 cc/kg
determine the maintenance fluid requirement
give the ½ of the fluid deficit over the 1st 8 hours then ½ over the next 16 hours
re-assess hydration status periodically
for moderate to severe dehydration, check serum electrolytes
ELECTROLYTES
Na 135-145; K 3.5-5; Ca 2.1-2.6; HCO3 22-26
IVF
IVF Na+
(meq/L) K+(meq/L) Cl-(meq/L) HCO3-(meq/L) Mg++(mg/dL) Ca++(mg/dL)
pLR 130 4 109 28 (lactate) - 3 pNSS 154 - 154 - - -D5 0.3NaCl 51 - 51 - - -D5IMB 25 20 22 - 3 -D5NR 140 5 98 27 (acetate) - -D5NM 40 13 40 16 (acetate) 3 -HYPONATREMIA Fast correction: -4mL/kg/dose of 3% NaCl
-3% NaCl= 1mL (2meqs/mL NaCl + 4mL sterile water) -Total Na required= (M+D) –bolus
M= 3meqs/kg/day
HYPERNATREMIA
Total water required for 2 days = (M for 2 days +D) – bolus
Ideal TBW (in liters)= wtx 0.6; ideal serum Na 140 Water deficit= ideal TBW – actual TBW
Actual TBW= ideal TBW x ideal serum Na/actual serum Na
CORRECTED SODIUM Glucose in mg/dL Na+ + Glucose -100 x 1.6 100 Glucose in mmol/L Na+ + Glucose -5.6 x 1.6 5.6 HYPOKALEMIA Fast correction
0.5meqs/kg/dose in PNSS diluent x 1hour x 3-5 doses (max 40meqs/L) Example: Wt 20kg: (0.5meg/kg/dose K? x 20kg =10meq/hr
Compute how much diluent is required. Central line (200meq/L concentration) 200meq = 10meq
1000mL x
X=50mL
Order: Give 10meq K in 50mL NSS x 1hr Peripheral line (60meq/L concebtration) 60meq = 10meq
1000mL x
X=170mL
Order: Give 10meq K in 170mL NSS x 1hr Bedside Pediatric Nephrology
PO correction is potassium chloride of 4-6meg/kg/day given in divided doses.
Parenteral correction
Intermittent Dosing: (for symptomatic hypokalemia)
0.5 to 1.0meq/kg/hr (maximum 30meq/hr) with maximum infusion rate of 0.5meg/kg/hr and given Q2-4hours until symptoms resolve.
Continuous Dosing: (for non-symptomatic hypokalemia) 0.2-0.3meg/kg/hr for 24hours
*always consider the possibility of Magnesium deficiency especially among patients with refractory hypokalemia. Magnesium is a important co-factor for the activity of the Na-K-ATPase pump which is necessary for potassium homeostasis.
Hariett Lane: Oral:
Child: 1-4meg/kg/24hr÷BID-QID Adult: 40-100meq/24hr÷BID-QID IV:
Child: 0.5-1meq/kg/dose given as an infusion of 0.5meq/kg/hr x 1-2hr Max: 1meq/kg/hr. This may be used in critical situations(i.e. hypokalemia with arrhythmia)
Adult:
Serum K >2.5meq/L:
Replete at rates up to 10meq/hr. Total dosage not to exceed 200meq/24hr
Serum K <2meq/L:
Replete at rates 40meq/hr. Total dosage not to exceed 400meq/24hr Maximum peripheral IV solution concentration: 40meq/L
Maximum concentration for central line administration : 150-200meq/L Kalium durule 10meq/durule
10% Oral KCl=1.34meq/mL
HYPERKALEMIA
10% Calcium Gluconate (100mg/kg/dose) + equal diluent x1 hour - aims to stabilize cell membrane and opposes the negative inotropic effect of hyperkalemia
Glucose-insulin drip: 5mL/kg D10 or 1mL/kg of D50 + 0.1unit/kg Humulin R over 30-60minutes
Beta2 adrenergic agonist- Salbutamol administration at 1-5mcg/kg/min IV or nebulized at 10-20mg over 15 minutes
- drive potassium into the cells just like insulin
sodium bicarbonate- 2meq/kg IV over 30minutes (except for ERD patients)
Polystyrene sulphonate resins-0.5-1gm/kg PO or PR Q4-6hours Sodium Bicardonate
Base deficit Wt (kg)x distribution of NaHCO3(0.3)
HYPOCALCEMIA
-100mg/kg/dose Calciumgluconate/IV + equal diluent to run for 1 hour x 4-6doses, Q6hours (Max 2g)
-Corrected Calcium:
= (40-albumin) x 0.002+ actual serum calcium
INFUSIONS / DRIPS
Dopamine
amount (cc) = dose (mcg/kg/min) x BW (kg) x 480 40,000
Dobutamine
amount (cc) = dose (mcg/kg/min) x BW (kg) x 480 12,500
Epinephrine
amount (cc) = 0.6(BW) + sterile water to make 100 cc 0.1 mcg/kg/min = 1 cc/hr
general formula
drip rate (cc/hr) = dose x BW x 60 x total volume___ preparation
Preparation Dose (mcg/kg/min)
Albumin 20% 10mg/50mL Abumin 25% 12.5mg/50mL Aminosteryl 6% 6g/100mL Dobutamine 250mg/20mL (250,000 mcg/20mL) 5-20 Dopamine 200mg/5mL (200,000mcg/5mL) 5-10 Epinephrine 1mg/mL (1000mcg/mL) 0.1-0.5 Furosemide 20mg/2mL 2 Midazolam 15mg/3mL (15,000mcg/3mL) 1 Milrinone 10mg/10mL 0.25-1 Nitroglycerine(NTG) 10mg/mL (10,000mcg/mL) 1-5
Norepinephrine 2mg/mL Max: 2mcg/kg/min
Thiopental 20mg/mL
(20,000mcg/mL)
Voluven 6% Max 50cc/kg/day
DEXTROSITY
Dextrosity of Fluids
D5W contains 5 g of glucose per 100 ml changing dextrosities of fluids –
factor = desired dextrosity – lower dextrosity higher dextrosity – lower dextrosity amount of D50 to be added to actual IVF =
(factor)(actual IVF being given) peripheral line D12
central line D20 Glucose Infusion Rate
determines adequacy of infused glucose (dextrosity)(drip rate in cc/hr)(0.167)
body weight (kg) nv: infants 6-8; children 4-6 GIR normal = 5-8
GIR = rate (gtts/min) x dextrosity x 1,000 Weight x 60
BURN -Parkland
D1: 4ml/ k/ %BSA burned
½ x hrs, ½ x 16hrs + maintenance D2: 50-75% of above
• Maintenance fluids should be estimated for children who weigh <40kg
• For adults and children who weigh >40kg, maintenance fluids are not included in the estimate of fluid requirements
• Half of this volume is given in the first 8 hours after injury and the other half is given in the following 16 hours
GASTROENTEROLOGY NUTRITIONAL STATUS ASSESSMENT
WATERLOWE CLASSIFICATION S: 90-95 (Mi); 80-90 (Mod); <80 (S) W: 80-90 (Mi); 70-80 (Mod); <70 (S) Stunting
Actual height x 100 Ideal ht for age
> 95% normal 90-95 mild 85-90 mod <85 severe Wasting Actual weight x 100 Ideal wt for ht >/= 90% normal 80-90 mild 70-80 mod < 70 severe DIARRHEA Plan A <2k 50-100ml 2-10k 100-200ml >10k as much Plan B 75ml/kg x 4hrs Plan C Infants 30ml/k x 1hrs, 70ml/k x 5hrs Older 30ml/k x 30mins, 70ml/k x 2hrs ReSoMal:
1Lpack Oresol, 1L water; 45mL 10% KCl, 50gm sucrose 1st 2hrs 5ml/k q30mins; 4-10hrs 5-10ml/k/hr
VOMITING
WARNING SIGNALS in the vomiting infant Bilious vomiting
GI bleeding (hematemesis, hematochezia) Forceful vomiting
Onset at 6 mos of life Failure to thrive Diarrhea Constipation Fever Lethargy Hepatosplenomegaly Bulging fontanelle Macro/microcephaly Seizures Ab tenderness/distention Genetic disorders (trisomy 21) Other chronic d/o (eg HIV)
GER – passage of gastric contents to esophagus
GERD – gastric contents to esoph/oropharynx and produce symptoms such as:
Recurrent vomiting hematemesis Wt loss/FTT dysphagia Irritability feeding refusal Regurgitation cough apnea/ALTE anemia recurrent pneum Hoarseness Heartburn/chestpain wheezing/stridor Esophagitis Barret’s esoph OMEPRAZOLE
- duodenal ulcer : 20-40 mg OD x 2-4 wks
- benign gastric ulcer, reflux esophagitis – 20-40 mg OD x 4-8 wks - children >2yrs serious reflux esophagitis 1 mkd for 4-8 wks
> 20 kg – 20 mg OD 10-20kg – 10 mg OD
- NSAID induced gastric and duodenal ulcer : 20 mg OD x 4-8 wks - GERD 10-20 mg OD x 2-4 wks
- symptomatic GERD w/ esophageal lesions 20 mg OD x 4 wks
-maintenance of healing of erosive esophagitis – 20 mg OD up to 12 mos Eradication of H. pylori
BID x 1 wk: Omeprazole 20 mg + Amox 1000 mg + clarithromycin 500 mg
BID x 1 wk: Omeprazole 20 mg + Metro 500 mg + clarithromycin 250 mg
CALORIC COMPUTATION
Protein: gm/k/d x wt x 4; requirement 0.5-3gm/k/d Lipid: gm/k/d x wt x 9; requirement 0.5-4gm/k/d CHO: gm/100cc x vol x 4 (eg. D5=5gm/100cc)
CALORIC DISTRIBUTION OF CHO, COOH, CHON OF TOTAL CALORIES GIVEN
CHO 60-70%
CHON 10-15%
Fats 20-30%
Breastmilk: 20cal/oz; VCO: 7.7cal/cc; Cereal 12.4cal/scoop 1gm Nitrogen = 6.25gm protein
Supplements for Severe Malnutrition:
50% MgSO4 2ml (2mmol/mL) IM x 1 dose; Zn 1mkd until diarrhea stops; Cu 0.1mkd; Folic acid 5mcg/k/d; Fe 3mkd; Vit A (if not given w/in 6mos) <6mos 50,000iu, 6-12mos 100,000iu, >1yr 200,000iu
Age REE Multiplication factor
0-1 55 Maintenance 0.2 1-3 57 Acitivity 0.1-0.25 4-6 48 Fever 0.13/deg >38C 7-10 40 Simple Trauma 0.2 11-14 32M/ 28F Multiple Injuries 0.4 15-18 27M/ 25F Burns/ GI surgery 0.5-1 Total Daily Energy Req:
REE + REE x Total factors Sepsis Growth 0.40.5
FORMULA FOR CALORIC REQUIREMENT FOR CATCH-UP GROWTH Get the height, weight
get ideal weight for actual height
kcal/kg=RDA for age (kcal/kg) x ideal wt/ht actual wt
CHON=CHON recommended for age x ideal wt/ht Actual wt
* start by 50-70% of caloric requirement
* increase calories by 20 kcal/kg/k every 2 days until caloric requirement is reached
* increase protein by 0.5 g/kg every 2 days until catch up is reached RDA for CHON (g/kg/day)
0-6 mos 2.2 7-12 mos 1.5 1-2 yrs 1.1 3-8 yrs 0.95 9-13 yrs 0.95 14-18 yrs 0.85
RECOMMENDED ENERGY INTAKE (kcal/kg)
per kg per day
Infants 0-6mos 108 650 6-12 mo 98 852 Children 1-3 yr 102 1,300 4-6 yr 90 1,800 7-10 yr 70 2,000 Males 11-14 yr 55 2,500 15-18 45 3,000 19-24 40 2,900 25-50 30 2,900 > 50 30 2,300 Females 11-14 yr 47 2,200 15-18 40 2,200 19-24 38 2,200 25-50 36 2,200 > 50 30 1,900 Pregnant +300 Lactating +500
CALORIC REQUIREMENT FOR PARENTERAL NUTRITION Neonate 90-120 cal/kg
</= 10 kg 100-170 cal/kg
11-20 kg 1000 cal + 50 cal/kg in xces of 10kg > 20 kg 1500 + 20 cal/kg in excess of 20 kg
FAT requirement in parenteral nutrition 0-12 mos 2 g/kg/day 1-8 yr 4 g/kg/day > 8 yr 2.5 g/kg/day CARBOHYDRATE reqt VLBW (<1.5 kg) 2.25 0-12 mo 2.5 1-8 yr 1.5-2 > 8 yr 1-1.5
NORMAL ELECTROLYTE REQT
Na 2-4 meq/kg/day K 2-3 Cl 2-3 Mg 0.25-0.5 Ca Infants 300-400 mg/kg/day Children 100-200 Adolescent 50-100 Phosphorous Infants 1-1.5 mmol/kg/day Children 1 Adolescent 0.5-1 F75 DIET: 75 cal/100 cc
Skimmed milk powder 25g
Veg. oil 20g
Sugar 60g
Rice (cereal) powder 60g Water to make 1,000 ml
*give 100-130 cc/kg/day F100 DIET: 100 cal/100 cc
Skimmed milk powder 80g
Veg. oil 60g
Sugar 50g
Water to make 1,000 ml
* minimum daily intake of 120-200 ml/kg RESOMAL (ORS for malnourished patients) Dilute 1 L of ORS with 1 L water
Add 45 ml of 10% KCl Add 50 g sucrose
Composition: Na 45 mmol/L K 40 mmol/L Sugar 25 g/L
FEEDING REGIMEN (ENTERAL NUTRITION) 1. Intermittent/bolus – more physiologic
- should only be used for gastric feed - start at 1-5 ml/kg/bolus
- every 3-6 hrs
- deliver over 30-120 min (2 hrs)
2. Continuous – better tolerated in px w/ feeding intolerance & significant GER
- for critically ill px
- start 1-2 ml/kg/hr in child/adol - can be increased by 1-2 ml/hr
- concentration shld be inc before volume
NUTRITIONAL GUIDELINE
Energy – caloric goal = 125% RDA based on wt/ht at 50th percentile * glucose polymer to in to 24-27 cal/mg formula
* MCT infant formula
* MCT oil supplement 1-2 ml/k/d 2-4 doses * supplemental nighttime NGT feeding Essential Fatty acids – corn oil
Protein intake (infants) 2-3 g/k/d (child) 0.5-1 g/k/d
Children Hospital Formulary
- started at 10-20 cc/kg/d as bolus or cont. - advance by </= 20-25 ml/kg/d
PERSISTENT DIARRHEA
First Diet: Reduced Lactose 70 cal/100g
Full fat dried milk 11g
(or whole liquid milk 85-295)
Rice 15g
Vegetable oil 3-5g
Cane sugar 3g
Water to make 200 ml
* 130 ml/kg provides 110 cal/kg
2nd Diet: Lactose free w/ reduced starch 75cal/100g
Whole egg 64g
Rice 3g
Vegetable oil 4g
Glucose 3g
Water to make 200 ml
* if finely ground cooked chicken meat is used instead of egg. Provides 70 cal/100
* 145 ml/kg provides 110 cal/kg MILK FORMULAS
Alfare: 72 cal/100 1:1 dilution 65 cal/100 15g:100 ml 65cal/100ml 72cal/100ml Fats 3.3g 3.6 g Linolento 0.38g 0.42 g CHON 22g 2.5g CHO 7 g 7.8 g Cal/100 ml D1: 1 scoop +100 ml 22 D2: 2 scoops + 100 ml 44 D3: 3 scoops + 100 ml 65 D4: 3 scoops + 90 ml 72
PEPTAMEN JUNIOR (1cal/ml) 7 scoops in 210 ml to make 250 ml 14 scoops in 425 ml to make 500 ml 28 scoops in 850 ml to make 1000 ml Per 1L preparation Fat 38.5g CHON 30.1 g CHO 138.4 g * 60% MCT
* 100% hydrolyzed when CHON 30 g /L NUTREN JUNIOR (same prep as peptamen)
1 cal/ml 12% CHON
35% COOH 53% CHO MCT 25%
Lactose free/ gluten free
Per 100 ml
CHON 3g
CHO 13.3g
COOH 3.9 g
PEDIASURE standard dilute
Per 100 ml
Caloric content 100cal
CHON 3g
COOH 4.78g
CHO 43.8g
* 190 ml of water + 5 scoops to make 225 ml
MICRONUTRIENTS
Vitamin A single dose
< 6mos 50,000 IU 6-12 mos 100,000 IU > 12 mos 200,000 IU Zinc 1mg/kg/d
Copper (infants) 0.2-0.6 mg/day (child/adol) 1-2 mg/day MgSO4 50% - 2ml IM/SQ Folic acid 5 ucg/kg/d
Iron – to start only in the 2nd week of illness when infection is better controlled at a dose of 3mg/kg/d
MICRONUTRIENTS FOR UPBUILDING Vitamin A
Folic Acid 800 ucg/prep
(5 ucg/kg/d) D1-LD 5 mg or 5 tabs D2 – 1 mg or 1 tab Zinc – 1-2 mg/kg/d Copper 0.2-0.6 mg/d (infant) 1-2 mg/d (children) FOR ACUTE DIARRHEA
Zinc <6mo : 10 mg/d for 10-14 days >6mo : 20 mg/d for 10-14 days Test dose for Intralipid
< 5kg : 0.1 g/kg x 1 hr > 5kg 0.01 g/min x 10-15 min
TOTAL PARENTERAL NUTRITION (TPN)
amino acids
make fluid D7.5/D10
NaCl (2.5 meq/ml) – 3 meq/kg KCl (2 meq/ml) – 2 meq/kg
Ca gluconate 10% - wt x 3, or wt x 300/100
MgSO4 (25% 1meq/ml, 50% 2meq/ml) -0.2 meq/kg
NEONATAL CHOLESTASIS CHOLERETIC DRUGS UDCA 250mg/tab, 15-45 mkd Rifampicin 5mkd Cholestyramine 4-16 g/d Phenobarital 3-10 mkd Vitamin A – 2,500-25,000 IU/day • Clusivol drops /0.6ml = 4,000 IU • Clusivol syrup /5ml = 2,500 IU • Nutrilin drops /ml = 5,000 IU • Nutrilin syrup /5ml = 1,500 IU • Enervon C drops /ml = 3,500 IU • Enervon C syrup /5ml = 100 IU Vitamin D 400-1,200 IU/day as D3 • Clusivol drops /0.6ml = 400 IU • Clusivol syrup /5ml = 500 IU • Nutrilin drops /ml = 333.33 IU • Nutrilin syrup /5ml = 100 IU • Enervon C drops /ml = 200 IU • Enervon C syrup /5ml = 200 IU
• Rocaltrol (Calcitriol) 0.25ucg/cap = 0.05-0.2 ucg/kg/d
Vitamin E 15mg/d -200 mg/kg/d or alpha tocopherol acetate (squibb) [100 or 200 or 400 IU/cap] 25-200 IU/kg/d, 1 cap at least q5 days in infants 100 IU = 65 mg Vitamin K 1-5 mg/d Ca (elemental) • 50-200 mg/kg/d • 25-100 mg/kg/d • Up to 800-200 mg/d • Ca Sandoz /5ml =110mg elemental
• Ca Sandoz /tab =500mg elemental
• *Corrected Ca = (40-actual)x.02 + actual Phosphorous (elemental)
• 25-50 mg/kg/d up to 500 mg/d Mg – Mg oxide 1-2 meq/kg/d PO
• deficiency: serum Mg <1.4 mg/L
• 50% solution of MgSO4 0.3-0.5 meq/kg IV over 3 hrs (max 3-6 meqs) Zinc - 1mg/kg/day PO x 2-3 mos elemental
• Gluconate 7 mg/kg/d • Sulfate 5mg/kg/d MEDICATIONS: Midazolam 5mg/ml – 0.1 mkdose Nalbuphine 10 mg/ml - 0.1 mkdose Propranolol (10 mg, 40 mg) - 0.6- 8 mkd
Somatostatin 3.5 ucg/kg/hr (250 ucg +50 cc or 3mg + 250 cc D5W or pNSS) Adult 3mg in 500cc D5W x 12 hr Octreotide 30 mg/m2/hr Spironolactone (25 mg, 50 mg) 3-5 mkd furosemide (20 mg, 40mg) 1-4 mkd Atenolol (25, 50mg) 1.2 mkd MOTILITY DRUGS
Domperidone (Motilium) 1mg/ml -0.3 mkdose, 3-4 doses, max 0.6 mkdose.
Erythromycin estolate 3mkdose or 20 mgd 2-4 doses
Metoclopramide 0.1mkdose up to 4x, max dose 0.5mkd. Adult: 10mg before meals & at bedtime
Loperamide 0.5-1.5mkd, 3-4 doses *Prophylaxis for cholangitis
Sultamicillin (Unasyn) 10mkd Cotrimoxazole 4mkd
Somatostatin – dec splanchnic blood flow in normal subjects, in cirrhotic pts not uniformly; used to control acute variceal hemrhge
Propranolol – beta blocker studied in use for recurrent variceal hmrhge; dec splanchnic blood flow and portal HPN by splanchnic vasoconstriction andcardiac output
LIVER FUNCTION
LIVER SPAN (Nelson)
12 wk 4.5-5 cm 12 yr (female) 6-6.5 cm 12 yr (male) 7-8 cm After 12 yr (female) 0.27 x wt (lbs)+ 0.22 x ht (in.) -10.75 (male) .032 x wt (lbs)+0.18 x ht (in.) -7.86
PTT – measures generation of thrombin through Intrinsic pathway (uses all coag factors including factor IX – vit K dependent, andVIII, EXCEPT for factor VII)
PT – measures time for prothrombin (factor II) to be converted into thrombin factors 1,2,5,7,10
- prolongation of >2sec is pathologic - >3 sec indicate risk for bleeding - evaluates extrinsic pathway
- prolonged when facter 1,2,5,7,10 deficient
- if prolonged in chronic liver dse – suggest poor prognosis NORMAL PT/PTT IN HEALTHY PRETERM
PT PTT Day1 13(10.6-16.2) 53(27.5-79.4) 5 12.5(10-15.3) 50.5(26.9-74) 30 11.8(10-13.6) 44.7(26.9-62.5) 90 12.3(10-14.6) 37.5(28.3-50.7) 180 12.5(10-15) 37.5(21.7-53.3) Adult 12.4(10.8-13.9) 33.5(26.6-40.3) Factor VIII- non-hepatic
- only factor not made in liver
- can be used to differentiate liver dse fr DIC (may be N or inc in liver dse)
Vit K deficiencies
Give Vit K 1mg/kg IM/IV, min: 1mg in FT Measure PT 4-6 hrs after
ROLE OF LIVER IN COAGULATION produce coag factors except von willebrand
produce & brkdown factors integral to fibrinolysis eg plasminogen & plasminogen activator
clears activated clotting factors fr circ Albumin – principal serum protein
- synthesized only in rough endoplasmic reticulum of hepatocytes at 150 mg/k/d
- half life: 20 d
- maintains colloid osmotic pressure - bind/carrier of bilirubin, Ca, other drugs
- in pts w/ ascites: may be dec due to inc in the distribution vol rather than dec synthesis
- often sign of chronic rather than acute liver dse (since long half life)
Other nonhepatic causes of low albumin
poor nutrition, nephrotic (urine loss), protein losing enteropathies (fr gut), inc degradation rate (poorly understood)
SERUM ALBUMIN LEVELS g/dL +1 SD 1-3mos 3.4 0.72 4-6mos 3.46 0.36 7-12 mo 3.62 0.6 13-24 mo 3.63 0.8 25-36mo 4.11 0.78 3-8yr 4 0.65 9-16 yr 4.25 0.7
serum albumin and PT are most impt parameters need liver transplant
HEPATOPULMONARY SYNDROME
1. Hypoxemia
2. Intrapulmonic right to left shunting of blood 3. Liver disease
Patient with chronic liver disease with history of shortness of breath or exercise inteolerance and clinical examination findings of cyanosis (particularly of the lips & fingers), digital clubbing, and O2 sats <96%, particularly in the upright position
Tx: Liver transplantation
ENDOSCOPIC ESOPHAGEAL VARICEAL LIGATION
- mucosal and submucosal tissue are ensnared strangulation
sloughing fibrosis obliteration of sub/mucosal vascular channels
- < complication then sclero eg esophageal stricture, pneumonia, bact.peritonitis
- fever treatment sessions
IRON
- absorption in prox small intestine - ferrous>ferric absorbed
- Increases absorption: Gastric acid, some sugars, aa, Bile - Decreased absorption: Oxalate, phosphates
- Stimulate inc absorption: 1. iron def, 2. hypoxia, 3. erythropoiesis
HEMORRHOIDS
Daflon – micronized purified flavonoid fraction chronic conditions & venous insufficiency: 2 tabs/day
acute hemorrhoidal attacks: 3tabs BID x 4 d, 2 tabs BID x 3 days Antibiotics in Gut Obstruction (rationale)
• Blood flow to the obstructed bowl decreases as the bowel dilates
• Blood flow is shifted away from the mucosa with loss of mucosal integrity
• Bacteria proliferates in the stagnant bowel with a predominance of coliforms and anaerobes
• Rapid proliferation of bacteria coupled with loss of mucosal integrity allows bacterial translocation across the bowel wall potentially resulting in endotoxinemia, bacteremia and sepsis
Bowel gas
• Air is usually demonstrable radiographically in the stomach of a normal infant immediately after birth
• Within 1 hour, air may reach the proximal portion of the small intestine and segments of the colon
• Air may become visible in the distal parts of the colon as early as the 3rd hour or as late as 18 hours
HEMATOLOGY and ONCOLOGY
ANEMIA
Measured Hgb > 2 SD below the mean for age
Age Mean -2SD 1 mo 14 10 2 mo 11.5 9 3-6 mo 11.5 9.5 .5-2 y 12 10.5 2-6 y 12.5 11.5 6-12 y 13.5 11.5 12-18 M 14.5 13 F 14 12 18-49 M 15.5 13.5 F 14 12 MCV
measures the average volume of a red blood cell categorizes red blood cells by size.
Formula (2-10 yrs old)
Lower limit: 70 fL + age in years
Upper limit: 84 fL + ( age in yrs x 0.6 ), until upper limit of 96 is r eached What’s the MCV range?
Give LL and UL of a 7 years old. Answer: LL: 77 fL; UL: 88.2 fL
RETICULOCYTE COUNT
Measures erythrocyte production Expressed as % of circulating rbc’s Take up reticulin stain (supravital):
bec of inc RNA
N = 0.5 % to 1.5 % or = .005 to .015
Reticulocyte index
Anemic patient --> increased retic
so have to correct: retic observed x px Hct / 0.45 Example: Hb 50 Hct 0.15 Retic count=.045= 4.5 % Corrected retic = 4.5% x .15/.45 = 1.5 % ( N = 0.5-1.5%)
Absolute Retic Count
More accurate
Compute as ff: RBC (in n x 1012 ) x # retic/1000 rbc x 1000 Normal = 40,000 – 100,000/uL
Example:
Compute for absolute retic count : Hb 90 RBC 3 x 1012 /L Retic .015 Answer: 45,000 retics / uL
IRON DEFICIENCY ANEMIA
- microcytic, hypochromic, increased RDW
Therapy: daily total dose of 4-6mg/kg of elemental iron in 3 divided doses
Response to therapy
Time after Iron administration Response
12-24hr Replacement of intracellular iron
enzyme; subjective improvement, decreased irritability, increased appetite
24-48 hrs Initial bone marrow response;
erythroid heperplasia
48-72 hrs Reticulocytosis, peaking at 5-7
days
4-30 days Increase in hemoglobin levels
1-3 months Repletion of stores
APLASTIC ANEMIA
Severe ANC 500-1000 Very Severe ANC 200-500
BLEEDING
Get Urinalysis with RBC, if RBC<5, may give Tranexamic Acid PO 25mg/kg max 1500/day; IV 15mg/kg max 500/day.