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Peds Hyper/Hypoglycemia/Fluids

Peds Hyper/Hypoglycemia/Fluids. Type I diabetes-most common peds endocrine disorder DKA leading cause of death in peds DM Overall mortality of peds DKA 3% Equal male:female Onset 11-12 y.o Genetic predisposition Most common cause poor compilance. Clinical .

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Peds Hyper/Hypoglycemia/Fluids

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  1. Peds Hyper/Hypoglycemia/Fluids

  2. Type I diabetes-most common peds endocrine disorder • DKA leading cause of death in peds DM • Overall mortality of peds DKA 3% • Equal male:female • Onset 11-12 y.o • Genetic predisposition • Most common cause poor compilance

  3. Clinical • Usually history of polyuria, polydipsia, weight loss. • N/V and abd. Pain • May mimic acute abd. • New onset of abd. Pain and enuresis think DM • BS>300, Ph <7.3, HCO3 <15

  4. Management • 0.9% NS at 20ml/kg/hr until stable • Then 0.45 NS at 1.5 maintanance in ED • 0.1 u/kg/hr of R insulin drip • Decrease glucose at 50-100 mg/dl/hr • Avoid HCO3 if possible • Monitor K+ and replace as needed • Add dextrose when BS in <200-250

  5. Monitor for hypokalemia and cerebral edema • Cerebral edema 6-12hrs after therapy: treat with mannitol/intubation • PICU • Bedside glucose q hour • Electrolyte panel and VBG q two hours

  6. Hypoglycemia • Serum glucose <50mg/100ml • Pediatric hypoglycemia is rare • Most often with fasting states • Nonspecific signs • Anxiety, tachy, nausea, weakness, abd pain • Confusion, headache, MS change, Seizure • Associated with ETOH and ASA ingestion

  7. The most common cause in NIDDM children older than 1 yr in idiopathic ketotic hypoglycemia. • Presents after a fasting period (after sleeping) • Return to normal after glucose load • Suspect with ketonemia & ketonuria

  8. Treatment • Oral replacement is preferred • D10 at 5 ml/kg bolus in infants then 4ml/kg/hr • D25 at 2.0 ml/kg bolus in children then 3 ml/kg/hr • D50 IV too caustic for neonatal and infants • Maintenance fluids for neonates D10: infants and children D5

  9. Fluids and Electrolytes • Abnormalities are primarily due to gastroenteritis. • Infants have a high metabolic rate and require a large amount of water • Fluid requirements: • For the first 10 kg: 100/ml/kg/day • For the second 10 kg: 50ml/kg/day • For more than 20 kg: 20ml/kg/day

  10. Hyper metabolic states such as fever increase the need for free water. • Electrolyte requirements for children is 3meq/kg/day for sodium and 2 meq/kg/day for potassium. • Isotonic dehydration ofter occurs from diarrhea. If lost over time, it is well tolerated. If rapid loss, it can be fatal.

  11. Physical exam is helpful in determining degree of dehydration. • Normal mental status-mild • Irritability-moderate • Lethargy-severe • Decreased skin turgor/sunken eyes/fontanel-moderate to severe

  12. Treatment for mildly dehydrated pts-oral fluids • Moderately dehydrated- IV or oral replacement • Severly dehydrated children-IV boluses of NS or LR 20 ml/kg until improved. May require 60-80ml/kg

  13. Rehydrating solutions in infants: • Infants are D5 .25 NS or D5 .45 NS • D5.20 NS is used for maintenance rehydration in infants in isotonic dehydration • D5 .45NS can be used for maintanence rehydration in children in isotonic dehydration

  14. Hypernatremic dehydration sodium > 150meq/L • Presents with gastro pts. who are treated with salt rich solutions • Replace free water with D .45 NS so that sodium falls slowly over days(max of 10-15 meq/L/Day) so that cerebral edema does not occur

  15. Hyponatremic dehydration-sodium less than 130meq/L • Occurs with vomiting and diarrhea and fluid replacement with water. • In extreme cases seizures can occur. Most common with Na <120 • Formula for correcting serum sodium • (Na desired-Na Measured) x 0.6x kg body wt

  16. Correction needs to take place over at least 24 hrs. • Rapid correction can lead to central pontine demyelinization. • With severe hyponatremia 3% NS may be needed.

  17. Hypokalemia- serum level <3.4 • Oral replacement over several days is adequate • If IV needed, 0.2 meq/kg/hr • In emergent situations, 1meq/kg/hr through central line with continuous ECG monitoring

  18. Hyperkalemia-potassium >5.5 • Most common due to hemolysis in blood draws. • Cardiac conduction delays most common problems and life threatening • EKG manifestations • First-peaked T’s • Prolonged PR interval • Wide QRS

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