Recognition & Management of Common Disease Processes with Known Electrolyte Abnormalities

1. Recognition & Management of Common Disease Processes with Known Electrolyte Abnormalities Desiree R. Eakin MD, FAAP Pediatric Hospitalist, Children’s Hospital Los Angeles Assistant Professor, Clinical Pediatrics USC Keck School of Medicine

2. Objectives • Briefly review clinical pearls for dehydration • Identify common disease processes with known electrolyte abnormalities • Recognize common clinical presentation of these disease processes • Understand the mechanism for such electrolyte abnormalities • Know how to manage the electrolyte abnormalities in these known conditions

3. Content Specifications • Dehydration • Recognize the clinical and laboratory abnormalities of hyponatremic dehydration • Know how to manage hypernatremic dehydration • Know how to manage hyponatremic dehydration • Understand the effectiveness of oral rehydration solutions in treating acute diarrheal dehydration • Understand the differences between and rationale for the composition of oral rehydration solutions • Know that hypotension is a very late sign of dehydration • Recognize the possibility of seizures in an infant with chronic hypernatremic dehydration

4. Case #1 A 4-year-old boy presents with a 3-day history of vomiting followed by diarrhea. The vomiting resolved after 24 hours, and for the past 2 days he has been keeping down clear liquids. On physical examination, the afebrile boy has a heart rate of 90 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 106/58 mmHg. He has tacky mucous membranes and a capillary refill time of 3 seconds. Other findings are within normal parameters. Laboratory evaluation reveals: Na 130 K 3.7 Cl 102 CO2 16 Glu 100 BUN 34 Crt 0.6 Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 1+ ketones, and otherwise negative findings Of the following, the MOST likely urine sodium concentration and urine osmolality for this patient are • Urine sodium = 6mEq/L; Urine osmolality = 1,100 mOsm/kg • Urine sodium = 28mEq/L; Urine osmolality = 300 mOsm/kg • Urine sodium = 60mEq/L; Urine osmolality = 450 mOsm/kg • Urine sodium = 90mEq/L; Urine osmolality = 900 mOsm/kg • Urine sodium = 130mEq/L; Urine osmolality = 1,100 mOsm/kg

5. Case #1 Answer A 4-year-old boy presents with a 3-day history of vomiting followed by diarrhea. The vomiting resolved after 24 hours, and for the past 2 days he has been keeping down clear liquids. On physical examination, the afebrile boy has a heart rate of 110 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 106/58 mmHg. He has tacky mucous membranes and a capillary refill time of 3 seconds. Other findings are within normal parameters. Laboratory evaluation reveals: Na 130 K 3.7 Cl 102 CO2 16 Glu 100 BUN 34 Crt 0.6 Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 1+ ketones, and otherwise negative findings Of the following, the MOST likely urine sodium concentration and urine osmolality for this patient are • Urine sodium = 6mEq/L; Urine osmolality = 1,100 mOsm/kg • Urine sodium = 28mEq/L; Urine osmolality = 300 mOsm/kg • Urine sodium = 60mEq/L; Urine osmolality = 450 mOsm/kg • Urine sodium = 90mEq/L; Urine osmolality = 900 mOsm/kg • Urine sodium = 130mEq/L; Urine osmolality = 1,100 mOsm/kg

6. Case #2 A 3 month old male infant presents with poor feeding and occasional vomiting. He has no history of fever, cough, irritability, constipation, or diarrhea. He has approximately 12 wet diapers per day. On physical examination, the afebrile infant has a heart rate of 130 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 94/50 mmHg. He has tacky mucous membranes and a capillary refill time of 2 seconds: all other findings are normal. Laboratory evaluation reveals: Na 160 mEq/L, K 3.7 mEq/L, Cl 122 mEq/L, CO2 16 mEq/L, Glu 100 mg/dL, BUN 34 mg/dL, Crt 0.6 mg/dL osmolality 345 mOsm/kg Of the following, the MOST likely urine specific gravity and urine osmolality for this patient are • Urine specific gravity = 1.001; Urine osmolality = 80 mOsm/kg • Urine specific gravity = 1.010; Urine osmolality = 300 mOsm/kg • Urine specific gravity = 1.015; Urine osmolality = 400 mOsm/kg • Urine specific gravity = 1.020; Urine osmolality = 600 mOsm/kg • Urine specific gravity = 1.030; Urine osmolality = 1,200 mOsm/kg

7. Case #2 Answer A 3 month old male infant presents with poor feeding and occasional vomiting. He has no history of fever, cough, irritability, constipation, or diarrhea. He has approximately 12 wet diapers per day. On physical examination, the afebrile infant has a heart rate of 130 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 94/50 mmHg. He has tacky mucous membranes and a capillary refill time of 2 seconds: all other findings are normal. Laboratory evaluation reveals: Na 160 mEq/L, K 3.7 mEq/L, Cl 122 mEq/L, CO2 16 mEq/L, Glu 100 mg/dL, BUN 34 mg/dL, Crt 0.6 mg/dL, osmolality 345 mOsm/kg Of the following, the MOST likely urine specific gravity and urine osmolality for this patient are • Urine specific gravity = 1.001; Urine osmolality = 80 mOsm/kg • Urine specific gravity = 1.010; Urine osmolality = 300 mOsm/kg • Urine specific gravity = 1.015; Urine osmolality = 400 mOsm/kg • Urine specific gravity = 1.020; Urine osmolality = 600 mOsm/kg • Urine specific gravity = 1.030; Urine osmolality = 1,200 mOsm/kg

8. Dr Eakin’s Clinical Pearls • Disorders of sodium are caused by derangements of water balance: excess water to sodium (hyponatremia) and insufficient water to sodium (hypernatremia) • Serum Na does not accurately reflect total body sodium – decrease in Na reflects and increase in total body water, increase in serum sodium reflects free water deficit • Hyponatremia • Defense against developing hypoNa: kidney’s ability to generate dilute urine & excrete free water • Consider checking urine electrolytes and osmolality • Tx depends on etiology and clinical manifestations

9. Hyponatremic Encephalopathy • Children are at high risk for developing symptomatic hyponatremia due to the higher brain-to-skull size ration leaving less room for brain expansion • Hypoxia impairs the ability of the brain to adapt to hyponatremia • Hyponatremia leads to decreased cerebral blood flow and arterial O2 content • Cerebral demyelination can occur after correction of symptomatic hypoNa

10. Dr Eakin’s Clinical Pearls • Hypernatremia • Two defenses against developing hyperNa: concentrating urine and thirst mechanism • Evaluate for contributing factors: water losses, decreased fluid intake, excess Na intake • Monitor I/Os, check urine osmolality and electrolytes • Tx by increasing free water: correction rate not >1mEq/hr or 15mEq/24 hr

11. Case #3 You are called to evaluate the abnormal laboratory findings for a 16-year-old boy who you admitted to the hospital yesterday for a presumed community-acquired pneumonia. The boy has been reported to be improving on the antibiotics you ordered, but his serum electrolyte results were abnormal this morning, so the resident on call obtained additional laboratory studies. On physical examination, the young man is alert and complains of no distress. His temperature is 37C, heart rate is 80 beats/min, respiratory rate is 15 breaths/min and blood pressure is 120/80mmHg. He reports that he has not urinated since yesterday afternoon. His skin turgor is normal, and you do not notice jugular venous distension or signs of edema. Results of his laboratory studies include: Na 125 K 4 Cl 95 CO2 25 BUN 10 Crt 1 Glu 100 Serum osmolality 260 Urine osmolality 500 Urine Na 30 Of the following, the MOST likely cause of this patient’s hyponatremia is • Acute renal failure • Congestive heart failure • Diabetes insipidus • Mineralcorticoid deficiency • Syndrome of inappropriate antidiuretic hormone

12. Case #3 Answer You are called to evaluate the abnormal laboratory findings for a 16-year-old boy who you admitted to the hospital yesterday for a presumed community-acquired pneumonia. The boy has been reported to be improving on the antibiotics you ordered, but his serum electrolyte results were abnormal this morning, so the resident on call obtained additional laboratory studies. On physical examination, the young man is alert and complains of no distress. His temperature is 37C, heart rate is 80 beats/min, respiratory rate is 15 breaths/min and blood pressure is 120/80mmHg. He reports that he has not urinated since yesterday afternoon. His skin turgor is normal, and you do not notice jugular venous distension or signs of edema. Results of his laboratory studies include: Na 125 K 4 Cl 95 CO2 25 BUN 10 Crt 1 Glu 100 Serum osmolality 260 Urine osmolality 500 Urine Na 30 Of the following, the MOST likely cause of this patient’s hyponatremia is • Acute renal failure • Congestive heart failure • Diabetes insipidus • Mineralcorticoid deficiency • Syndrome of inappropriate antidiuretic hormone

13. Case #3 Revisited Of the following, the MOST appropriate treatment for the patient’s condition is to • Administer demeclocycline • Administer 3% sodium chloride solution to raise the sodium to 130 mEq/L • Induce a water diuresis with chlorothiazide • Initiate IV fluids with 0.9% sodium chloride • Restrict free water intake

14. Case #3 Revisited Answer Of the following, the MOST appropriate treatment for the patient’s condition is to • Administer demeclocycline • Administer 3% sodium chloride solution to raise the sodium to 130 mEq/L • Induce a water diuresis with chlorothiazide • Initiate IV fluids with 0.9% sodium chloride • Restrict free water intake

15. Syndrome of Inappropriate ADH Secretion • One of the MCC of hyponatremia in hospitalized pts • Caused by elevated ADH secretion in the absence of an osmotic or hypovolemic stimulus • Characterized by euvolemic hyponatremia, decreased UOP, decreased serum osmolality & increased urine osmolality

16. SIADH Treatment • Fluid restriction • Close monitoring of fluid status & electrolytes • All IVF should be at least 0.9%NaCl • 3% NaCl may be needed • Loop diuretics • Increase Na intake • Demeclocycline

17. Case #4 A 5-month-old infant who has been fed cow milk protein-based formula presents to the ED following 2 days of watery diarrhea that she has passed up to 10 x’s per day. She weighed 3,100g when born at term and has been gaining weight and growing normally. Her weight at the 4-month visit was 5.5kg. On physical examination today, her weight is 5.8kg, temperature is 37.7C, and heart rate is 140 beats/min. She appears alert, her mucous membranes are dry, and skin recoil is less than 2 seconds. Capillary refill is slightly prolonged. The remainder of the physical examination findings are unremarkable. A capillary blood gas on room air reveals a pH of 7.22, PaCO2 of 25mmHg, and bicarbonate of 10 mEq/L. Initial electrolyte values are: Na 141 mEq/L, K 4.0 mEq/L, Cl 120 mEq/L, CO2 11 mEq/L, Glu 100mg/dL Of the following, the MOST likely cause of the infant’s metabolic acidosis is • Gastrointestinal loss of bicarbonate • Hypoaldosteronism • New-onset diabetes mellitus • Renal failure • Septic shock

18. Case #4 Answer A 5-month-old infant who has been fed cow milk protein-based formula presents to the ED following 2 days of watery diarrhea that she has passed up to 10 x’s per day. She weighed 3,100g when born at term and has been gaining weight and growing normally. Her weight at the 4-month visit was 5.5kg. On physical examination today, her weight is 5.8kg, temperature is 37.7C, and heart rate is 140 beats/min. She appears alert, her mucous membranes are dry, and skin recoil is less than 2 seconds. Capillary refill is slightly prolonged. The remainder of the physical examination findings are unremarkable. A capillary blood gas on room air reveals a pH of 7.22, PaCO2 of 25mmHg, and bicarbonate of 10 mEq/L. Initial electrolyte values are: Na 141 mEq/L, K 4.0 mEq/L, Cl 120 mEq/L, CO2 11 mEq/L, Glu 100mg/dL Of the following, the MOST likely cause of the infant’s metabolic acidosis is • Gastrointestinal loss of bicarbonate • Hypoaldosteronism • New-onset diabetes mellitus • Renal failure • Septic shock

20. Rotavirus AGE MC cause of AGE is rotavirus Delayed GE promotes vomiting Inhibition of sodium cotransport mechanisms decreased brush border disaccharidase activity stimulation of the enteric nervous system to increase bowel transit hypersecretion & reduced absorption

21. Case #4 Revisited A 5-month-old infant who has been fed cow milk protein-based formula presents to the ED following 2 days of watery diarrhea that she has passed up to 10 x’s per day. She weighed 3,100g when born at term and has been gaining weight and growing normally. Her weight at the 4-month visit was 5.5kg. On physical examination today, her weight is 5.8kg, temperature is 37.7C, and heart rate is 140 beats/min. She appears alert, her mucous membranes are dry, and skin recoil is less than 2 seconds. Capillary refill is slightly prolonged. The remainder of the physical examination findings are unremarkable. Of the following, the MOST appropriate immediate treatment for this infant is • IV hydration with an initial infusion of 120mL 0.9% sodium chloride over 2 hours • IV hydration with 5% dextrose and 0.33% sodium chloride at 40ml/hr • Oral feedings with half-strength soy-based formula, mixed 1:1 with a glucose-electrolyte solution • Oral rehydration with a solution containing 20mEq/L sodium chloride • Oral rehydration with a solution containing 75mEq/L sodium chloride

22. Case #4 Revisited Answer A 5-month-old infant who has been fed cow milk protein-based formula presents to the ED following 2 days of watery diarrhea that she has passed up to 10 x’s per day. She weighed 3,100g when born at term and has been gaining weight and growing normally. Her weight at the 4-month visit was 5.5kg. On physical examination today, her weight is 5.8kg, temperature is 37.7C, and heart rate is 140 beats/min. She appears alert, her mucous membranes are dry, and skin recoil is less than 2 seconds. Capillary refill is slightly prolonged. The remainder of the physical examination findings are unremarkable. Of the following, the MOST appropriate immediate treatment for this infant is • IV hydration with an initial infusion of 120mL 0.9% sodium chloride over 2 hours • IV hydration with 5% dextrose and 0.33% sodium chloride at 40ml/hr • Oral feedings with half-strength soy-based formula, mixed 1:1 with a glucose-electrolyte solution • Oral rehydration with a solution containing 20mEq/L sodium chloride • Oral rehydration with a solution containing 75mEq/L sodium chloride

23. Management of Acute Gastroenteritis • Continuation of regular diet • Not dehydrated and not vomiting • Supplement with oral rehydration solution (ORS): 2ml/kg for ea emesis & 10ml/kg for ea watery stool • Oral rehydration therapy (ORT) • ORT should be instituted for pts whose deficit is <10% and able to tolerate po • Mildly dehydrated needs ~50ml/kg in first 4hrs; mod dehydrated needs 100ml/kg of ORT • Pts who are dehydrated need 75-90mEw Na (maint is 40-50) • Glucose is an important component of all ORT due to Na/Glucose coupled transport in small intestine epithelial cells

24. Oral Rehydration Therapy

25. Management of AGE • Intravenous fluids • Severely dehydrated should be rehydrated by intravenously • 10-20ml/kg of NS or LR • Add’l crystalloid is given over the next 2-4 hours for total of 40-100ml/kg over first 4 hours • Re-starting diet • Usually can tolerate ORS after initial 30ml/kg of IV fluid • Refeeding is recommended ASAP with usual age-appropriate unrestricted diet • BRAT diet good or bad?

26. Case #5 A 3½-week-old male infant presents to your office with a history of 2 to 3 days of vomiting. He was born at term and his birthweight was 3,250 g. He is breastfed. He has been exhibiting nonbilious vomiting after each feeding, and according to his mother, the emesis now appears to "shoot out of his mouth." After vomiting, he seems eager to resume feeding. Over the past 24 hours, his mother has noted fewer wet diapers and less stool than usual. The baby has experienced no diarrhea or upper respiratory tract symptoms. Physical examination demonstrates an alert, afebrile infant who weighs 3,550 g and is sucking vigorously on a pacifier. His skin turgor is normal. The remainder of the examination findings are unremarkable, except for slight abdominal distention. You refer the baby to the local emergency department and order measurement of serum electrolytes. What is your diagnosis?

27. Pyloric Stenosis A 3½-week-old male infant presents to your office with a history of 2 to 3 days of vomiting. He was born at term and his birthweight was 3,250 g. He is breastfed. He has been exhibiting nonbilious vomiting after each feeding, and according to his mother, the emesis now appears to "shoot out of his mouth." After vomiting, he seems eager to resume feeding. Over the past 24 hours, his mother has noted fewer wet diapers and less stool than usual. The baby has experienced no diarrhea or upper respiratory tract symptoms. Physical examination demonstrates an alert, afebrile infant who weighs 3,550 g and is sucking vigorously on a pacifier. His skin turgor is normal. The remainder of the examination findings are unremarkable, except for slight abdominal distention. You refer the baby to the local emergency department and order measurement of serum electrolytes. What electrolyte abnormalities do you expect?

28. Hyponatremic, hypochloremic, metabolic alkalosis • Sodium, 132 mEq/L (132 mmol/L) • Potassium, 3.2 mEq/L (3.2 mmol/L) • Chloride, 95 mEq/L (95 mmol/L) • Bicarbonate, 30 mEq/L (30 mmol/L) If diagnosed early in course, may not have classical electrolyte findings --> Should have high index of suspicion What other electrolyte abnormality may also be seen in HPS?

29. HCl- H+ K+ Further loss of volume & H+ Intravascular volume contraction HCO3- Contraction alkalosis Further decrease in K+

30. Case #5 Revisited Of the following, the MOST appropriate initial treatment for this infant is toA. administer 70 mL 0.9% sodium chloride intravenously over 1 hour, followed by infusion with 5% dextrose and 0.225% sodium chloride at 15 mL/hr • B. begin intravenous fluids with 5% dextrose and 0.3% sodium chloride at 15 mL/hr • C. encourage continued nursing, pending results of further diagnostic tests • D. initiate intravenous fluids containing 5% dextrose and 0.45% sodium chloride at 25 mL/hr • E. institute oral rehydration therapy with a glucose-electrolyte solution

31. Case #5 Revisited Answer Of the following, the MOST appropriate initial treatment for this infant is to • administer 70 mL 0.9% sodium chloride intravenously over 1 hour, followed by infusion with 5% dextrose and 0.225% sodium chloride at 15 mL/hr • begin intravenous fluids with 5% dextrose and 0.3% sodium chloride at 15 mL/hr • encourage continued nursing, pending results of further diagnostic tests • initiate intravenous fluids containing 5% dextrose and 0.45% sodium chloride at 25 mL/hr • institute oral rehydration therapy with a glucose-electrolyte solution

32. Case #5 Revisited Answer A 3½-week-old male infant presents to your office with a history of 2 to 3 days of vomiting. He was born at term and his birthweight was 3,250 g. He is breastfed. He has been exhibiting nonbilious vomiting after each feeding, and according to his mother, the emesis now appears to "shoot out of his mouth." After vomiting, he seems eager to resume feeding. Over the past 24 hours, his mother has noted fewer wet diapers and less stool than usual. The baby has experienced no diarrhea or upper respiratory tract symptoms. Physical examination demonstrates an alert, afebrile infant who weighs 3,550 g and is sucking vigorously on a pacifier. His skin turgor is normal. The remainder of the examination findings are unremarkable, except for slight abdominal distention. You refer the baby to the local emergency department and order measurement of serum electrolytes.

33. Treatment of Pyloric Stenosis • Initial goals of tx is IV rehydration • Gradual correction of any electrolyte disturbances • Must be done prior to surgical pyloromyotomy • Usually fluids with 5% dextrose and ½ NS with 20mEq/L KCl at maintenance to 1 ½ maintenance is sufficient depending on degree of dehydration at presentation

34. Case #6 A previously healthy 7-year-old boy presents with a 4-day history of vomiting associated with body aches, rhinorrhea and cough. On physical examination, his temperature is 38.2C, heart rate of 120 beats/min, respiratory rate of 30 breaths/min and blood pressure of 110/65 mm Hg. He has tacky mucus membranes, periorbital puffiness, and mild pitting edema of the lower extremities. His urine has been brown and he has urinated twice on the past 48 hours. Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 1+ ketones, +blood, urine Na 60, urine osmolality 320, urine fractional excretion of sodium is 2.5%. What is the MOST likely cause of acute renal failure in this patient? • Prerenal due to hypovolemia • Prerenal due to nephrotic syndrome • Prerenal due to renal insufficiency • Intrinsic renal disease due to glomerulonephritis • Postrenal due to ureteropelvic obstruction

35. Case #6 Answer A previously healthy 7-year-old boy presents with a 4-day history of vomiting associated with body aches, rhinorrhea and cough. On physical examination, his temperature is 38.2C, heart rate of 120 beats/min, respiratory rate of 30 breaths/min and blood pressure of 110/65 mm Hg. He has tacky mucus membranes, periorbital puffiness, and mild pitting edema of the lower extremities. His urine has been brown and he has urinated twice on the past 48 hours. Urinalysis reveals a specificgravity of 1.030, pH of 5.5, 1+ ketones, +blood, urine Na 60, urine osmolality 320, urine fractional excretion of sodium is 2.5%. What is the MOST likely cause of acute renal failure in this patient? • Prerenal due to hypovolemia • Prerenal due to nephrotic syndrome • Prerenal due to renal insufficiency • Intrinsic renal disease due to glomerulonephritis • Postrenal due to ureteropelvic obstruction

37. Causes of Acute Renal Failure

38. Case # 6 Revisited A previously healthy 7-year-old boy presents with a 4-day history of vomiting associated with body aches, rhinorrhea and cough. On physical examination, his temperature is 38.2C, heart rate of 120 beats/min, respiratory rate of 30 breaths/min and blood pressure of 110/65 mm Hg. He has tacky mucus membranes, periorbital puffiness, and mild pitting edema of the lower extremities. His urine has been brown and he has urinated twice on the past 48 hours. Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 1+ ketones, +blood, urine Na 60, urine osmolality 320, urine fractional excretion of sodium is 2.5%. The most important INITIAL step in the management of this patient is an immediate infusion of: • Diazoxide • Dopamine • Furosemide • Mannitol • Normal saline

39. Case # 6 Revisited Answer A previously healthy 7-year-old boy presents with a 4-day history of vomiting associated with body aches, rhinorrhea and cough. On physical examination, his temperature is 38.2C, heart rate of 120 beats/min, respiratory rate of 30 breaths/min and blood pressure of 110/65 mm Hg. He has tacky mucus membranes, periorbital puffiness, and mild pitting edema of the lower extremities. His urine has been brown and he has urinated twice on the past 48 hours. Urinalysis reveals a specificgravity of 1.030, pH of 5.5, 1+ ketones, +blood, urine Na 60, urine osmolality 320, urine fractional excretion of sodium is 2.5%. The most important INITIAL step in the management of this patient is an immediate infusion of: • Diazoxide • Dopamine • Furosemide • Mannitol • Normal saline

40. Fluid Management in ARF • Depends on hemodynamic status of patient • 20ml/kg boluses of isotonic solution, PRBC’s or albumin should be given as rapidly as possible • Repeat boluses may be given is remains unstable • Once intravascular volume re-established, fluid intake should be restricted to 400 mL/m 2 per day plus urinary output and extrarenal losses*

41. A 9-month-old girl presents to the emergency department (ED) with a 4-day history of profuse diarrhea and poor oral intake. On physical examination, she appears irritable. Her respiratory rate (RR) is 70 breaths/min, heart rate (HR) is 180 beats/min, and blood pressure (BP) is 80/50 mm Hg. She has cool, mottled extremities, with sluggish capillary refill and weak peripheral pulses. A 17-year-old boy presents to the ED with a 1-day history of headache, general malaise, and fevers. On physical examination, he appears confused. He has a temperature of 39.9°C, HR of 120 beats/min, and BP of 85/28 mm Hg. His skin appears plethoric. His extremities are hot, with flash capillary refill and bounding pulses. A 17-year-old boy presents to the ED with a 1-day history of headache, general malaise, and fevers. On physical examination, he appears confused. He has a temperature of 39.9°C, HR of 120 beats/min, and BP of 85/28 mm Hg. His skin appears plethoric. His extremities are hot, with flash capillary refill and bounding pulses. What do all 3 of these patients have in common?

42. SHOCK Septic Hypovolemic Cardiogenic Distributive/Neurogenic EARLY RECOGNITION is key

43. Treatment of Shock • Isotonic fluid boluses 20ml/kg usually require 60ml/kg • Crystalloid vs colloid is under much debate • Frequent reassessment • Other interventions may be necessary depending upon the type of shock

44. Case #7 You are evaluating a 4-year-old boy in the emergency department for septic shock. On physical examination, his heart rate is 140 beats/minute, respiratory rate is 30 breaths/minute, and blood pressure is 65/40 mm Hg.Of the following, the MOST appropriate next step is administration ofA. 5 mL/kg of 25% albumin B. 5 mL/kg of 3% normal saline C. 10 mL/kg of 5% albumin D. 20 mL/kg of 0.45% normal saline E. 20 mL/kg of 0.9% normal saline

45. Case #7 Answer You are evaluating a 4-year-old boy in the emergency department for septic shock. On physical examination, his heart rate is 140 beats/minute, respiratory rate is 30 breaths/minute, and blood pressure is 65/40 mm Hg.Of the following, the MOST appropriate next step is administration ofA. 5 mL/kg of 25% albumin B. 5 mL/kg of 3% normal saline C. 10 mL/kg of 5% albumin D. 20 mL/kg of 0.45% normal saline E. 20 mL/kg of 0.9% normal saline

46. Case #8 A 4-year-old girl is being evaluated for cough, loose stools, and poor weight gain of 6 months’ duration. Her parents have noticed that she craves salty foods. Two separate sweat electrolyte tests performed at a CF Foundation-accredited laboratory show chloride values of 70 mEq/L (70 mmol/L) and 64 mEq/L(64 mmol/L), respectively. Which of the following MOST closely reflects this patient’s electrolytes? • Sodium: Low Potassium: Low Chloride: High CO2: High • Sodium: Low Potassium: N/A Chloride: Low CO2: High • Sodium: N/A Potassium: High Chloride: High CO2: High • Sodium: High Potassium: N/A Chloride: Low CO2: Low • Sodium: High Potassium: High Chloride: High CO2: Low

47. Case #8 Answer A 4-year-old girl is being evaluated for cough, loose stools, and poor weight gain of 6 months’ duration. Her parents have noticed that she craves salty foods. Two separate sweat electrolyte tests performed at a CF Foundation-accredited laboratory show chloride values of 70 mEq/L (70 mmol/L) and 64 mEq/L(64 mmol/L), respectively. Which of the following MOST closely reflects this patient’s electrolytes? • Sodium: Low Potassium: Low Chloride: High CO2: High • Sodium: Low Potassium: N/A Chloride: Low CO2: High • Sodium: N/A Potassium: High Chloride: High CO2: High • Sodium: High Potassium: N/A Chloride: Low CO2: Low • Sodium: High Potassium: High Chloride: High CO2: Low

48. Cystic Fibrosis • Hyponatremic, hypochloremic metabolic alkalosis is commonly seen in patients with CF • Defective CFTR causes Na and Cl- movement and reabsoprtion into lumen to be impeded

49. ThankYou

50. Content Specifications • Pyloric stenosis • Recognize that the differential diagnosis of metabolic alkalosis includes HPS • Recognize the acid-base changes seen in pyloric stenosis, and manage appropriately • Gastroenteritis • Plan the management of acute gastroenteritis • Acute renal failure • Know the challenging fluid requirements in patients with severe oliguria • Know that coexisting volume depletion should be corrected in patients with ARF