ARTERIAL BLOOD GAS Acidosis Alkalosis
pH pCO2 pO2 HCO3 BE O2 sat
ph<7.35 ph>7.45
Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis Hypoxemia pO2 <85
pCO2 >45 pCO2 <35 HCO3 <24 dec BE HCO3 >24 inc BE
At birth Birth to 3 months 3-6 months 6-9 months 9-12 months 1 year and above
Note: For every 10mmHg ↑ pCO2 = ↓ pH of 0.05 For every 10mmHg ↓ pCO2 = ↑pH of 1
pH ↓ ↑ ↓ ↑
Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis
BLOOD GAS ANALYSIS NB & Infants Children & Adults 7.25-7.45 7.35-7.45 27-40 35-48 54-95 83-100 20-22 22-27 -10 to -2 -7 to -1 + 2 40-90 95-99
HCO3 ↓ ↑ ↑ ↓
pCO2 ↓ ↑ ↑ ↓
MECHANICAL VENTILATOR NICU: FiO2 100 Pip/PEEP: 18/4 TV: wt x 10 x 6 – 8 IT -0.5 – 18cc
1-4 months 4 -12 months 1-2 years 3-5 years 6-20 years
DESIRED LENGTH 50 cm +9 cm +8 cm +5 cm +3 cm Age in years x 5 + 80
3cm/month 2.67cm/month 1.6cm/month 2cm/month
HEAD CIRCUMFERENCE + 5.08cm (1.27cm per month) + 5.08cm (0.635cm per month) +2.54cm +3.81cm (1.27cm per month) +3.81cm (1.27cm per month)
WATERLOW CLASSIFICATION Wasting Actual weight x 100 Ideal weight for actual length/height
Child: PEEP 2-4cm H2O PIP = 20-30 cm H2O Rate – 16-20 TV: 10-15ml/kg
Classification: Normal 90%, Mild 80-90%, Moderate 70-80%, Severe 70% Stunting
Pressure Vent: Restrictive Lung Disease Volume vent: Non pulmo TV : wt x 10
Actual Height/Length Ideal Length/Height for Age
x 100
Classification: Normal 95%, Mild 90-95%, Moderate 80-90%, Severe 80%
AC control: with peep SIMV: back up T piece: Fio2 only
Head Circumference 0-3 months 3-6 months 6-9 months 9-12 months 1-3 y/o 4-6 y/o
(cm/mo) 2 1 0.50 0.50 0.25 1cm/yr
RDA (kcl/kg) 115 110 100 100 100 90-100
DESIRED WEIGHT At birth < 6 months (Kg) >6 months (Kg) 2 – 6 years old (Kg) 6-12 years old (lbs)
3kg (Filipino) or 3.25kg (Caucasian) Age in months x 600 + birth weight Age in months x 500 + birth weight Age in years x 2 + 8 Age in years x 7 + 5
AGE OF INFANT 4-5 months 1 year old 2 years old 3 years old 5 years old 7 years old 10 years old
IDEAL WEIGHT 2 x birth weight 3 x birth weight 4 x birth weight 5 x birth weight 6 x birth weight 7 x birth weight 10 z birth weight
AGE Preterm 0-3 months 3-6 months 6mons -1 y/o 1-3 y/o 3-6 y/o 6-12 y/o 12 y/o
HR 120-170 100-150 90-120 80-120 70-110 65-110 60-95 55-85
RR 40-70 35-55 30-45 25-40 20-30 20-25 14-22 12-18
BP 55-75/40-70 65-85 / 45-55 70-90 / 50-65 80-100 / 55-65 90-105 / 55-70 95-110 / 60-75 100-120 / 60-75 100-135 / 65-85
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ENDOTRACHEAL TUBE SIZE ET Size = age in years +4 4 Size in mm= 16 + age in years /4 ET Level= ET size x 3 OR Add 6 to infant’s weight Weight <1000 1000-2000 2000-3000 >3000 NB Infant 1 year 3years 6years 10years Adolescent Adult
Gesta age <28 28-34 34-38 >38
Tube size 2.5 3.0 3.5 3.5-4.0 3.0-3.5 3.5-4.0 4.0-4.5 4.5-5.0 5.0-5.5 6.0-6.5 7.0-7.5 7.5-8.0
Plan B Weight (Kg) x 75mL to be given in 4 hours Plan C Age <12 months >12 months
<15 Kg >15 Kg Mild
30cc/kg st 1 hour 30 minute
70cc/kg 5 hours 2 ½ hours
ORAL REHYDRATION SOLUTIONS Na Cl K WHO/ DOH 90 80 20 Pedialyte 45 45 35 20 Oreges (250mL) 90 80 20 Hydrite (2/200) 90 80 20 Glucolyte (per L) 63 50 20 Formulated ORS 50 50 20 Reformulated ORS 75 65 20
Ludans: hydration LUDAN’S HYDRATION MILD MODERATE 50 100 30 60
WHO Hydration Plan A <24 months 50-100mL 2-10 years old 100-200mL >10 year old Ad libitum
SEVERE 150 90
Wt x factor (50 or 30) = _ugtts/min D5 0.3 NaCl 6 or 8 hours Moderate Wt x Factor (100 or 60) = _cc 1st hour: 1/4 (PNSS or PLR) to run for 1 hour Next 7hours: 3/4 (D50.3NaCl) to run for 7 hours Severe Wt x Factor (150 or 90) = _cc st
1 hour: 1/3 (PNSS or PLR) to run for 1 hour Next 7hours: 2/3 (PNSS or PLR) to run for 7 hours IVF Use PLR if with UO, PNSS if without UO Use D5.03 if 0-7 years old, D5LR if 8-10 years old
HOLIDAY SEGAR 100 x Weight 24hours >10Kg: Weight -10 x 50 + 1000 24 hours >20Kg: Weight-20 x20 + 1500 24 hours
Glucose 111 140 111 111 126.53 20 75
TOTAL FLUID REQUIREMENTS (TFR) 0-1 150 mkD 1-3 140 mkD 4-6 120 mkD 7-9 100 mkD 10-12 90 mkD 13-15 70 mkD 16-17 50 mkD BSA 0-5 wt x .05+ .05 6-10 wt x .04+ .1 10-20 wt x .03+ .2 20-40 wt x .02+ .4 > 40 wt x .01+ .8 Hema/Endo: Square root of wt x ht 3600 FLUID LIMITATION ER: BSA X 500 Wards: BSA X 400 + ½ UO in 24hrs
<10 Kg:
IVF: <20Kg: D5IMB (500cc is the only preparation) >20Kg: D5NM
DEXTROSITY D5
D7.5
D10
D12.5
D15
D17.5
D20
0
.055
.11
.17
.22
.28
.33
D50 1.0
Add 10% if there are losses (Fever, vomiting, lbm…)
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DEXTROSITY Example
GLUCOSE INFUSION RATE NB and Infants = 6-8mg/kg/min Children = 4-6 mg/kg/min
Inc dextrosity from D5 to D7.5 TFR 210, d5imb 70cc x 8-9ugtts/min x 3doses 0.055 x 70 = 4cc D5imb D50-50
= 66cc = 4cc 70cc x 8-9ugtts/min x 3doses
GIR = 0.167 X Dextrosity X ugtts/min Weight
INTRALIPID Prep: 10% , 20% Dose: 0.5-3g/kg/day ; inc by 0.5 until 3 is reached 20% = 20g/100ml Ex: Wt 2.35kg Wt x 3 x 100 x 1.1 20
===== NEWBORN WEIGHT GAIN
= 38cc x 20-24hrs at 1.9cc/hr
th
Birth weight regained on 10 DOL; 2-3 wks preterm Preterm: 15-20gm/day Term: 20-30gm/day Fullterm: age in days – 10 x 20 +BW Preterm: age in days – 14 x 15 +BW
MAGNESIUM SULFATE Prep: 250mg/ml LD: 100-200mg/kg/dose over 30mins MD: 20-30mg/kg/day Ex: wt = 3.2kg
FLUIDS IN NEONATES A. Term: 60cc/kg/day, inc daily by 10 until 150
Loading dose: Wt x 200 = 3.2kg x 200 = 640mg / 250 = 2.56cc + EAD in 30mins
B. Preterm AGA (>2.5kg) LBW (<2.5kg) VLBW (<1.5kg) ELBW (<1kg)
Maintenance dose: Wt x 30 = 3.2kg x 30 = 96mg x 24hrs = 2304mg / 250 = 9.2ml in 24 hrs
70cc/kg/day 70CC/kg/day 80cc/kg/day 100cc/kg/day
C. Types of Fluids 1st 24hr : electrolyte free, D5W, D10W Next 24hrs: with electrolytes, D5 0.3NaCl then D5imb D. TPN Electrolytes Preparation NaCl KCl 10% Ca gluc 7% AA
2.5mEq/mL 2 mEq/mL 100mg/mL 7g/100mL
Order: Mg SO4 9.2ml + D5W 14.8ml to make 24cc to run at 1cc/hr for 24hrs 250mg/ml LD: 100-200mg/kg/dose over 30mins MD: 20-30mg/kg/day
Normal 2-4 mEq/kg/day 1-3 mEq/kg/day 100-400 g/kg/d 0.5-3 g/kg/day
NaCl: 3mEq/kg/day X wt / 2.5 mEq/ml X 1.1 / 3 KCl: 2mEq/kg/day X wt / 2 mEq/ml X 1.1 / 3 Ca: 200g/kg/day X wt / 100g/ml X 1.1 / 3 AA: 3g/kg/day X wt 100 X 1.1 / 3 7
CPAP Settings FiO2 60% 80%
O2 3 4.5
PEEP 6
FiO2 and PEEP = already set 1.
Determine CA first
2.
CA = 100 – FiO2 X PEEP (60-80) x 4-6 79 (K) PEEP – CA = O2
DEXTROSITY D10 = ___ml D50-50 D10 = 10 D7.5 = 7.5
CA 3 1.5
Dr.Murallon CPAP D50-50 = (10 x TFR) – 5 (TFR – total electrolytes) 45 / 3
FiO2 = compressed air (0.21) + O2 (0-5lpm) compressed air + O2
D5W = TFR – Electrolytes – D50 = ____ / 3 To check, compute D10 50 x D50-50 = 5 x D5W = ______ Total divided by TFR If < 10: correct
ex. 5 (0.21) + 1 = 0.34 6 BPD regimen Budesonide q8 Salbutamol q6 Furosemide q12
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G-CSF (granulocyte-colony stimulating factor) Brand: Filgrastim Prep: 300mcg/ml Dose: 5mcg/kg/day OD IV or SQ To boost the immune system Stimulates the production of WBC SODIUM Deficit: (desired-actual) x wt x 0.6 137 - 129 x 11 x 0.6 = 53 Maintenance: wt x (2-3meq) Deficit + Maintenance = total infusion st Give 50% - 1 8 hours 25% - next 8 hrs 25% - next 8 hrs Normal:135-145 meq/L Significant hyponatremia: 120 meq/L Maintenance dose: 2-3 meq/kg/24 hr Prep: 2.5meq/ml/amp Fast Correction: (values <120meq) 4ml/kg of 2.5 meq/ml prep (For every ml of NaCl = 4ccsterile water)
POTASSIUM Nephro 0.2-0.3meq/kg/hr Ex. Wt = 10kg 0.2 x wt (10) = 2meq x 24 hrs = 48meqs (deficit) 2 x wt (10) = 20meq (maintenance) 68 meqs Prep: 2meq/ml Intensivist Wt x 50 x transcellular K = ____ / 3 Transcellular K = 50mmol/kg 2.5 – 3 0.05 (5%) 2 – 2.5 0.10 (10%) 1.5 – 2 0.20 (20%)
NEPHROLOGY ESTIMATED GFR Ht in cm x 0.55 /serum crea (mg/dl) Ht in cm x BSA x 0.48 /serum crea x 1.73 m2 Values: 90-120mL/min < 89 mL/min < 30 mL/min < 10 mL/min
CREATININE CLEARANCE Creatinine Clearance ml/min For urine vol > 1liter = TV ml x Ucr mg% x 1.73m2 1440 min x Crea mg% x bsa For urine volume <1 liter = wt kg x [140-age] x 0.85 72 x Serum crea mg % x bsa Creatinine clearance = K x height (cm) Plasma crea (mmol/L) K= 29 (<2.5 kg) 40 (0-18mos) 49 (2-16yrs girls) 49 (2-13yrs boys) 62 (13-16 yrs boys)
Normal Renal impairment Renal insufficiency Renal failure 5-20 Uremia
80-120 50-80 20-50 <5
To get % = creatinine clearance divided by 120 Creatinine divided by 88.4; K in decimal point (0.29); if >3 renal failure
Cardio Desired – actual x wt x 0.3 = deficit Wt x 2 meq/kg/day = maintenance Deficit + Maintenance = total infusion q8 3 40meq/day/L = maximum; excess will cause arrhythmia
Normal Renal Insufficiency CRF (Chronic Renal Failure) ESRD
TOTAL PROTEIN SPILLAGE =UTP / bsa - g/day =1000xUTP / BSA x 24hmg/m2/hr N = <4mg/m2/hr or 100mg/m2/day
100-300 mg/kg/day Prep: 100mg/ml
For nephrotics =if >40mg/m2/hr or 4g/day start pred at 60mg/m2
Ex 2.6kg 2.6x100x 1= 2.6 /3 = 0.9cc in IVF for 8 hrs 100
Normal : 20
CALCIUM
0.9ml of 10% Ca gluc add in 100 ml NaHCO3 Base excess x wt x 0.3 (half correction) X 0.6 (full correction) To be given as 50% slow IV push 50% incorporate in IVF to run 6-8hrs 1-2meqs/kg if deficit is too large CHLORIDE: 5meq/100ml
ANION GAP
Na - ( HCO3 + Cl ) 134 – (12 + 98) = 24 ALBUMIN TRANSFUSION Prep: 12.5gm/50ml (25%) OR 10gm/50ml (20%) Dose: 0.5 - 1gm per day; 1ml = 0.25gm to run for 2-4hrs as q12 or OD Wt 0.81 Wt x 50 = 3.2ml 12.5
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Ca Carbonate (TUMS) Prep: 500mg tab Dose: 50mkD Ca Gluconate Prep: 10cc/vial Max 10cc vial + EAD q8 SIVP in 30mins Alkalka Prep: 10mg tab = 10meq Dose: 1-2mkD May give 2 tabs q8 K: 0.2-0.5kg/hr, inc to 0.5 if sx noted
ACUTE GLOMERULONEPHRITIS Typical course Latent : few days- 3 wks Oliguric : 7 - 10 days Diuretic : 7- 10 days Convalescent : 7 - 10 days Normalization of urine sediment Gross hematuria : 2 - 3 wks Complement level : 6 - 8 wks Protenuria : 3 - 6 mos Micro- hematuria : 6 - 12 mos Bladder capacity: y/o x 2 oz x 30
NEPHORITIC SYNDROME Prednisone >40mg/kg/day, hypoalb <2.5mg/dl 60mg/kg/day x 4-6 weeks theN 40mg/kg/day (am) x 2-3mos alternate day dose If steroid resistant: +2protein q 8 weeks steroid dependent: relapse within 28 days frequent relapse: relapse >12x per month Cyclophosphamide 2-3mk/24hrs single dose 8-12wks 500m/kg/m2/day x 3-5days (max 1g/day x 3days) Methylpred 30mkD x 3-5days (max 1gm)
24 HOUR URINE PROTEIN Urine protein = 1.12 100mg/g x urine protein BSA x 24 hours Example 100 x 1.12 = 6.86 normal 0.68 x 24
URINE CONCENTRATING ABILITY Osmolality Urine osmolality : more precise that usg Urine osmolality = (usg-1.000) x 40000 Normal = 400to 600 mOsm/L Serum osmolality = 2Na + {glucose (mg/dl)/18} + {bun (mg/dl)/2.8} Normal = 230 to 300 mOsm Urine Specific Gravity Each 15 mmol/L (2.7 g) glucose : inc USG by 0.001 Each 4 g/L Protein : inc USG by 0.001
Normal bladder residual <5cc or 10% of bladder capacity means greater risk for UTI Clean catch : >100,000/ml catheter : >100/ml suprapubic : 1 col/ml
NEPHROTIC SYNDROME Remission: protein free/ edema free x 3-4 mos Relapse: recurrence of edema & or proteinuria Steroid responsive: (-) protein after 4-6 weeks Steroid resistant: (+) protein after 4-6 weeks of continuous daily divided doses of prednisone (60mkd); use methyl prednisolone Steroid dependent: - if you withdraw the tx, protenuria recur - 2 consecutive relapses occurring during therapy or w/in 14 days of completing steroid therapy Frequent relapser - responds to corticosteroid treatment but experiences 2 relapses w/in 6 mos after the initial response - has 4 relapses w/in any 1 yr
RENAL FAILURE STAGES Diminished renal reserve GFR 50-80 may still be asymptomatic Chronic renal insufficiency GFR 30-50; Hypocalcemia; decrease tolerance to stress Chronic renal failure GFR 10-30 Anemia,hpn, bone problem, metab disorder dialysis End stage renal disease GFR <10 Kidneys are small and contracted dialysis, kidney transplant
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DIABETIC KETOACIDOSIS Antibodies: 1CA, 1AA, GADA, 1A2 (if + should wof development of dm in the future) Start of symptoms: 80-85% of islet cells have been destroyed Diagnosis: (Signs and Symptoms +) FBS more than or equal to 126 or RBS more than 200 heavy glycosuria (more than 55mmol/L) possible ketonuria Additional workups: insulin levels, c-peptide Management: Fluid requirement in 48hrs: 2 FM + deficit 48 Deficit: wt x 30 48 hr maintenance dose: 2 x FM
DIABETIC KETOACIDOSIS2
DIABETIC KETOACIDOSIS4 Transition of Insulin IV to SQ Clinical improvement No acidosis Oral intake to prevent rebound hyperglycemia, stop iv infusion only after 60min of giving the 1st sq injection of regular insulin Split-mixed insulin injection: <2yo =0.5u/kg/day >2yo = 1u/kg/day pubertal = 0.8-1.5u/kg/day AM: 2/3 = 2/3 intermediate + 1/3 short PM: 1/3 = 2/3 intermediate + 1/3 short Fluids with the CBG of: >300: PNSS 1L + 40meqs KCl x 28gtts/min 100-300: D5 0.45 NaCl x 28cc/hr (D5W 500 + D5 0.9 NaCl + 40meqs KCl) <100: D10 0.45 NaCl x 28cc/hr (D10W 500 + D5 0.9 NaCL + 40meqs KCl)
Insulin drip: >2yo = 0.1u/kg/hr <2yo = 0.05u/kg/hr make 5u in 50cc pnss or 10u in 100cc pnss to run __cc/hr (running rate is equivalent to weight in kg) ECG Na, K, Phos, Mg, Ca Hba1c FBS BUN, Crea ABG Urine ketones Strict uo q1 with monitoring sheet at bedside May start NaHCO3 at 1meq/kg sivp to run for 30 mins DIABETIC KETOACIDOSIS3 If plasma glucose =14-17mmol/L (250-300) give PNSS If less than 250 CBG give D5 0.45nacl to prevent rapid decrease in plasma glucose conc and hypoglycemia: 500 d5 0.9 nacl + 500 d5w = d5 0.45 nacl If less than 100 CBG give D10 0.45 NaCl When rbs is decreasing by > or = 100mg/hr, may titrate insulin drip by 25% until 0.05u/kg/hr
PHLEBOTOMY FFP transfusion: Wt x EBV (70-80) x 0.15 (.10-.15) Give ½ 30-1hr before phlebo, then remaining during phlebotomy PNSS can be also be used 1meq/kg NaHCO3 if with hypoxic spells
NUTRITION Daily requirements per kg desirable Body Weight (Filipinos) for Calories and Proteins: Age 0-5 mos 6-11 mos 1-2yrs 3-6yrs 7-9yrs 10-12yrs 13-15yrs 16-19yrs
cal/kg 115 110 110 90-100 80-90 70-80 55-65 45-50
protein g/kg 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2
1g cho = 4 cal 1g chon =4 cal 1g fats = 8 cal 1000cal = 1kcal 1kcal = 4.184 kj In general, the ave distribution of calories would be: 11% = proteins 35% = fats 60% = carbohydrates
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NUTRITION Approximate daily water requirements of filipino infants and children Age 0-3days 10days 1-5mos 6-12mos 1-3yrs 4-6yrs 7-9yrs 10-12yrs 13-15yrs 16-19yrs
Water (ml/kg) 120 150 150 150 140 120 100 90 70 50
ANALGESIC & ANTI-PYRETIC 60-80 mkD st T: 80mg, 100mg, 325mg RHD: 100mkD (1 2 wks), 75 mkD (4 wks) Anti-inflammatory: 60-90 mkD Kawasaki: 80-100mkD q6 Indomethacin 1-2 mkD x 3 (PDA) Aspirin
C: 100mg
Ibuprofen
6-8 mkd q6
D: 100mg/2.5mL S: 100mg/5mL, 200mg/5mL C: 200mg, 800mg
Mefenamic Acid
6.5 mkd q6
S: 50mg/5mL C: 250mg, 500mg
Meperidine Midazolam
6 mkD/ 0.5-1 mkD 0.2 mkd
T: 15mg V: 1mg/mL, 5mg/mL
Morphine
0.1-0.2 mkd q6 (max 15mg)
T: 10mg, 30mg, 60mg, 100mg V: 10mg/mL
Nalbuphine
0.1-0.2 mkd IM, IV
V: 10mg/mL
Naproxen
5-7 mkD q8-q12 (>2y/o)
T: 275mg, 550mg
Paracetamol
10-15 mkd q4
D: 100mg/mL S: 120mg/5mL, 250mg/5mL T: 80mg, 500mg V: 150mg/mL, 300mg/2mL Supp: 125mg, 250mg
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