Pediatrics: Fever, Dehydration, and Oral Replacement Therapy- Cruz

Define each of the following:

• fever

• hyperthermia

• hyperpyrexia

• fever: core body temperature >100ºF (37.8ºC)

  • caused by a regulated rise in body temperature, maintained by the hypothalamus in response to a pyrogen

• hyperthermia: a malfunction of normal thermoregulatory processes at the hypothalamic level caused by excessive heat exposure or production

• hyperpyrexia: body temp >106ºF (41.1ºC)—> associated with mental and physical signs of symptoms

What is the primary reason for treating a pediatric fever?

idk how important

To alleviate discomfort (should still find underlying cause)

Most accurate method of assessing fever is through a ____________.

thermometer

Which thermometer site is considered the gold standard?

Rectal temperature measurement.

Major risks associated with fever?

idk how imp

seizures, dehydration, change in mental status

Definition of a febrile seizure?

defined as seizure accompanied by fever in infants or children with no intracranial infection, metabolic disturbance, or an otherwise defined cause

2 most important RFs for febrile seizures?

1. severity of fever

2. rate of temp increase

True or False: Prophylaxis against simple febrile seizure with antiepileptic or antipyretic is recommended by the APP.

false—> not rec

NON-PHARM TX FOR FEVER:

• adequate fluids

• wearing light clothing

• removing blankets

• maintain comfy room temp (~68^oF)

• body sponging with tepid water (exclusions apply)

PHARM TX FOR FEVER:

APAP and Ibuprofen

State the dosing for pediatric acetaminophen for fever:

10–15 mg/kg every 4–6 hours; max 5 doses/day

State the dosing for pediatric ibuprofen for fever.

5–10 mg/kg every 6–8 hours; max 4 doses/day

Ibuprofen is only approved for fever in pts. >__ months of age

6

What 2 concentrations are available for Ibuprofen?

• 100mg/5ml

• 50mg/1.25ml

Does the AAP RECOMMEND ALTERNATING different antipyretics in the same regimen? why or why not?

DOES NOT RECOMMEND—> Increased risk of dosing errors, overdose, and adverse events

What are the exclusions to self-care with fever?

(sorry there’s so many.)

• Patients >3 months of age with a rectal temperature ≥104.0ºF (40.0ºC) or equivalent

• Children <3 months of age with a rectal temperature ≥ 100.4ºF (38.0ºC)

• Severe symptoms of infection that are not self-limiting

• Risk for hyperthermia

• Impaired oxygen utilization (e.g., CV, pulmonary disease)

• Impaired immune function (e.g., cancer, HIV)

• CNS damage (e.g., head trauma, stroke)

• Children with history of febrile seizures or seizures

• Patients >2 years of age with fevers that persist >3 days with or without treatment

• Child who:

  • develops spots or rash

  • refuses to drink any fluids

  • is very sleepy, irritable, or hard to wake up

  • vomiting and cannot keep down fluids

  • has repeated diarrhea

• Children <2 years of age with fevers that persist >24 hours

• Fever that repeatedly rises above 104.0ºF (40.0ºC) in a child of any age

• Child with a stiff neck

How do you calculate maintenance fluids using the Holiday-Segar Method?

• NOTE*** WILL BE GIVEN EQUATIONS ON EXAM

• JUST RECOGNIZE AND KNOW HOW TO SOLVE

• 100 mL/kg for first 10 kg

• 1,000 mL + 50 mL/kg for each kg >10 kg

• 1,500 mL + 20 mL/kg each kg >20 kg

PRACTICE:

1. What is the total fluid amount in milliliters to be given to a patient weighing 6 kg using the Holiday-Segar Method?

   • What is the fluid rate in milliliters per hour?

2. What is the total fluid amount in milliliters to be given to a patient weighing 17 kg using the Holiday-Segar Method?

   • What is the fluid rate in milliliters per hour?

3. What is the total fluid amount in milliliters to be given to a patient weighing 21 kg using the Holiday-Segar Method?

   • What is the fluid rate in milliliters per hour?

1. tbd

____________ is the mainstay of treatment for patients who are mildly or moderately dehydrated.

_____________ is recommended for patients who are severely dehydrated.

oral rehydration therapy (ORT) is the mainstay of treatment for patients who are mildly or moderately dehydrated.

• note: ORT is not like soda or juice but fluid with Na+, Glu, etc.

IV replacement therapy is recommended for patients who are severely dehydrated.

Be able to solve problems using the % dehydration equation:

PIW= pre-illness weight

IW= illness weight

EQUATION GIVEN ON EXAM

PIW= pre-illness weight

IW= illness weight

EQUATION GIVEN ON EXAM

Be able to solve problems using the total fluid deficit(TDF) equation:

TDF (mL) = (% dehydration)(weight kg)(1,000 mL/kg)

EQUATION GIVEN ON EXAM

TDF (mL) = (% dehydration)(weight kg)(1,000 mL/kg)

EQUATION GIVEN ON EXAM

There are 3 types of dehydration—>isonatremic, hypernatremic, and hyponatremic.

describe the serum Na+ levels of each.

• iso: serum Na+ 130-150 mEq/L

• hyper: serum Na+ >150 mEq/L

• hypo: serum Na+ <130 mEq/L

Describe phase I, II and III of isonatremic dehydration:

• Phase I: Rapid Phase

  • mild/mod: 20ml/kg bolus over 30-60min

  • severe: may repeat bolus

  • fluids: NS or LR

  • goal: restore circulation, re-perfuse brain/kidneys

• Phase II: Replacement Phase

  • fluid type: D5W ½ NS or NS (±20 mEq KCl if voided)

  • amount: ½ deficit + 1/3 daily maintenance

  • time: 8 hrs

  • goal: replace deficit of fluids and electrolytes

• Phase III: Stabilization Phase

  • fluids: D5W ½ NS or NS + 20 mEq KCl

  • amount: ½ deficit + 2/3 daily maintenance

  • time: >16 hours

  • goal: transition to maintenance fluids

The 3 phases of tx for isonatremic is similar to hypernatremic except for…

in hyper we treat slower

• phase II: over 24 hrs

• phase III: over 24-48 hrs

For hypernatremic dehydration, what is the maximum recommended Na⁺ correction rate?

No more than 10–12 mEq/L per 24 hours

Acute severe hyponatremia is a serum Na+ <____ mEq/L and causes what symptoms?

<120 mEq/L, CNS symptoms

What is the tx for acute severe hyponatremia?

• fluid

  • how must it be infused?

• bolus

  • what must be monitored?

• Na+ deficit

  • max correction rate?

• fluid:

  • administer 3% saline

  • MUST BE INFUSED VIA CENTRAL LINE

• bolus

  • 2-5 ml/kg over 20 minutes

  • monitor serum sodium 20 minutes after dose

  • can repeat up to 2 times

• Na+ deficit

  • max correction rate: 0.5 mEq/L/hr or 10 mEq/L/24 hrs

What complication prompted ISMP’s warning about hypotonic fluids in 2009?

Hospital-acquired hyponatremia leading to neurologic dysfunction and deaths

What are the degrees of dehydration?

A 10 kg patient presents with a 1-day history of vomiting and diarrhea. Serum sodium is within normal range. Based on symptoms he is 8% dehydrated. He received two 20 mL/kg boluses in the ER. Calculate the amount of fluid to be given the first 8 hours for the remaining deficit plus maintenance and the fluid to be given in the following 16 hours for the remaining deficit plus maintenance.