MNJ12-001
Mohan, 2-year-old child, weighing 10 kg is admitted with loose stools and vomiting with no obvious signs of dehydration. His serum sodium is 161 mEq/L and serum potassium is 3.5 mEq/L. Urine output is adequate:

1. Calculate the free water deficit
2. Write the fluid orders for this child.

Answer

MNJ12-002
2-year-old child weighing 9.2 kg brought to the hospital with dehydration (8%). Na: 172, K; 4.2, Cl: 101, blood sugar: 80 mg/dL, BUN: 65, serum creatinine: 1. Calculate (with formulae) and write final IV fluid orders for first 24 hours.

Answer

MNJ12-003
In relation to hyponatremia in a child:

1. Whats the dreaded complication of overzealous correction of hyponatrerma im children?
2. This complication is more common during correction of chronic than acute hyponatremia— True / False.
3. What 1s the advisable rate of correction of hyponatremia to prevent this complication im case of hyponatremia?
4. When do the clinical features develop in this condition?
5. What are the neurological features seen?

Answer

MNJ12-004
A 10-year-old child meets with a RTA and has injury to the cervical region. Vitals are as follows: Airway partially obstructed with snoring noises, RR: 22/min, paradoxical breathing, mild retractions, SpO,: 95%, HR: 78/min, peripheral pulses are feeble, cold extremities, BP: 88/36, cold peripheries, GCS: 13/15.

1. Whats the physiological status of this child?
2. Whats the probable cause of shock?
3. What are the pomts 1n favor of your diagnosis?
4. Inital steps in management.

Answer

MNJ12-005
Write total parental nutrition order for a 3-year-old boy with weight of 10 kg who is getting all his drugs and infusions in 200 ml of 5% dextrose.

Answer

MNJ12-006
Serum Na: 136, Cl: 101 and HCO,: 10

• * Diarrhea * Lactic acidosis * DEA

• * ARF * RTA * Salicylate poisoning

• * Urinary tract diversion * TEM * Septic shock

* Post-hypocapnea

1. What 1s the anion gap?
2. What is the normal anion gap?
3. In which of the following is amnion gap normal or increased?

Answer

MNJ12-007

• * Sodium *® Potassium ® Bicarbonate /Chloride

168

ANSWERS

Ans. 1. FWD =

= $560\text{ ml}$

Hypernatremia should be corrected over 48 hours (slowly)

Serum sodium should be monitored serially (6-8 hourly)

Fluid order for each day = maintenance fluid + half of FWD + ongoing losses

Adequate urine out implies 2 ml/kg/hour = 480 ml/day

(Maintenance fluid = 1000 ml + half of FWD = 280 ml + ongoing losses = 480 ml total fluid requirement per day = 1760 ml)

45DNS 440 ml IV Q 6 hourly with 5 mEq inj KCl in each 500 ml of IV fluid to be given each day for two days.

Ans. 2. Pre admission weight 10 kg ( 10 kg - 8% = 9.2 kg)

• FWD = 450 = 3 ml/kg (Na >170) × 10 kg × 15 mEq (target reduction max 15 mEq)
• TFD = 8 × 10 × 10 = 800
• SFD = 800 450 = 350
• Solute Na deficit = 0.6 × 145 × 0.35 = 30.5
• Solute K deficit = 0.4 × 150 × 0.35 = 21
• Maintenance:
• Water 1000/Na 30/K 20
• 1st 24 hours
  • Fluids: Maintenance + ½ FWD + SFD = 1575 ml
• Fluids: Maint + ½ FWD + SFD = 1575 ml
• Total Na 30 + 30.5 = 60
• Total K 20 + 21 = 41

Ans. 3. 1. Central pontine myelinolysis/osmotic demyelination syndrome

Ans. 4. 1. Airway obstructed/respiratory distress/hypotensive shock/ALOC

• Normal heart rate, paradoxical breathing (diaphragmatic breathing), hypotensive shock and wide pulse pressure.

  • a. Stabilise airway by jaw-thrust maneuver, C-spine immobilisation.
  • b. High flow O2 by NRBM
  • c. Trendelenberg position
  • d. Isotonic fluid NS 20 ml/kg boluses as rapidly as you can up to 3 boluses/till perfusion improves and ionotropes if fluid refractory
  • Look for and evaluate other life-thtreatening conditions like systemic bleeding and pneumothorax

• Ans.5. * Fluids 100 ml/kg = 1000 ml

  • 200 ml 5% dextrose = Calories = 10 x 34=34
  • Total calories needed = 1000
  • Protein 2 g/kg = 20 2
  • Fat 3 g/kg = 30 g x 10 = 300 cal
  • 20% fat 150 ml = 110 cal
  • 20% amino acid solution = 100 ml = 80 cal
  • 1000 410 = 590 cal in 600 ml
  • 25% dextrose 600 ml = 150 x 3.4 = 510 cal
  • Na3 x 10=30
  • K 2 x 10 = 20, 30/600 ml = 1/20 = 50/1000, N/3
  • 20/600 = 1/30 =3.3/100 = 1.5 ml, KC1/100 ml
  • 1 ml KCl =2 mEq
  • Final order = 600 ml N/3 in 25% dextrose with KC] 15/100 IV over 24 hr
  • 150 ml 20% intralipid over 18 hour
  • 100 ml 20% amino acid IV over 24 hour

Ans. 6. (136)-(102 + 10) = 24

• 8-16
• Diarrhea—normal
  • « Lactic acidosis—increased
  • * DKA—increased
  • * ARF—increased
  • « RTA—normal
  • * Salicylate—increased
  • * Urinary tract diversion—normal
  • * JIEM—increased
  • * Septic shock—increased
  • * Post-hypocapnea—normal
• Ans. 7. 1. Replace stools ml by ml every 1-6 hours using: D5 0.2 Normal saline + 20 mEq/L Sod bicarb + 20 mEq/L KCI
  • z Average composition of diarrhea with respect to

1. How will you replace ongoing loss in diarrhea?
2. What is the average composition of diarrhea and gastric fluid with respect to
3. ml (5% dextrose) + 7 ml CRL + 7 ml KCl at a rate of 65 (60) ml/hour.
4. True
5. Not >12 mEq/L/day (usually .5 mg/L/hour)
6. At least 2-6 days after the rapid correction of hyponatremia
7. Spastic quadri-/paraparesis, locked-in syndrome, obtundation, seizures, dysarthria.
8. Neurogenic shock
9. Initial steps in management:
   a. Stabilise airway by jaw-thrust maneuver, C-spine immobilisation.
   b. High flow O2 by NRBM
   c. Trendelenberg position
   d. Isotonic fluid NS 20 ml/kg boluses as rapidly as you can up to 3 boluses/till perfusion improves and ionotropes if fluid refractory
10. ml 5% dextrose = Calories = 10 x 34=34
11. 410 = 590 cal in 600 ml
12. ml KCl =2 mEq
13. ml 20% intralipid over 18 hour
14. ml 20% amino acid IV over 24 hour

Answer