ACUTE

GASTROENTERITIS
SUD
Cause Treatment
Cholera Rehydration; Single dose Doxycycline
Rotavirus (stools -free of blood and leukocytes) Hydration; Lactobacillus
Salmonella gastroenteritis Cefotaxime, Ceftriaxone, Ampicillin,
Cefixime
Shigella (Bacillary dysentery) Ciprofloxacin
•  Dysentery: bloody diarrhea with fever, abdl
cramps, rectal pain and mucoid cells
Enterotoxigenic E. coli Hydration
Shiga-toxin/ Enterohemorrhagic E. coli Hydration
Enteroinvasive E. coli TMP-SMX
Campylobacter Eryhtromycin or Azithromycin
Yersinia enterocolitica TMP-SMX
Amebiasis / Entamoeba histolytica Metronidazole then Diloxanide furoate
Holiday- Segar Method
Water per 24 hours
Body Weight mL/kg/day ml/kg/hr
First 10kg x 100 4
Second 10kg x 50 2
Each additional kg x 20 1
Fluids
1.  Maintenance
2.  Deficit
3.  Replacement

*Don’t forget to always order replacement for losses.

DEFICIT THERAPY
INFANT OLDER
CHILD
MILD <5% <3% Normal or increased pulse Thirsty
Decreased UO Normal PE

MOD 5-10% 3-6% Tachycardia Dry mucous membranes

Little or no UO Mild delay in elasticity (skin
Irritable/lethargic turgor)
Sunken eyes and fontanel Delayed capillary refill (> 1.5
Decreased tears sec)
Cool and pale

SEVERE >10% >6% Rapid, weak or absent Parched mucous membranes

peripheral pulses Very delayed CRT (>3)
Decreased BP Cold and mottled, limp
No UO Depressed consciousness
Very sunken eyes and fontanel
NELSONS
Ludan’s Method
Mild DHN Moderate Severe
<15kg 50cc/kg 100 150
< 2y/o
> 15kg 30 60 90
> 2 y/o
¼ in 1 hour 1/3 in 1 hour
¾ in next 7 2/3 in next 7
hours hours
Consensus statements
Mild Moderate Severe
3-5% deficit 6-10% 9-15%
Infant 50 ml/kg 100 ml/kg 150 ml/kg
Child/Adol 30 ml/kg 60ml/kg 90 ml/kg
¨  Administer 50% deficit in the first 8 hours then the
remaining volume in the next 16 hours
1st 8 hours 50% deficit + 1/3 of maintenance
2nd 8 hours 50% deficit + 2/3 of maintenance
3rd 8 hours
WHO – SOME signs of DHN
Age <4 mo 4-11 mo 12-23 mo 2-4 yrs 5-14 yrs >15 yrs
Wt (kg) < 5 5-7.9 8-10.9 11-15.9 16-29.9 >30
in mL 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

¨  Approximate ORS (mL) = wt (kg) x 75

WHO – SEVERE signs of DHN
100 ml/kg/hr < 12 mo Older
First 30 ml/kg 1 hour 30 mins
Then 70 ml/kg 5 hours 2 ½ hours

¨  Reassess hydration every 1-2 hours

IV fluids
Na (meq/ K Cl HCO3 Mg (mg/ Ca (mg/
L) dl) dl)
pLR 130 4 109 28 - 3
lactate
pNSS 154 - 154 - - -
D5 0.3 51 - 51 - - -
NaCl
D5IMB 25 20 22 - 3 -
D5NR 140 5 98 27 - -
acetate
D5NM 40 13 40 16 3
acetate
Selection of Maintenance Fluids
¨  NPO
¤  1 L D5 ½ NS + 20 meqs KCl
n  Recommended in the child who is NPO and does not have
volume depletion or risk factors for nonosmotic ADH
production
¨  Surgical patients
¤  Isotonic
fluid (NS, LR) during surgery and in the
recovery room for 6-8 hours postop
¤  Subsequent: D5NS or LR with addition of 10-20 meqs
KCl
Replacement fluid for Diarrhea
¨  High bicarb concentration in stool
¨  1 L D5 ½ NS + 30 meqs NaHCO3 + 20 Meqs/L
KCl
¨  Replace stool ml/ml every 1-6 hours

¨  Formula for D5 ½ NS or D5 0.45NaCl:

¤  Half vol D5NSS + half D5 water
¤  1 L D50.3 NaCl + 25 meqs NaCl

NELSONS
Replacement Fluid for emesis or NG losses

¨  Loss of potassium
¨  1 L NS + 10 meqs KCl

¨  Replace output ml/ml every 1-6 hours

NELSONS
Decreased or Increased UO
¨  Oliguria/anuria
¤  25-40% of maintenance as replacement for insensible losses
with D5 ½ NS
¤  Replace UO ml/ml with D5NS +/- KCl

¨  Polyuria
¤  25-40% of maintenance as replacement for insensible losses
with D5 ½ NS +/- KCl
¤  Measure urine electrolytes
¤  Replace UO ml/ml with solution based on measured urine
electrolytes
NELSONS
Electrolytes

Electrolyte Daily requirement (meqs/kg/day)

Na 2.5-3.0
K+ 2-2.5
Hyponatremia < 135 meqs/L
¤  Maintenance: 3 meqs/kg/day
¤  Deficit: (Desired Na – actual Na) x 0.6 x weight
¤  Total Na required: M+D – bolus
¤  Correction: not more than 12meqs/L/24hr or >18meq/L/
48hr

¤  Fast
correction: 4 ml/kg/dose of 3% NaCl
¤  3% NaCl = 1 ml 2meqs/ml NaCl + 4 ml sterile water
¨  Brain swelling - hyponatremia
¨  Rapid correction of hyponat -> Central pontine
myelinolysis (CPM)
Hyponatremia - example
¨  Serum Na 125, wt 12kg

¨  Maintenance: 3 x 12 kg = 36 meqs
¨  Deficit: (135-125) x 0.6 x 12 kg = 72 meqs
¤  Why 135 as desired? Remember: not more than 12meqs/L/
24hr (I use 10meqs difference between desired and actual
para safe)
¤  Why 0.6? Total body water is 60% of body weight
¨  Total Na required: M + D = 36 + 72 = 108 meqs
HyperNatremia >145 meqs/L
¤  Totalwater required for 2 days = M for 2 days + D
¤  Ideal TBW (liters): weight x 0.6
¤  Actual TBW = ideal TBW x ideal serum Na/actual Na

¤  Water deficit: ideal TBW – actual TBW

¨  Untreated Hypernatremia -> Brain Hemorrhage

HypoKalemia
¨  Fast correction: 0.5-1 meqs/kg/dose in PNSS diluent to
run for 1 hour (0.5 meqs/kg/hr) x 3-5 doses (max: 40)
¤  Max peripheral line: 40 meqs/L
¤  Max central line: 150-200 meqs/L

¨  Oral: 1-4 meqs/kg/24 hr BID- QID

¤  Kaliumdurule = 10 meqsK/ durule
¤  Oral KCl 10% soln = 1.34 meqs/ ml

Harriet Lane
HypoKalemia
¨  PO correction
¤  Oral KCl 10% of 4-6 meqs/kg/day in divided doses
¨  Parenteral
¤  Intermittent dosing (symptomatic): 0.5 to 1 meqs/kg/hr
with max infusion rate of 0.5 meqs/kg/hr given q2-4
hours until sxs resolve
¤  Continuous (nonsymptomatic): 0.2-0.3 meqs/kg/hr for
24 hours
Bedside Pediatric Nephrology
Hypokalemia - example
¨  We use 3-4 meqsK/kg/day for correction
¨  Example: wt 6 kg, K 2.0, will choose/deliver 3.5

meqsK/kg/day as correction
¤  3.5 x 6 kg = 21 meqs/day
¨  PO
¤  OralKCl 10% (1.34meqsK/ml): 21 meqs/1.34meqs =
15.6 ml divided in 3 doses = ~5ml tid x 3 doses only

PGH
Hypokalemia - example
¨  IV
¤  3.5x 6 kg = 21 meqs/day
¤  Maintenance fluid: 600 ml/day at 25 cc/hr

x = 35 meqs
21 Order: 1 Liter D5NSS + 35 meqs KCl at
x
meqs 25 cc/hr
(delivering 3.5 meqs K /kg/day) to run
600 1000 for 24 hours ONLY
ml ml Measure serum K after correction
PGH
HyperKalemia
HyperKalemia
Pharmacotherapies for Vomiting
DRUG DOSE
Reflux Metoclopramide 0.1-0.2 mg/kg PO or IV qid

Gastroparesis Metoclopramide 0.1-0.2 mg/kg PO or IV qid

Erythromycin 3-5 mg/kg PO or IV tid-qid
Chemotherapy Metoclopramide 0.5-1mg/kg IV qid
Ondansetron 0.15-0.3 mg/kg IV or PO tid
Postoperative Ondansetron 0.15-0.3 mg/kg IV or PO tid

Intestinal Octreotride 1 ug/kg SC bid-tid

Pseudoobstruction

Nelsons