Q HINT: Avoidance of hyperkalemia is critical in patients with kidney dis- f@ ease and reduced glomerular filtration rate (GFR). These patients require frequent lab monitoring. Some may require restriction of potassium intake, avoidance of certain medications (e.g., renin-angiotensin system blockade), and use of potassium-free solutions for intravenous fluid therapy. Alll patients receiving intravenous fluids with potassium should have renal function assessed prior to administration. g HINT: The presence of acidosis doos not always account for the hyper- fe kalemia and may lead to failure to recognize and treat another cause. HINT: The administration of intravenous glucose, especially in high fe concentrations, may worsen hypokalemia by stimulating insulin raleaso, which increases cellular uptake of potassium. 9 HINT: In acute metabolic acidosis, the serum potassium level may be fe increased owing to extracellular shift while the total body potassium level fiminished, A rule of thumb is that a 0.1 decrease in pH acutely results in an increase in potassium level of 0.7 mEq/L. HINT; Intravenous potassium at concentrations of 240 mEq/L are irritat- f@ ing to small peripheral veins and often result in pain or loss of access site. HINT: Aco Q HINT: Hypomagnesemia frequently accompanies hypocalcemia, so “stones, bor J® the magnesium level should always be measured, and if low, should be corrected. HINT: Hypercalcemia reduces renal blood flow and, as a result, m@ decreases the GFR; increases sodium, potassium, and magnesium excre- tion; decreases renal concentrating capacity; and leads to metabolic acidosis. HINT: A change in the bicarbonate concentration of 10 mmol/Lis ‘® expected to lead to a change in pH of 0.15 in the same direction. HINT: Metabolic alkalosis and frank alkalemia may occur if long- fe standing respiratory acidosis is corrected suddenly (e.g., with mechanical ventilation). This condition is called “posthypercapnic alkalosis.”HINT: Hypercalciuria is the most common metabolic abnormality found ‘@ in patients with renal calculi. Table 7-3. Differential diagnosis of hypocalcemia Diagnosis Hypoparathyroiaism, Pseudohypoparathyroidism ‘Vitamin D disorders Inadequate vitamin D intake, absorption or production Inadequate hepatic 25-hydroxylation Lack of renal 1-hydroxylation End-organ vitamin D resistance Hypematremic dehydration Pancreatitis Phosphate overload (tenal failure, tumor lysis, enemas) Severe acute illnesses Overwhelming sepsis, Rhabdomyolysis Cardiac bypass surgery Differentiating features 1 phosphate; normal alkaline phosphatase; LeTH T phosphorous and PTH Mental retardation Short 4th and Sth metacarpals/metatarsals {serum phosphate; | alkaline phosphatase, PTH [serum 25-hydroxy vitamin D {serum LFTs Notmal renal function and 25-hydroxyvitarin D | serum cakitriol T serum calcitriol 1 serum sodium ‘T serum amylase and lipase ‘Abdominal pain and vomiting Postve history Positive history Pre-mortbid finding ‘Acute phase Positive historyG2, HINT: Tumor sis syndrome (a metabclc wad of hyperuricemia, hyperkae- f mia, and hyperphosphatemia) is a complication of therapy that occurs when leukemic cells lyse in response to cytotoxic chemotherapy and release their intracellular contents into the bloodstream. This occurs commonly in cells with a high-growth fraction (T-cell leukemia/lymphoma and Burkitt lymphoma). Aggressive hydration, alkalinization, and allopurinol administra- tion before initiating chemotherapy may allaviate serious renal dysfunction. The first two maneuvers promote uric acid and phosphate excretion, and allopurinol reduces uric acid formation. Potassium should not be added to hydration fluids. By monitoring the electrolyte concentrations and renal function closely, one can often avoid the development of renal failure. G2, HINT: Because kidney function is preserved, prerenal azotemiis rapid fe reversible ifthe underlying cause is corrected (e.9., restoring intravas- cular volume in a dehydrated patient). Intrarenal causes are not usually readily reversible. G2. HINT: Hypoglycemia isthe one metabolic abnormality tat can cause f@ focal neurologic findings. HINT: Children who have ingested codeine, dextromethorphan, LAAM ‘ (long-acting acetyl morphine), oxycodone, or methadone may require up 0 10 mg of naloxone to fully reverse the opioid effects. HINT: Institution of supportive care is most important ta the successful ‘® resuscitation of the poisoned patient. Q HINT: The absence of radiopaque pills or fragments does not exclude '@ the possibility of ingestion if the film is taken after the substance (e.g., iron) has been absorbed. Q HINT: Given the risks of physostigmine, it should be reserved for patients f with a clear central anticholinergic syndrome who display hyperthermia, seizures, or severe agitation and only if no evidence exists of cyclic anti- depressant toxicity. Consultation with a medical toxicologist is strongly Q HINT: If intravascular volume has been restored and minimal or no urine Fe output is observed, other diagnoses should be considered, such as ATN. Continuing to administer fluid to such patients will be of no benefit and could precipitate volume overload.CSI ea eres Ipecac is no longer routinely recommended for poisoning. Activated charcoal is most efficacious if given within 1 hour of ingestion. Gastric lavage has unproven efficacy for most ingestions. Whole bowel irrigation is indicated for sustained-release or enteric-coated substances. Akkalinization of urine still considered valuable in the management of acute overdoses of salicylates, barbiturates, or tricyclic antidepressants. Drugs causing most risk to toddlers B-blockers Digoxin Calcium antagonists Tricyclic antidepressants Oral hypoglycaemics Opioids ~ pain relief (codeine), drug-habit management (methadone) or antidiarrhoeals (diphenoxylate (Lomotil®)) Table 4.2 Some ingested agents have specific antidotes ‘Agent Antidote Benzodiazepines Flumazenil B-Adrenergic blockers Glucagon, adrenaline infusion Carbon monoxide Oxygen 100% inhalation, consider hyperbaric oxygen for severe cases Digoxin Fab antibodies (Digibind®) ron Desferrioxamine Isoniazid Pyridoxine Opiates Naloxone Paracetamol (acetaminophen) N-Acetyleysteine (NAC)Dosage for NAC infusion - children <12 years From Royal College of Paediatrics and Child Health (2003) Medicines for Children. Consult the original document for full details of administration and alternative routes of administration © Body weight 20kg or more 1 150 mg/kg IV infusion in 100mL 5 per cent dextrose” over 15 minutes, then 2 50 mg/kg IV infusion in 250 mL 5 per cent dextrose over four hours, then 2 100mg/kg IV infusion in 500mL 5 per cent dextrose over 16 hours © Body weight under 20 ke 1 150 mg/kg IV infusion in 3 mL/kg body weight 5 per cent dextrose over 15 minutes, then 2 50 mg/kg IV infusion in 7 mL/kg 5 per cent dextrose over four hours, then 2 100 mg/kg IV infusion in 14 mL/kg 5 per cent dextrose over 16 hours “If dextrose is unsuitable, use 0.9 per cent sodium chloride solution. HINT: The following can cause falso-positive results on dipstick analysis: @ alkaline urine (pH >7.0), prolonged immersion, placing the sirip directly in the urine stream, cleansing of the urethral orifice with quaternary ammo- nium compounds prior to collecting the sample, pyuria, and bacteriuria. False-negative results can occur when the urine is too dilute (i.e., the specific gravity is <1.005) or when the patient excretes abnormal amounts of proteins other than albumin. HINT: Simple radiographs can detect kidney stones if the stone is radio- @ opaque (calcium, oxalato, cystino, or struvite). Uric acid stones and some cystine stones are radiolucent and not seen by plain film.SOU TES Ce CCU nord Type Typo2 Typo 4 Renal function? Normal Normal Normal or decreased Failure to thrive? ‘Yes Yes Yes Polyuria or polydinsia?’ Yas Yes No Potassium level? Normal or Normal or low Elevated low Bicarbonate leak? Usually Significant Small Urine maximally aid? No (pH>6) Yes (below serum threshold) Yes Nephrocalcinasis or Yes No No nophrolthiasis? Fanconi syndrome? No Often No Ostoomalaca or rickets? Raroly if Fanconi smdrome is present No R HINT: Remember that, although these children do not appear dehy- drated, their intravascular volume may be decreased, and they are at increased risk for hypovolemic shock in the setting of vomiting or diarrhea HINT: In chronic kidney disease, the sequelae of ongoing impairment of other renal functions may be seen such as significant anemia, hypocal- cemia, and secondary hyperparathyroidism, which may also need to be addressed. The Parkland formula Total volume of Ringer Lactate = patient weight (in kg) X per cent burn area (as a number) Half of this volume is given over the first eight hours, the remainder over the subsequent 16 hours.