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pH

pCO2
pO2 GAS
ARTERIAL BLOOD
HCO3
BE
Acidosis ph<7.35
O2 sat
Alkalosis ph>7.45

BLOOD GAS ANALYSIS


NB &
Children &
Infants
Adults
3 years old
7.25-7.45
7.35-7.45
5 years old
27-40
35-48
7 years old
54-95
83-100
10 years old
20-22
22-27
-10 to -2
-7 to -1 + 2
40-90
95-99

5 x birth weight
6 x birth weight
7 x birth weight
10 z birth weight

Respiratory Acidosis pCO2 >45


Respiratory Alkalosis
pCO2 <35
Metabolic Acidosis HCO3 <24 dec BE
Metabolic Alkalosis HCO3 >24 inc BE
Hypoxemia
pO2 <85
Note:
For every 10mmHg pCO2 = pH of 0.05
For every 10mmHg pCO2 = pH of 1

Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Acidosis
Respiratory
Alkalosis

pH

HCO3

pCO2

MECHANICAL VENTILATOR
NICU: FiO2 100
Pip/PEEP: 18/4
TV:wt x 10 x 6 8
IT -0.5 18cc

DESIRED LENGTH
50 cm
+9 cm

At birth
Birth to 3
months
3-6 months
6-9 months
9-12 months
1 year and
above

+8 cm
+5 cm
+3 cm
Age in years x 5
+ 80

1-4 months
4 -12 months
1-2 years
3-5 years
6-20 years

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)

Child:PEEP 2-4cm H2O


PIP = 20-30 cm H2O
Rate 16-20
TV: 10-15ml/kg

Wasting

Pressure Vent: Restrictive Lung Disease


Volume vent: Non pulmo
TV : wt x 10

Classification: Normal 90%, Mild 80-90%, Moderate 70-80%,

WATERLOW CLASSIFICATION

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

Severe 70%

Stunting
Actual Height/Length x 100
Ideal Length/Height for Age
(cm/mo)
2
1
0.50
0.50
0.25
1cm/yr

RDA (kcl/kg)
115
110
100
100
100
90-100

DESIRED WEIGHT
3kg (Filipino) or 3.25kg
(Caucasian)
< 6 months (Kg)
Age in months x 600 + birth
weight
>6 months (Kg)
Age in months x 500 + birth
weight
2 6 years old
Age in years x 2 + 8
(Kg)
6-12 years old
Age in years x 7 + 5
(lbs)
At birth

AGE OF INFANT
4-5 months
1 year old
2 years old

Actual weight x 100


Ideal weight for actual length/height

Classification: Normal 95%, Mild 90-95%, Moderate 80-90%, Severe


80%

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

IDEAL WEIGHT
2 x birth weight
3 x birth weight
4 x birth weight

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 infants
weight
Weight Gesta age
<1000
<28
1000-200028-34
2000-300034-38
>3000
>38
NB
Infant
1 year
3years
6years
10years
Adolescent
Adult

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

Ludans: hydration
LUDANS HYDRATION
MILD
MODERA
TE
50
100
30
60

<15 Kg
>15 Kg
Mild
Wt x factor (50 or 30)
6 or 8 hours

SEVERE
150
90

= _ugtts/min D5 0.3 NaCl

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

WHO Hydration
Plan A
<24 months
50-100mL
2-10 years old 100-200mL
>10 year old
Ad libitum
Plan B
Weight (Kg) x 75mL to be given in 4 hours
Plan C
Age
<12 months
>12 months

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
<10 Kg: 100 x Weight
24hours
>10Kg: Weight -10 x 50 + 1000
24 hours
>20Kg:Weight-20 x20 + 500
24 hours

70cc/kg
5 hours
2 hours

ORAL REHYDRATION SOLUTIONS


Na
Cl
K
Gluco
se
WHO/ DOH
90
80
20
111
TOTAL FLUID REQUIREMENTS
Pedialyte 45
45
35
20
140
(TFR)
Oreges
80
20
111
0-1
15090
mkD
(250mL)
1-3
140 mkD
Hydrite (2/200)
90
80
20
111
4-6
120 mkD
Glucolyte (per
63
50
20
126.53
7-9
100 mkD
L)
10-12
90 mkD
Formulated
50
50
20
20
13-15
70 mkD
ORS
16-17
50 mkD
Reformulated
75
65
20
75
ORS
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

Severe
Wt x Factor (150 or 90) = _cc
1st hour: 1/3 (PNSS or PLR) to run for 1 hour
Next 7hours: 2/3 (PNSS or PLR) to run for 7 hours

30cc/kg
1st hour
30 minute

3600
FLUID LIMITATION
ER: BSA X 500
Wards: BSA X 400 + UO in 24hrs

D
5
0

D7.
5
.
055

D1
0
.11

DEXTROSITY
D12
D1
D17
.5
5
.5
.17

.22

.28

D2
0

D50

.33

1.0

IVF:
<20Kg: D5IMB (500cc is the only preparation)
>20Kg: D5NM
Add 10% if there are losses (Fever, vomiting,
lbm)

Total divided by TFR


DEXTROSITY

If < 10: correct

Example
Incdextrosity from D5 to D7.5
TFR 210, d5imb 70cc x 8-9ugtts/min x
3doses
0.055 x 70 = 4cc
D5imb
= 66cc
D50-50
= 4cc
70cc x 8-9ugtts/min x 3doses

GLUCOSE INFUSION RATE


NB and Infants = 6-8mg/kg/min
Children = 4-6 mg/kg/min
GIR = 0.167 X Dextrosity X ugtts/min
Weight

=====
NEWBORN WEIGHT GAIN
Birth weight regained on 10th 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
FLUIDS IN NEONATES
A. Term:
60cc/kg/day, inc daily by 10 until 150
B. Preterm
AGA (>2.5kg)
LBW (<2.5kg)
VLBW (<1.5kg)
ELBW (<1kg)

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
Normal

Preparation

NaCl
2.5mEq/mL
KCl
2 mEq/mL
mEq/kg/day
10% Cagluc100mg/mL
7% AA
7g/100mL

2-4 mEq/kg/day
1-3
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
DEXTROSITY
D10 = ___ml D50-50
D10 = 10
D7.5 = 7.5
D50-50 = (10 x TFR) 5 (TFR total
electrolytes)
45 / 3

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
= 38cc x 20-24hrs at 1.9cc/hr
MAGNESIUM SULFATE
Prep: 250mg/ml
LD: 100-200mg/kg/dose over 30mins
MD: 20-30mg/kg/day
Ex: wt = 3.2kg
Loading dose:Wt x 200
= 3.2kg x 200 = 640mg / 250
= 2.56cc + EAD in 30mins
Maintenance dose:Wt x 30
= 3.2kg x 30 = 96mg x 24hrs
= 2304mg / 250
= 9.2ml in 24 hrs
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

CPAP
Settings
FiO2
CA
60%
3
80%
1.5

O2
3
4.5

PEEP
6

FiO2 and PEEP = already set


1.

2.

Determine CA first

CA = 100 FiO2 X PEEP (60-80) x


4-6
79 (K)
PEEP CA = O2

D5W = TFR Electrolytes D50 = ____ / 3

Dr.Murallon CPAP

To check, compute D10


50 x D50-50 =
5 x D5W
= ______

FiO2 = compressed air (0.21) + O2 (05lpm)


compressed air + O2

ex. 5 (0.21) + 1 = 0.34


6
BPD regimen
Budesonide q8
Salbutamol q6
Furosemide q12

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
Give 50% - 1st 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%)
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
CALCIUM
100-300 mg/kg/day
Prep: 100mg/ml
Ex 2.6kg
2.6x100x 1= 2.6 /3 = 0.9cc in IVF for 8 hrs
100

0.9ml of 10% Cagluc 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
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 Normal
< 89 mL/min
Renal Insufficiency
< 30 mL/min
CRF (Chronic Renal Failure)
< 10 mL/min
ESRD

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
80-120
Renal impairment 50-80
Renal insufficiency 20-50
Renal failure
5-20
Uremia
<5
To get % = creatinine clearance divided by
120
Creatinine divided by 88.4; K in decimal
point (0.29);
if >3 renal failure
TOTAL PROTEIN SPILLAGE
=UTP / bsa - g/day
=1000xUTP / BSA x 24hmg/m2/hr
N = <4mg/m2/hr or 100mg/m2/day
For nephrotics
=if >40mg/m2/hr or 4g/day
start pred at 60mg/m2
ANION GAP
Normal : 20
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 = 0.25gmto run for 2-4hrs as q12 or OD
Wt 0.81
Wt x 50 = 3.2ml
12.5
Ca Carbonate (TUMS)
Prep: 500mg tab
Dose: 50mkD
CaGluconate
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
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)
Methylprednisone: 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
0.68 x 24

6.86 normal

URINE CONCENTRATING ABILITY


Osmolality
Urine osmolality : more precise than 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

ACUTE GLOMERULONEPHRITIS
TYPICAL COURSE
Latent
: few days- 3 wks
Oliguric
: 7 - 10 days
Diuretic
: 7- 10 days
Convalescent : 7 - 10 days
NORMALIZATION OF
Gross hematuria
Complement level
Protenuria
Micro- hematuria

URINE SEDIMENT
: 2 - 3 wks
: 6 - 8 wks
: 3 - 6 mos
: 6 - 12 mos

Bladder Capacity: age x 2 oz x 30


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

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

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

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

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, cpeptide
Management:
Fluid requirement in 48hrs: 2 FM + deficit
48
Deficit: wt x 30
48 hr maintenance dose: 2 x FM

DIABETIC KETOACIDOSIS2
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

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:
PM:

2/3 = 2/3 intermediate + 1/3 short


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)

PHLEBOTOMY
FFP transfusion:

Wt x EBV (70-80) x 0.15 (.10-.15)

Give 30-1hr before phlebo, then


remaining during phlebotomy
PNSS can be also be used
1meq/kg NaHCO3 if with hypoxic spells

Strict uo q1 with monitoring sheet at bedside


May start NaHCO3 at 1meq/kg sivp to run for
30 mins

NUTRITION
Daily requirements per kg desirable
Body Weight (Filipinos) for Calories and

Proteins:
Age
g/kg
0-5 mos
6-11 mos
1-2yrs
3-6yrs
7-9yrs
10-12yrs
13-15yrs
16-19yrs

cal/kg

protein

115
110
110
90-100
80-90
70-80
55-65
45-50

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

7-9yrs
10-12yrs
13-15yrs
16-19yrs

100
90
70
50

ANALGESIC & ANTI-PYRETIC


60-80 mkD
T: 80mg, 100mg,
RHD: 100mkD (1st 2 wks),
325mg
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

Mefenamic Acid

6.5 mkd q6

D: 100mg/2.5mL
S: 100mg/5mL,
200mg/5mL
C: 200mg, 800mg
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)

Nalbuphine

0.1-0.2 mkd IM, IV

T: 10mg, 30mg, 60mg,


100mg
V: 10mg/mL
V: 10mg/mL

Naproxen

5-7 mkD q8-q12 (>2y/o)

Paracetamol

10-15 mkd q4

T: 275mg, 550mg

NUTRITION
Approximate daily water requirements
of filipino infants and children
Age
0-3days
10days
1-5mos
6-12mos
1-3yrs
4-6yrs

Water (ml/kg)
120
150
150
150
140
120

D: 100mg/mL
S: 120mg/5mL,
250mg/5mL
T: 80mg, 500mg
V: 150mg/mL,
300mg/2mL
Supp: 125mg, 250mg