Journal Review

1. Journal Review American Academy of Family Physicians October 1st, 2009 Am Fam Physician.2009; 80 (7)

2. Journal Review • Diagnosis and Management of Dehydration in Children • Henoch-Schönlein Purpura • Gadolinium-Associated Nephrogenic Systemic Fibrosis • Diagnosis and Treatment of Bladder Cancer

3. Diagnosis and Management of Dehydration in Children

4. Diagnosis and Management of Dehydration in Children • Fluid and electrolyte disturbances from acute gastroenteritis result in 1.5 million outpatient visits, 200,000 hospitalizations, and 300 deaths per year, among children in the United States. • Clinical dehydration scales based on a combination of physical examination findings are the most specific and sensitive tools for accurately diagnosing dehydration in children.

5. Diagnosis and Management of Dehydration in Children • Parental report of vomiting, diarrhea, or decreased oral intake is sensitive, but not specific, for identifying dehydration in children. • Comparing change in body weight from before and after rehydration is the standard method for diagnosing dehydration.

6. Diagnosis and Management of Dehydration in Children • To identify dehydration in infants and children before treatment the most useful individual signs for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. • Combination of physical examination findings are much better predictors.

7. Diagnosis and Management of Dehydration in Children • Gorelick et al. found that the presence of two or more of these four factors indicates a fluid deficit of at least 5%: • capillary refill time of more than two seconds • absence of tears • dry mucous membranes • ill general appearance • Goldman et al. found that the presence of this factors were associated with length of hospital stay and need for IV fluids: • ill general appearance • degree of sunken eyes • dry mucous membranes • tear production

8. Diagnosis and Management of Dehydration in Children • Assessment of capillary refill time, done in warm temperature. Measured on the sternum of infants and on a finger or arm at heart level, in older children. Not affected by fever . NL is < 2 seconds. • Skin turgor is the time required for the skin to recoil, NL is instantaneous. Assessment is done by pinching skin on the lateral abdominal wall at the level of the umbilicus. Increases with degree of dehydration.

9. Diagnosis and Management of Dehydration in Children Labs: • Serum creatinine level changes with age. Therefore, BUN/creatinine ratio is not useful in children. • A serum bicarbonate level of <17 mEq/L may improve sensitivity of identifying children with moderate to severe hypovolemia. • A serum bicarbonate level of <13 mEq/L is associated with increased risk of failure of outpatient rehydration efforts.

10. Diagnosis and Management of Dehydration in Children • The AAP recommends oral rehydration therapy (ORT) as the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration. • It is as effective as IV fluid and, can be initiated more quickly, and can be administered at home. • Parents are more satisfied with the visit when ORT had been used. • With ORT, the same fluid can be used for rehydration, maintenance, and replacement of stool losses.

11. Diagnosis and Management of Dehydration in Children • Contraindications for ORT: AMS with risk of aspiration, abdominal ileus, and underlying intestinal malabsorption. • Nasogastric rehydration therapy with ORT solution is an alternative to intravenous fluid therapy in patients with poor oral intake. • A regular age-appropriate diet should be initiated as soon as children with acute gastroenteritis are rehydrated.

12. Diagnosis and Management of Dehydration in Children • Commercial ORT solutions (Pedialyte)are recommended over homemade solutions because of the risk of preparation errors. • They typically contain: • 50 mEq per L of sodium: consistent with the sodium content of diarrhea caused by rotavirus • 25 g /L of dextrose: helps prevent hypoglycemia without causing osmotic diuresis • 21 and 30 mEq per L of bicarbonate: leads to less vomiting and more efficient correction of acidosis. • Clear sodas and juices should not be used for ORT because hyponatremia may occur.

13. Diagnosis and Management of Dehydration in Children

14. Diagnosis and Management of Dehydration in Children • For mild dehydration, 50 mL/kg of ORT solution should be administered over 4hours using a spoon, syringe, or medicine cup = 1 mL/kg q5 minutes. • If the child vomits, resume treatment after 30 minutes. • After the 4hour treatment period, maintenance fluids should be given and ongoing losses assessed and replaced q2 hours. • Maintenance therapy includes providing anticipated water and electrolyte needs for the next 24 hours in the child who is now euvolemic .

15. Diagnosis and Management of Dehydration in Children • Holliday-Segar method formula for estimating water needs. • Based on average weights of infants and children. • Maintenance ORT at home: 1oz/hr for infants, 2oz/hr for toddlers, and 3oz/hr for older children. • Ongoing losses, 10mL/kg for every loose stool and 2mL/kg for every episode of emesis.

16. Diagnosis and Management of Dehydration in Children

17. Diagnosis and Management of Dehydration in Children • For moderate dehydration, 100 mL/kg of ORT should be given over 4hours in the physician’s office or ER. • If successful the child may be sent home, where caregivers should provide maintenance therapy and replace ongoing losses q2 hours as for mild dehydration. • Unsuccessful = severe, persistent vomit of at least 25 % of the hourly oral requirement or if ORT cannot keep up with the volume of stool losses.

18. Diagnosis and Management of Dehydration in Children • Severe dehydration should be treated with 20mL/ kg IV of isotonic crystalloid over 10 to 15 minutes .Repeat as necessary. • Monitor pulse strength, capillary refill time, mental status, urine output and electrolyte s • After resuscitation administer 100mL/kg of ORT solution over 4hours, then maintenance fluid and replacement of ongoing losses. • If ORT fails administer 100mL/kg IV of isotonic crystalloid over 4hours, followed by a maintenance solution.

19. Diagnosis and Management of Dehydration in Children • IV maintenance fluid should be D5 and ¼ NS, plus 20 mEq/L of K. • I&O, and VS q4 hours • If stool output >30 mL/kg per day, replace equal volume q4 hours with an IV comparable in electrolytes with the stool (1/2 NS plus 20 to 30 mEq per L of potassium), in addition to the volume of maintenance fluid, until ORT can be tolerated.

20. Diagnosis and Management of Dehydration in Children • Fever may require 1 mL/kg/Cqhour. • Postoperatively and in children with CNS infection or injury 20% to 50% less fluid and fluid with higher sodium content may be needed because of abnormal antidiuretic hormone.

21. Diagnosis and Management of Dehydration in Children • Medication to decrease diarrhea is not recommended. • Lactobacillus effectiveness in patients with diarrhea has not been demonstrated. • A single dose of ondansetron (Zofran) has been shown to facilitate ORT. Recurrent dosing has not been studied.

22. Diagnosis and Management of Dehydration in Children • Complications of dehydration include hypernatremia, hyponatremia, and hypoglycemia.

23. Diagnosis and Management of Dehydration in Children • Hypernatremia indicates water loss in excess of sodium. • Signs of dehydration are less pronounced in this setting. • Circulatory disturbance is not likely to be noted until dehydration reaches 10%. • Findings include a “doughy” feeling rather than tenting when testing for skin turgor, increased muscle tone, irritability, and a highpitched cry.

24. Diagnosis and Management of Dehydration in Children • Hyponatremia is often caused by inappropriate use of oral fluids that are low in sodium. • If severe dehydration is present, hydrate with isotonic crystalloid until stabilized. • If after initial volume repletion, hyponatremia remains moderate to severe (serum Na <130 mEq/L) replacement of the remaining fluid deficit should be altered, with a principal goal of slow correction.

25. Diagnosis and Management of Dehydration in Children • Wathen et al. found blood glucose levels of <60mg/dL in 9% of children < 9years admitted to the hospital with diarrhea. • Blood glucose screening may be indicated for toddlers with diarrhea.

27. Diagnosis and Management of Dehydration in Children • 1. Which one of the following statements about oral rehydration therapy (ORT) for moderate dehydration in children is correct, compared with intravenous fluid therapy? • A. ORT leads to a higher hospitalization rate. • B. ORT has a higher failure rate. • C. ORT requires more emergency department staff time. • D. Parents are more satisfied with ORT.

28. Diagnosis and Management of Dehydration in Children • 1. Which one of the following statements about oral rehydration therapy (ORT) for moderate dehydration in children is correct, compared with intravenous fluid therapy? • A. ORT leads to a higher hospitalization rate. • B. ORT has a higher failure rate. • C. ORT requires more emergency department staff time. • D. Parents are more satisfied with ORT.

29. Diagnosis and Management of Dehydration in Children • 2. Which of the following is/are contraindications for ORT in children with diarrhea?  (check all that apply) • A. Ondansetron (Zofran) use. • B. Abdominal ileus. • C. Altered mental status with risk of aspiration. • D. Intestinal malabsorption.

30. Diagnosis and Management of Dehydration in Children • 2. Which of the following is/are contraindications for ORT in children with diarrhea?  (check all that apply) • A. Ondansetron (Zofran) use. • B. Abdominal ileus. • C. Altered mental status with risk of aspiration. • D. Intestinal malabsorption.

31. Diagnosis and Management of Dehydration in Children • 3. Which of the following recommendations for children with gastroenteritis is/are correct?  (check all that apply) • A. A normal diet should be initiated after they are rehydrated. • B. Diphenoxylate/atropine (Lomotil) may be used to reduce diarrhea. • C. A single dose of ondansetron may be used to increase ORT tolerance. • D. Hypernatremia should be suspected if the child’s skin feels “doughy.”

32. Diagnosis and Management of Dehydration in Children • 3. Which of the following recommendations for children with gastroenteritis is/are correct?  (check all that apply) • A. A normal diet should be initiated after they are rehydrated. • B. Diphenoxylate/atropine (Lomotil) may be used to reduce diarrhea. • C. A single dose of ondansetron may be used to increase ORT tolerance. • D. Hypernatremia should be suspected if the child’s skin feels “doughy.”

33. Henoch-SchönleinPurpura

34. Henoch-Schönlein Purpura • Henoch-Schönlein purpura is an acute, systemic, immune complex–mediated, leukocytoclastic vasculitis. • Clinical triad: palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. • Complications: glomerulonephritis and gastrointestinal bleeding.

35. Henoch-Schönlein Purpura • 10 to 22 persons in 100,000 each year. • Most common from late autumn to early spring • > 90% of patients are children <10 years, with a peak incidence at six years of age. • Milder in infants and children younger than 2 years. • More severe in adults. • Slight male predominance.

36. Henoch-Schönlein Purpura • Pathophysiology: • Immunoglobulin A (IgA) immune complexes are deposited in small vessels, which causes petechiae and palpable purpura. • Small vessels of the intestinal wall involvement may lead to GI hemorrhage. • In the kidney, it may produce glomerulonephritis. • Exposure to an antigen from an infection, medication, or other environmental factor may trigger antibody and immune complex formation.

37. Henoch-Schönlein Purpura • Group A streptococcus found in more than 30% of cases with nephritis. • Parvovirus B19, Bartonella henselae, Helicobacter pylori, Haemophilus parainfluenza, Coxsackie virus, adenovirus, hepatitis A and B viruses, mycoplasma, Epstein-Barr virus, varicella, campylobacter and MRSA.

38. Henoch-Schönlein Purpura • Purpura, abdominal pain, arthritis, fatigue and low-grade fever. • Nonpruritic rash that starts as erythematous papules or urticarial wheals, and then matures into crops of petechiae and purpura. • Timing of symptoms may be within days or weeks. • Usually follows an upper respiratory infection.

39. Henoch-Schönlein Purpura • Purpura is defined as nonblanching cutaneous hemorrhages that > 10 mm in diameter. • May enlarge into palpable ecchymoses. • The lesions change from red to purple to rust-colored before fading over a period of approximately 10 days. • Rash most common in dependent areas that are subject to pressure (lower extremities, belt line, and buttocks. • Purpura most common on extensor surfaces of the extremities.

40. Henoch-Schönlein Purpura

41. Henoch-Schönlein Purpura • A nonmigratory arthritis occurs in 75% of patients. • Affects knees and ankles. • Transient swelling, warmth, and tenderness. Leave no deformity. • May precede the purpuric rash in 15% to 25% of patients.

42. Henoch-Schönlein Purpura • Abdominal Pain in 60% to 65% of patients. • May mimic an acute abdomen. • Colicky, occurs about one week after the onset of the rash. • Vomiting and GI bleeding will develop in 30% of patients. • Complications: severe GI hemorrhage and intussusception.

43. Henoch-Schönlein Purpura • Renal disease 40% to 50% of patients. • Leading cause of death . • Risk greatest in pt > 10 years with persistent purpura, severe abdominal pain, or relapsing episodes. • Usually starts within the first month and rarely six months after the illness begins. • Microscopic hematuria, red cell casts, and proteinuria. • Will spontaneously remit in most patients. • May progress to glomerulonephritis

44. Henoch-Schönlein Purpura • Diagnosis: • Clinical triad: purura, abdominal pain and arthritis • Palpable purpura in the absence of thrombocytopenia. • Punch biopsy of the skin: leukocytoclastic vasculitis • Renal biopsy: membranoproliferative glomerulonephritis

50. Henoch-Schönlein Purpura • Treatment: • Spontaneous resolution in 94% of children and 89% of adults. • Supportive treatment is the primary intervention. • Acetaminophen for arthralgia • NSAIDS may aggravate GI symptoms and should be avoided in patients with renal involvement. • Relative rest and elevation of affected extremities during the active phase. • Pt may have recurrent purpura as they increase their activity level.