Case Study - Pediatric - Dehydration - Leukemia

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5 year-old girl with leukemia. …

5 year-old girl with leukemia.

Taken to ED with history of sudden onset of fever, vomiting and increased stool frequency for 6 hours.

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  • Hyperdynamic circulation ? Due to high HRWith a relative hypovolemiaLow SVRI!
  • Mild Hypovolemia
  • ? Volume or contractility issue
  • Here is the graphical display showing measures over time.Note the resemblance to the frank-Starling curve.Now what to do?
  • Here is the graphical display showing measures over time.Note the resemblance to the frank-Starling curve.Now what to do?

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  • 1. Dehydration - Leukemia History 5 year-old girl with leukemia. Taken to ED with history of sudden onset of fever, vomiting and increased stool frequency for 6 hours.www.uscom.com.au The Measure of Life
  • 2. Dehydration - Leukemia Assessment on PICU admission Mildly dehydrated Temperature 38.4o C CVS: HR 121 bpm, BP 96/51 mmHg Warm peripheries, capillary refill time 2 sec RS: RR 26 ipm SaO2 100% in oxygen NS: A little agitatedwww.uscom.com.au The Measure of Life
  • 3. Dehydration - Leukemia Initial Assessment USCOM: Slightly elevated MD Low SV High SVV Low SVRI A) fluid bolus B) fluid + vasopressor C) fluid + inotropewww.uscom.com.au The Measure of Life
  • 4. Dehydration - Leukemia Initial Treatment Fluid 40 ml/kg Titrating vasopressor 30 minutes Temperature 37.8o C CVS: HR 112 bpm, BP 98/53 mmHg Warm peripheries, capillary refill time 2 sec USCOM: Improved but still low SV Little elevated SVV Improved SVRIwww.uscom.com.au The Measure of Life
  • 5. Dehydration - Leukemia Treatment Fluid 40 ml/kg 30-90 minutes Temperature 37.0o C CVS: HR 105 bpm, BP 105/55 mmHg Capillary refill time 2-3 sec Urine output < 1.0 ml/kg/h USCOM: Adequate SVwww.uscom.com.au The Measure of Life
  • 6. Dehydration – Leukemia Treatment Fluid 20 ml/kg 90 minutes CVS: HR increased 120 bpm, same BP 105/55 mmHg Capillary refill time 2-3 sec Urine output < 1.0 ml/kg/hwww.uscom.com.au The Measure of Life
  • 7. Dehydration - Leukemia 90 minutes USCOM: Decrease in SV Decrease in CI Normal SVV A) more fluid B) more vasopressor C) add inotrope D) remove fluid E) add inotrope and remove fluidwww.uscom.com.au The Measure of Life
  • 8. Dehydration - Leukemia 90 minutes USCOM: Decrease in SV Decrease in CI Normal SVV A) more fluid B) more vasopressor C) add inotrope D) remove fluid E) add inotrope and remove fluidwww.uscom.com.au The Measure of Life
  • 9. Dehydration - Leukemia Summary Some subspecialties are loathe to give fluids due to the negative affect of overloading in the cancer population. Conclusion Using USCOM to monitor hemodynamics increased the awareness (and quantification) of the process.www.uscom.com.au The Measure of Life