ANASARCA IN CHILDREN - WPS Office.pptx
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This document discusses anasarca, or massive generalized edema, in pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). It defines anasarca and lists its main causes. There are two main mechanisms for anasarca - underfilling and overfilling. Underfilling is caused by reduced intravascular volume due to sodium and water retention, while overfilling is caused by sodium and water retention leading to expanded plasma and tissue fluid volumes without adequate sodium excretion. The document focuses on the most common clinical case scenario of anasarca from nephrotic syndrome and provides a general approach for management.
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This document discusses vasopressor and inotropic support in septic shock. It begins by describing the pathophysiology of septic shock and how it differs from other forms of shock. It then reviews the available vasopressor agents used in clinical practice for septic shock, including norepinephrine, dopamine, epinephrine, and phenylephrine. The document discusses the challenges in making recommendations due to the lack of controlled trials. It then outlines the end points used to guide resuscitation in septic shock, including arterial blood pressure, cardiac output, mixed venous oxygen saturation, blood lactate levels, and gut tonometry.
Portal Hypertension in pediatric population
PORTAL HYPERTENSION
OUTLINE:
Definition
Causes
Pathogenesis
Clinical features
Investigations
Management
Complications
Prognosis
Approach
Definition:
Defined as:
Portal Pressure > 10-12 mm Hg, with diameter >10mm Or
Hepatic Venous Pressure Gradient > 4 mm Hg
increased portal resistance or increased portal venous blood flow
major cause of morbidity and mortality in chronic liver diseases
Portal Vein:
Causes of Portal HTN:
Extrahepatic/Pre-hepatic
Hepatic
Pre-Sinusoidal
Sinusoidal
Post-Sinusoidal
Post-hepatic
A. Extra-hepatic:
Portal Vein Thrombosis- Most common
Neonates: Omphalitis, Umbilical Vein Catheterization, Dehydration, Sepsis
Older Children: Intra-abdominal infections e.g., Appendicitis, IBD, PSC
Hypercoagulable states: Deficiencies of factor V Leiden, protein C, S
Blunt Abdominal Trauma
Portal vein agenesis, atresia, stenosis
Splenic vein thrombosis
Biliary tract disease
Extrahepatic biliary atresia
Choledochal cyst
B. Intra-hepatic:
C. Post-hepatic:
Budd-Chiari Syndrome
IVC Webs
Chronic Constrictive Pericarditis
Pathogenesis And Consequence of Portal HTN
Portosystemic collaterals:
Sites:
Lower part of esophagus
Lower part of rectum
Around Umbilicus
Clinical Features:
Bleeding:
Most common presentation
risk of first bleed in cirrhosis is 22%
rises to 38% in with known varices >5-yr period
Pattern of bleeding
Hematemesis/Malena: Most common
worsened by Stress / Intercurrent illness
Size of varices → Bleeding
Splenomegaly:
2nd Most common presentation
asymptomatic or associated with cytopenia
Ascites:
Seen in 7-21% patients
Less common but important manifestations
Portal Hypertensive Biliopathy
Growth Failure
Hepatopulmonary Syndrome
Porto-pulmonary HTN
Caput Medusae:
Abnormal, dilated venous network on anterior abdominal wall, radiating from the umbilicus
Not seen in extra-hepatic portal HTN
Seen in intra-hepatic portal HTN
Continuous murmur between umbilicus and lower sternum
Cruveilhier-Baumgarten Murmur
Investigations
USG with Doppler
portal vein diameter > 10 mm
hepatic diseases, masses, presence of varices and ascites
ascertain pattern of flow
Reversal of portal blood flow (Hepatofugal flow) - Associated with bleeding varices
Cavernous transformation of the portal vein in EHPVO
Increased thickness of lesser omentum
CECT and MRA: Needed in selective cases
Selective Arteriography: When surgical decompression is being planned
GIT Endoscopy: Most reliable to detect varices
Other investigations:
CBC
LFT
Barium swallow
Portal angiogram
Percutaneous intrasplenic measurement of portal pressure
Venography
A. Emergency Management of Bleeding Varices
1st Step (Initial resuscitation):
airway protection
Obtain I/V Access
Restoration of IV volume: fluid and BT
PRBC: Target Hb: 7-9 g/dL
Correction of coagulopathy: vitamin K, FFP/PC
NG
Microcirculation alterations in severe covid 19 pneumonia
This study assessed microcirculation alterations in 27 mechanically ventilated COVID-19 patients with acute respiratory distress syndrome. Patients showed prolonged capillary refill time and sublingual microcirculation abnormalities, including increased total and perfused vascular density, decreased proportion of perfused vessels and blood flow velocity, and increased heterogeneity of flow. These findings suggest impaired tissue perfusion and oxygenation in COVID-19, which may contribute to multiple organ dysfunction. The increased vascular density could result from hypoxia-induced angiogenesis or capillary recruitment, and microthrombosis may also play a role.
Sibylle Kozek-Langenecker - Fluid strategy shock - IFAD 2012
1) The document discusses fluid strategies for hemorrhagic shock, noting the importance of stopping bleeding, maintaining the intravascular compartment, and ensuring tissue perfusion.
2) It describes the physiology of fluid distribution in the body and the pathophysiology of hemorrhagic shock. Optimal fluid resuscitation involves balanced isotonic crystalloids for fluid substitution and isooncotic colloids for volume replacement.
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shock types management
The document discusses various types and causes of shock, including hypovolemic, cardiogenic, septic, neurogenic, hypoadrenal, and anaphylactic shock. It covers the pathophysiology, signs and symptoms, classification, management, and treatment of shock. Key points include that shock results from inadequate tissue perfusion due to various etiologies, management involves identifying the cause and restoring circulating volume through intravenous fluids, blood products, and surgical intervention if needed.
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Acute respiratory distress syndrome (ARDS) is an inflammatory lung condition caused by a variety of direct and indirect insults to the lungs. It is characterized by diffuse pulmonary edema and hypoxemia that is not fully explained by cardiac failure or fluid overload. The Berlin definition classifies ARDS as mild, moderate, or severe based on ratios of oxygen levels to supplemental oxygen provided. Sepsis is the most common risk factor. Treatment focuses on mechanical ventilation with low tidal volumes, maintaining oxygen saturation above 90%, treating underlying causes, and managing fluids to avoid overload. Complications can include lung scarring, ventilator-associated pneumonia, and multi-organ failure.
Blts
This document discusses bronchiolitis, which is the most common lower respiratory tract infection in infants under 2 years of age. It is usually caused by viral infections like respiratory syncytial virus. The symptoms include wheezing, difficulty breathing, coughing, and nasal congestion. Treatment is supportive and involves fluids, nasal suctioning, oxygen supplementation, and in severe cases, mechanical ventilation. Preventive measures include palivizumab injections for high-risk infants to reduce hospitalizations from RSV infection.
FORMATO CASO CLÍNICO U2 M4 T1.docx
I) The patient is a 30-year-old man presenting with 4 weeks of progressive edema in the lower extremities and eyelids over the past week. Laboratory tests show proteinuria, hypoalbuminemia, and kidney dysfunction.
II) A renal biopsy revealed focal and segmental glomerulosclerosis. This, along with the clinical presentation, makes focal segmental glomerulosclerosis with nephrotic syndrome the most likely diagnosis.
III) Treatment involves a low-sodium diet, diuretics, ACE inhibitors, steroids, and monitoring for complications of nephrotic syndrome such as infection or renal dysfunction.
How_to_monitor_cardiovascular_function_in_critical.11.pdf
This document discusses approaches for monitoring cardiovascular function in critically ill patients in resource-limited settings. It finds that repeated physical exams and basic observations remain important for monitoring patients. Additional feasible approaches for tissue perfusion monitoring include urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements. Echocardiography and noninvasive cardiac output measurements are feasible approaches for cardiovascular monitoring. Ultrasound is a promising monitoring tool that is increasingly available in low-resource settings. Future research should focus on developing and testing robust monitoring technologies appropriate for resource-limited contexts.
Dic
DIC during Pregnancy is the most dreaded complication and matter to clear the concepts is required.
the slides clear and give a better idea about disseminated intravascular coagulation.
hope you find all your answers to queries in these slides.
shock-190119202315.pdf
Neonatal shock is characterized by an imbalance between oxygen delivery and demand in tissues leading to hypoxia. The pathophysiology of neonatal shock involves myocardial dysfunction, abnormal vasoregulation, and hypovolemia decreasing oxygen delivery. Relative adrenal insufficiency also contributes. Therapeutic goals include normal capillary refill time, pulses, temperature, urine output, blood pressure, glucose, and calcium. Echocardiography assists in assessing volume status, cardiac function, shunts, and pulmonary hypertension to guide shock management. Inotropes and vasopressors are used but evidence is limited regarding optimal drugs and doses.
Sudden onset shortness of breath in patient with chronic renal failure
A 45-year-old man with chronic renal failure presented with sudden onset shortness of breath and chest pain after dialysis. Investigations showed pulmonary edema, sepsis, and severe metabolic acidosis. The provisional diagnosis was acute pulmonary edema and sepsis from his dialysis catheter. Management included oxygen, nitrates, antibiotics, fluid removal, and addressing his acidosis with bicarbonate and urgent dialysis. Pulmonary edema is a complication of dialysis that can be caused by fluid overload from non-adherence to diet or an intercurrent illness exacerbating renal failure.
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- 1. ANASARCA IN CHILDREN (SPECIFIC SCENARIOS IN PICU & NICU) Dr Akshay P Jadhav MD, Fellow Ped ICU. Fellow Ped ER, Lead & Senior Consultant Pediatrician, Belenus Champion Hospital, Bengaluru, KA, IN
- 2. A N A S A R C A 1 C a s e s i n P I C U 3 M e c h a n i s m s 2 C a s e s i n N I C U 4 C O N T E N T S
- 3. 01 Defn: Causes: Specific Presentations Expected: A N A S A R C A
- 5. Defn: ANASARCA (OR Massive Generalised Edema : 2022 ICD-10-CM Diagnosis Code R60.1) - A condition that is characterized by the presence of massive generalized edema. - Courtesy : Curofy
- 10. Other causes:
- 11. Other causes:
- 12. Based on Distribution of edema
- 13. TWO main mechanisms : Mechanism of Under Filling • Reduced intravascular volume due to retention of Na and hence water Mechanism of Over Filling • Na and Water retention secondary to expanded plasma and intracellular tissue fluid Volume, which is accompanied by LACK OF NATRIURESIS
- 14. Under-filling
- 15. Over-Filling What is SNS and RAAS? Blood pressure and blood volume are closely regulated by the interrelated actions of the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS). Reflex vasoconstriction caused by parallel SNS and RAAS activation is modulated by two interactive negative feedback systems called baroreflex.
- 17. The “ Underfilling ” theory of sodium retention in the nephrotic syndrome. AVP Arginine vasopressin, ALDO aldosterone, ANP atrial natriuretic peptide, NE norepinephrine, GFR glomerular filtration rate, FF filtration fraction.
- 18. The “Overfilling” theory of sodium retention in the nephrotic
- 19. Overfill and Underfill edema in Nephrotic Syndrome Studies suggest that the pathogenesis of edema in individual patients may occur via widely variable mechanisms, i.e., intravascular volume underfilling versus overfilling. Managing edema should therefore be directed to the underlying pathophysiology.
- 21. 01 02 03 Cardiac - Breathlessness cyanosis, underlying CHD , Hepatic Ascites caput medusae varices rectal and esophageal,, Renal system Proteinuria, Microscopic hematuria with casts, Primary Organ / Organ Systems involved
- 41. Generalised Approach to ANASARCA with focus on MOST COMMON Clinical Case Scenario - NS (Nephrotic Syndrome):
- 70. References:
- 71. Multiple choice questions: 1) The following are more suggestive of underfilling than overfilling in nephrotic syndrome EXCEPT: a. Serum albumin concentration below 2 g/dL b. Minimal change histology c. Hypertension d. Postural hypotension 2) The following should be considered in the management of severe anasarca and mild pulmonary edema in a hypertensive nephrotic child with serum albumin concentration 2.7 g/dL and other findings consistent with the overfill hypothesis EXCEPT: a. Loop diuretics b. Addition of a thiazide or metolazone to enhance diuresis c. Daily intravenous administration of 25 % albumin d. Fluid restriction
- 72. Multiple choice questions (Continuation): 3) The following are commonly known secondary complications of active nephrotic syndrome EXCEPT: a. Subclinical hypothyroidism b. Thromboembolism c. Hypogammaglobulinemia d. Hepatitis. 4) A teenage girl with membranous nephropathy presents with left flank pain, gross hematuria, and thrombocytopenia. The most likely etiology related to her nephrotic syndrome is: a. Urolithiasis b. Left renal vein thrombosis c. Urinary tract infection d. Wilms tumor
- 73. THANK YOU FOR PATIENT HEARING
- 74. E C M S THANK YOU Dr Nithin Chawla Sir