Critical Appraisal of a Mortality case presentation

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1. CASE 2 CRITICAL ANALYSIS 10/02/2012 Saptharishi L G 2. Fluid and Electrolytes 2 doses of NaHCO3 BETTER OPTIONS ã K in PD fluid ã HCO3 based PD ã 6 hrly fluid…
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  • 1. CASE 2 CRITICAL ANALYSIS 10/02/2012 Saptharishi L G
  • 2. Fluid and Electrolytes 2 doses of NaHCO3 BETTER OPTIONS • K in PD fluid • HCO3 based PD • 6 hrly fluid charting I/v/o significant negative balance Hypernatremia Urine replacement Replacement with N/4 5%D K containing IVF Fluid boluses 20 ml/kg x 3 80 % Maint P. D. Anuric regimen 70 % Maint fluids Hyperkalemia K – 7.5
  • 3. Few References…
  • 4. Acute Kidney Injury • Inappropriate diuretic usage • Indication for LASIX infusion post-PD ?? • Indication for LASIX infusion on the pre-terminal day, that led to worsening shock?? • CEFTRIAXONE – Good choice initially ?? • Is Ceftriaxone fully safe in ARF? Pediatric Nephrology, Fifth Edition Jaypee publications AUTHORS R N Srivastava / A Bagga
  • 5. Neurological Status Posturing at admission Differentially reacting pupils Sensorium – E2 M4 V3 INDICATION FOR INTUBATION AT ADMISSION
  • 6. Neurological Status Persistently Low GCS despite initial clinical improvement Hb 3.4 at admission Indication for NEURO-IMAGING – CT Head ? Intra-cranial Bleed
  • 7. Supportive Care Shock onset a/w Prolonged HYPOTHERMIA Could Hypothermia have been managed better?? Documented Calcium of 6.6 mg% How was Hypocalcaemia managed in this case ?
  • 8. Concept of Vit D in ARF
  • 9. Management of Hyperglycemia in PD children
  • 10. Sepsis • At Admission, 1. 15 day duration of illness + Outside hosp admission 2. Shock requiring multiple ionotropes 3. Multi-Organ Dysfunction Syndrome 4. Elevated TLC (25,000) Was the initial choice of CEFTRIAXONE appropriate ??
  • 11. Sepsis Post Peritoneal dialysis, • Worsening of clinical status • Re-appearance of SHOCK • Fever spike documented upto 40° C • CXR showing bilateral heterogeneous opacities Should we have up-graded the antibiotics ?? Role for Antifungals ??
  • 12. Summary of Queries • Why was intubation withheld at admission? • Could a Neuro-imaging have helped in management? • What was the rationale for the use of LASIX infusion post PD ? • Why was Bicarbonate-based PD not considered? • Potassium and Hyperglycemia management, Could it have been different ? • Why was antibiotic up-gradation not considered? Could Antifungals have helped?
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