A child with DKA develops a worsening headache, altered mental status, and bradycardia: the hosts explain why suspected cerebral injury should be treated before imaging. Dr. Pradip Kamat and Rahul Damania bring that same bedside focus to a rapid-fire pediatric critical care board review, covering medication dosing, kidney and electrolyte emergencies, endocrine crises, and liver failure. Along the way, they explain why a normal anion gap can hide acidosis when albumin is low, how a dangerously wide QRS in hyperkalemia changes the treatment order, and why acute liver failure can meet criteria even without obvious encephalopathy. Short cases, clear answers, and practical physiology make this a focused review for the PICU and the boards.
Show Highlights:
- Medication dosing in acute kidney injury, including loading versus maintenance doses
- Phenytoin’s nonlinear kinetics and extended-infusion beta-lactam antibiotics
- Kidney and electrolyte disorders, including metabolic alkalosis, hypokalemia, and anion-gap interpretation
- Hyponatremia, sodium correction, cerebral salt wasting, and pseudohyponatremia
- Hyperkalemia management, rhabdomyolysis, and kidney replacement therapy
- Diabetic ketoacidosis and suspected cerebral injury
- Endocrine emergencies, including adrenal crisis, thyroid storm, and hypoglycemia
- Metabolic disorders, including urea cycle disorders and hyperammonemia
- Pediatric acute liver failure and lactulose’s role in ammonia management
- Nutrition assessment and the effects of inflammation on albumin and prealbumin
References:
Medication questions
- FDA Dilantin prescribing information: saturable metabolism and interpretation of unbound phenytoin in hypoalbuminemia and renal/hepatic disease.
- Fuhrman & Zimmerman’s Pediatric Critical Care, 6th edition: background pharmacology, renal physiology, acid–base, and endocrine chapters.
Electrolytes and kidney support
- Royal Children’s Hospital clinical guideline: Hyponatraemia.
- Royal Children’s Hospital clinical guideline: Hyperkalaemia.
- Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury. N Engl J Med. 2022;386:964–975. doi:10.1056/NEJMra2104090.
- Stanski NL, Fuhrman D, Basu RK. Controversies in paediatric acute kidney injury and continuous renal replacement therapy. Curr Opin Crit Care. 2021;27:604–610. doi:10.1097/MCC.0000000000000888.
Endocrine and metabolic questions
- Glaser N, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23:835–856. Full guideline.
- Kuppermann N, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378:2275–2287. The trial did not find significant neurologic outcome differences among the fluid regimens studied.
- American Thyroid Association: Hyperthyroidism in Children and Adolescents; 2016 ATA guideline.
- Additional background and references are provided in the linked hypoglycemia and hyperammonemia episodes.
Liver and nutrition questions
- Squires JE, et al. NASPGHAN Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022;74:138–158. Full position paper.
- Squires RH, et al. Intravenous N-acetylcysteine in Pediatric Patients with Non-Acetaminophen Acute Liver Failure. Hepatology. 2013;57:1542–1549.
- Evans DC, et al. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021;36:22–28. PubMed.
Board review scope