WEBVTT 00:00:06.339 --> 00:00:08.880 Welcome to the bed. When you get up to the bed, 00:00:09.000 --> 00:00:11.199 we'll go ahead and give you the story. This is 00:00:11.199 --> 00:00:14.699 all going to happen super fast. Welcome to the 00:00:14.699 --> 00:00:48.570 emergency room. Welcome back to the Deep Dive. 00:00:49.080 --> 00:00:52.219 Today we are wading into what I honestly think 00:00:52.219 --> 00:00:54.659 is one of the most deceptively difficult topics 00:00:54.659 --> 00:00:56.740 we have ever covered. Oh, absolutely. It's a 00:00:56.740 --> 00:00:59.359 beast. Yeah, we were talking about the pediatric 00:00:59.359 --> 00:01:03.460 genitourinary system or as I like to call it 00:01:03.579 --> 00:01:06.319 the area where basic plumbing meets really high 00:01:06.319 --> 00:01:08.319 -level chemistry. Right. And you have to layer 00:01:08.319 --> 00:01:11.159 on top of that some incredibly sensitive social 00:01:11.159 --> 00:01:13.819 development issues. Exactly. I was looking through 00:01:13.819 --> 00:01:16.599 our source material for today, specifically the 00:01:16.599 --> 00:01:19.400 deep dive into nursing care for a child with 00:01:19.400 --> 00:01:22.379 an alteration and elimination. It is a massive 00:01:22.379 --> 00:01:24.519 amount of material. It really is. I mean, you've 00:01:24.519 --> 00:01:26.959 got infections, structural defects, where things 00:01:26.959 --> 00:01:29.140 are literally inside out. Which is terrifying 00:01:29.140 --> 00:01:31.579 for parents. Totally. And then you've got acute 00:01:31.579 --> 00:01:33.980 kidney failure. It's a lot for anyone to take 00:01:33.980 --> 00:01:36.819 in. So our mission today for you listening is 00:01:36.819 --> 00:01:39.260 to apply the Pareto principle. The 80 -20 rule. 00:01:39.439 --> 00:01:41.340 Right. We are going for the 80 -20 synthesis. 00:01:41.519 --> 00:01:43.340 We aren't going to read a list of diseases from 00:01:43.340 --> 00:01:46.599 a textbook. We want to identify the 20 % of concepts 00:01:46.599 --> 00:01:49.799 that answer 80 % of your exam questions. And 00:01:49.799 --> 00:01:52.439 more importantly, the concepts that prevent critical 00:01:52.439 --> 00:01:55.420 errors at the bedside. Yes. Safe bedside care 00:01:55.420 --> 00:01:58.760 is the ultimate goal here. So, looking at this 00:01:58.760 --> 00:02:01.379 massive list of conditions, nephrotic syndrome, 00:02:01.959 --> 00:02:06.500 HUS, hypospadias, VUR, it just feels like a laundry 00:02:06.500 --> 00:02:09.780 list of random. Latin words. It does, but there 00:02:09.780 --> 00:02:11.740 is an underlying logic. That's why we mapped 00:02:11.740 --> 00:02:14.000 out a few master patterns for you. Yeah, these 00:02:14.000 --> 00:02:15.939 are like the big buckets that most of these GU 00:02:15.939 --> 00:02:18.360 problems fall into. If you understand these patterns, 00:02:18.699 --> 00:02:20.939 you can usually figure out what's going on, even 00:02:20.939 --> 00:02:23.120 if blank on the specific details of a disease. 00:02:23.500 --> 00:02:25.979 It is all about clinical reasoning. You don't 00:02:25.979 --> 00:02:28.580 want to rely on rote memorization because under 00:02:28.580 --> 00:02:31.270 stress, memory fails. So true. Let's start with 00:02:31.270 --> 00:02:33.430 pattern one. You call this the swollen child 00:02:33.430 --> 00:02:35.870 dichotomy. Yeah, this is a classic trap, both 00:02:35.870 --> 00:02:38.409 on exams and in the ER. You have a child who 00:02:38.409 --> 00:02:40.610 comes in and they are swollen, edematous. Like 00:02:40.610 --> 00:02:42.629 puffy eyes in the morning. Right, periorbital 00:02:42.629 --> 00:02:44.710 edema. Or maybe the parents say their shoes don't 00:02:44.710 --> 00:02:47.349 fit suddenly, or they just look heavy. And the 00:02:47.349 --> 00:02:49.870 question is always why. From the sources, it 00:02:49.870 --> 00:02:52.150 seems like in pediatrics, you are almost always 00:02:52.150 --> 00:02:55.379 choosing between two main conditions here. Exactly. 00:02:55.520 --> 00:02:59.300 Nephrotic syndrome or acute post -structococcal 00:02:59.300 --> 00:03:01.819 glomerulonephritis. We usually just call that 00:03:01.819 --> 00:03:04.199 APSGN because it's a mouthful. It really is. 00:03:04.259 --> 00:03:07.099 But they sound so similar. They both involve 00:03:07.099 --> 00:03:09.680 the kidneys and they both cause a kid to swell 00:03:09.680 --> 00:03:11.939 up. They do sound similar, but the mechanism 00:03:11.939 --> 00:03:14.620 behind them, the actual why is totally different. 00:03:14.759 --> 00:03:16.939 The risks are different too. Okay, so break that 00:03:16.939 --> 00:03:19.340 down for us. What is the decision point? If I'm 00:03:19.340 --> 00:03:21.520 looking at this swollen kid, what determines 00:03:21.520 --> 00:03:24.030 which bucket they are in? It comes down to what 00:03:24.030 --> 00:03:26.449 is leaking from the kidney and what their blood 00:03:26.449 --> 00:03:28.949 pressure is doing. So in nephrotic syndrome, 00:03:29.129 --> 00:03:32.840 I want you to think O for nephrotic. an O for 00:03:32.840 --> 00:03:35.659 protein. Wait, there's no O in protein. Ha! Well, 00:03:35.659 --> 00:03:37.500 think of the O in nephrotic. They are losing 00:03:37.500 --> 00:03:40.599 massive amounts of protein. Ah, got it. Massive 00:03:40.599 --> 00:03:42.460 protein area. And that makes their urine look 00:03:42.460 --> 00:03:44.400 weird, right? Yeah, it makes the urine frothy, 00:03:44.659 --> 00:03:47.099 like beer foam. This is the very vivid visual. 00:03:47.319 --> 00:03:50.159 Frothy equals protein. Exactly. And because they 00:03:50.159 --> 00:03:52.979 lose that protein, specifically albumin, they 00:03:52.979 --> 00:03:55.539 lose the sponge in their blood. Because albumin 00:03:55.539 --> 00:03:58.039 holds water inside the blood vessels. Right. 00:03:58.060 --> 00:04:00.500 It maintains the oncotic pressure. So if you 00:04:00.500 --> 00:04:03.639 lose the albumin, The water just leaks out into 00:04:03.639 --> 00:04:06.159 the tissues. So they are swollen everywhere. 00:04:06.360 --> 00:04:09.740 Yes, anisarca. But here is the key, and this 00:04:09.740 --> 00:04:13.599 is a huge exam favorite, because the fluid isn't 00:04:13.599 --> 00:04:15.819 in the blood vessels anymore. It's in the tissue. 00:04:16.199 --> 00:04:18.579 Right. Because of that, their blood pressure 00:04:18.579 --> 00:04:21.639 is usually normal or even a little low. They 00:04:21.639 --> 00:04:25.240 are intravascularly dry. OK, so nephrotic syndrome 00:04:25.240 --> 00:04:28.779 equals frothy urine, massive swelling, but a 00:04:28.779 --> 00:04:31.550 normal to low blood pressure. Spot on. So what 00:04:31.550 --> 00:04:34.569 about the other one? APSGN. This is an inflammation 00:04:34.569 --> 00:04:36.949 problem. Think of it as a clogged filter, not 00:04:36.949 --> 00:04:39.529 a leaky one. Clogged with what? Usually immune 00:04:39.529 --> 00:04:41.490 complexes from a recent strep infection, they 00:04:41.490 --> 00:04:44.290 get stuck in the glomerulus. So like a drain 00:04:44.290 --> 00:04:46.750 filled with hair. Gross, but yes. Yeah. Very 00:04:46.750 --> 00:04:48.550 accurate. And because the filter is clogged, 00:04:48.730 --> 00:04:50.889 they cannot pee out fluid. It stays in the blood 00:04:50.889 --> 00:04:52.529 vessels. This means the tank is totally full. 00:04:52.810 --> 00:04:55.230 Exactly. And a full tank means high blood pressure. 00:04:56.310 --> 00:04:58.790 Hypertension. That is a massive distinction. 00:04:58.829 --> 00:05:01.730 It really is. The decision point here is also 00:05:01.730 --> 00:05:04.750 the urine color. It is not frothy. It is tea 00:05:04.750 --> 00:05:07.569 colored or Kula colored. Because of blood. Yes, 00:05:07.730 --> 00:05:10.829 hematuria. The inflammation damages the capillaries 00:05:10.829 --> 00:05:13.689 so red blood cells leak out, but they get broken 00:05:13.689 --> 00:05:16.129 down in the process. That's what turns the urine 00:05:16.129 --> 00:05:18.970 that dark rusty brown color. Okay, let's summarize 00:05:18.970 --> 00:05:21.550 pattern one for you listening. If the urine is 00:05:21.550 --> 00:05:24.949 frothy and the kid is puffy, but has normal BP, 00:05:25.129 --> 00:05:28.089 It's nephrotic. If the urine is T -colored and 00:05:28.089 --> 00:05:30.910 the kid has high blood pressure, it's APSGN. 00:05:31.250 --> 00:05:34.009 Exactly. If you see high blood pressure in a 00:05:34.009 --> 00:05:37.250 GU question, your brain should immediately scream 00:05:37.250 --> 00:05:40.490 glomerulonephritis or renal failure. Perfect. 00:05:40.790 --> 00:05:42.629 Let's look at pattern two, the plumbing problem. 00:05:42.790 --> 00:05:44.870 This one is simple, but it's really critical 00:05:44.870 --> 00:05:47.509 for safety. Structural defects almost always 00:05:47.509 --> 00:05:49.850 lead to urinary tract infections. Because in 00:05:49.850 --> 00:05:52.009 adults, we usually think of UTIs as, you know, 00:05:52.129 --> 00:05:54.350 hygiene issues. Or related to sexual activity. 00:05:54.540 --> 00:05:56.839 But in pediatrics, the rule of thumb is this. 00:05:57.100 --> 00:05:59.579 If a newborn or a young infant gets a UTI, it 00:05:59.579 --> 00:06:02.160 is structurally suspicious until proven otherwise. 00:06:02.399 --> 00:06:04.420 Right, because babies shouldn't get UTIs just 00:06:04.420 --> 00:06:06.920 from sitting in a dirty diaper. Precisely. If 00:06:06.920 --> 00:06:08.920 you have a four -month -old male with a UTI, 00:06:09.100 --> 00:06:12.500 that is not a hygiene issue. That is likely vesicoretoral 00:06:12.500 --> 00:06:16.930 reflux or VUR. or maybe an obstruction. So we 00:06:16.930 --> 00:06:19.029 treat the infection, but then we have to go looking 00:06:19.029 --> 00:06:21.350 for the defect. Right. You have to order the 00:06:21.350 --> 00:06:23.870 ultrasound or the voiding sister ethrogram to 00:06:23.870 --> 00:06:27.329 find the why. A VCUG. We'll get into that procedure 00:06:27.329 --> 00:06:29.129 later because it's a big one. Oh, definitely. 00:06:29.430 --> 00:06:31.790 Okay, pattern three is about surgical timing 00:06:31.790 --> 00:06:35.069 and safety. You flagged a very specific latex 00:06:35.069 --> 00:06:37.779 rule. This is a massive can't miss safety item. 00:06:37.920 --> 00:06:40.620 Any child who has frequent bladder interventions. 00:06:40.740 --> 00:06:43.579 Like kids with bladder exestrophy or spina bifida. 00:06:43.759 --> 00:06:46.160 Exactly. They are exposed to latex catheters 00:06:46.160 --> 00:06:48.800 constantly right from birth. So they have a huge 00:06:48.800 --> 00:06:51.759 risk of developing a severe latex allergy. Is 00:06:51.759 --> 00:06:53.819 it just the frequency of the exposure? Yeah. 00:06:53.980 --> 00:06:56.500 The repeated mucosal exposure sensitizes them 00:06:56.500 --> 00:06:58.939 very quickly. So clinically, we just treat them 00:06:58.939 --> 00:07:01.199 as if they are latex allergic from day one. So 00:07:01.199 --> 00:07:03.980 latex -free gloves. Latex -free catheter. Latex 00:07:03.980 --> 00:07:06.279 -free everything. And it's not just in the hospital 00:07:06.279 --> 00:07:09.040 room. No latex balloons from the gift shop. Oh, 00:07:09.040 --> 00:07:11.560 that's a classic NCLE -X trap right there. The 00:07:11.560 --> 00:07:14.000 balloon in the room. They love testing that. 00:07:14.180 --> 00:07:15.980 And under that same surgical umbrella, there's 00:07:15.980 --> 00:07:18.639 a hard rule about circumcision, right? Yes. If 00:07:18.639 --> 00:07:20.899 a baby is born with hypospadias, which is where 00:07:20.899 --> 00:07:23.139 the urethral opening isn't at the tip of the 00:07:23.139 --> 00:07:25.060 penis... It's on the underside. Right, the ventral 00:07:25.060 --> 00:07:27.800 side. If they have that, you do not circumcise 00:07:27.800 --> 00:07:30.740 them. Because the surgeon needs the foreskin. 00:07:31.399 --> 00:07:34.680 Exactly. They use that tissue to rebuild the 00:07:34.680 --> 00:07:37.379 urethra later. If you circumcise them, you've 00:07:37.379 --> 00:07:39.000 essentially thrown away the repair material. 00:07:39.220 --> 00:07:41.740 That's a great visual to remember. Don't cut 00:07:41.740 --> 00:07:43.560 until you've checked the plumbing. Good rule 00:07:43.560 --> 00:07:47.579 for life, really. Yeah. Okay, pattern four. The 00:07:47.579 --> 00:07:50.100 pediatric emergency flags. Two big ones to keep 00:07:50.100 --> 00:07:53.360 in mind here. First is testicular torsion. Torsion 00:07:53.360 --> 00:07:56.800 equals ischemia. Yes. Time is testicle. You have 00:07:56.800 --> 00:07:59.360 a very short window. about six to eight hours 00:07:59.360 --> 00:08:01.860 to un -pwist it and save it before the tissue 00:08:01.860 --> 00:08:03.939 dies. It's an absolute surgical emergency. And 00:08:03.939 --> 00:08:06.339 the second emergency. Hemolytic Uremic Syndrome. 00:08:06.339 --> 00:08:10.060 Yeah. HUS. This is usually caused by an E. coli 00:08:10.060 --> 00:08:12.759 infection. The hamburger disease. Right. The 00:08:12.759 --> 00:08:16.040 rule here is incredibly counterintuitive. Do 00:08:16.040 --> 00:08:18.540 not give antibiotics for the bloody diarrhea. 00:08:18.600 --> 00:08:20.819 That just feels so wrong. It's a bacterial infection. 00:08:20.899 --> 00:08:22.560 Why wouldn't we want to kill it? I know, but 00:08:22.560 --> 00:08:24.879 if you kill the bacteria rapidly with antibiotics, 00:08:25.160 --> 00:08:27.740 they lees. They literally burst open. And that 00:08:27.740 --> 00:08:30.939 releases a massive waves of toxins. Exactly. 00:08:31.279 --> 00:08:34.899 Shiga toxin. That sudden massive toxin load is 00:08:34.899 --> 00:08:37.600 what actually destroys the kidneys. So you actually 00:08:37.600 --> 00:08:40.539 make the HUS significantly worse by treating 00:08:40.539 --> 00:08:42.919 the initial infection with antibiotics. Wow. 00:08:43.179 --> 00:08:45.399 Okay, so those are our four master patterns. 00:08:45.840 --> 00:08:48.899 The swollen child, the plumbing problem, the 00:08:48.899 --> 00:08:51.799 latex and surgical rules, and the pediatric emergencies. 00:08:52.039 --> 00:08:54.279 Keep those frameworks in mind as we dive into 00:08:54.279 --> 00:08:56.840 the specific diseases. Let's start with the foundation. 00:08:57.559 --> 00:09:00.200 Anatomy and physiology. Because, as we always 00:09:00.200 --> 00:09:02.879 say, kids are not just small adults. They really 00:09:02.879 --> 00:09:04.899 aren't, especially their kidneys. Yeah. From 00:09:04.899 --> 00:09:06.980 the sources, the most important need to know 00:09:06.980 --> 00:09:10.659 here is about kidney maturity. A child's kidneys 00:09:10.659 --> 00:09:13.360 do not actually reach functional maturity until 00:09:13.360 --> 00:09:15.799 they are about two years old. Which is wild when 00:09:15.799 --> 00:09:17.820 you think about it. What does that mean practically 00:09:17.820 --> 00:09:20.700 at the bedside? It means they are terrible at 00:09:20.700 --> 00:09:22.679 concentrating their urine. Because the loop of 00:09:22.679 --> 00:09:25.700 henna is short. Exactly. An adult kidney can 00:09:25.700 --> 00:09:28.580 hold on to water if you get dehydrated. An instance 00:09:28.580 --> 00:09:31.100 kidney can't do that. It just keeps dumping dilute 00:09:31.100 --> 00:09:33.889 urine no matter what. So that puts infants and 00:09:33.889 --> 00:09:37.110 toddlers at a massively higher risk for severe 00:09:37.110 --> 00:09:40.549 dehydration. Huge risk. It also means they don't 00:09:40.549 --> 00:09:43.389 clear drugs as effectively, so weight -based 00:09:43.389 --> 00:09:46.049 dosing and monitoring are critical. And there's 00:09:46.049 --> 00:09:48.389 a very specific formula for bladder capacity 00:09:48.389 --> 00:09:50.549 I saw in the notes. Yes, a general rule of thumb 00:09:50.549 --> 00:09:52.809 for bladder capacity announces is the child's 00:09:52.809 --> 00:09:55.769 age in years plus two. Okay, so if I have a four 00:09:55.769 --> 00:09:58.220 -year -old Their bladder capacity is roughly 00:09:58.220 --> 00:10:00.779 six ounces. Right. And compare that to a newborn. 00:10:01.080 --> 00:10:04.399 A newborn holds about 30 mLs, which is just one 00:10:04.399 --> 00:10:07.740 ounce. Exactly, one ounce. That explains why 00:10:07.740 --> 00:10:09.879 parents are changing diapers basically around 00:10:09.879 --> 00:10:12.159 the clock. It's essentially a continuous flow 00:10:12.159 --> 00:10:14.820 system at that age. And this anatomy piece connects 00:10:14.820 --> 00:10:17.240 directly to a massive developmental milestone, 00:10:18.080 --> 00:10:20.259 toilet training. It really does. You physically 00:10:20.259 --> 00:10:22.820 cannot toilet train a child until they have the 00:10:22.820 --> 00:10:25.059 physiological maturity. The nerve innervation 00:10:25.059 --> 00:10:27.759 and the actual physical bladder capacity. Right. 00:10:28.000 --> 00:10:30.000 Which, again, usually happens around age two. 00:10:30.240 --> 00:10:32.399 Before that, if you try to potty train a baby, 00:10:32.899 --> 00:10:35.159 you are just training the parent to catch the 00:10:35.159 --> 00:10:37.039 pee. You aren't training the child to actually 00:10:37.039 --> 00:10:39.039 hold it. Exactly. They literally don't have the 00:10:39.039 --> 00:10:41.220 hardware for it yet. Let's move to our first 00:10:41.220 --> 00:10:43.960 major disease cluster based on those patterns. 00:10:45.039 --> 00:10:48.919 UTI and VUR. We touched on this with the plumbing 00:10:48.919 --> 00:10:52.299 pattern, but let's go deeper. What is VUR exactly? 00:10:52.620 --> 00:10:55.940 That's a caroteral reflux. Right. So normally 00:10:55.940 --> 00:10:58.559 urine flows from the kidneys, down the ureters, 00:10:58.840 --> 00:11:01.559 into the bladder, and then out. It's strictly 00:11:01.559 --> 00:11:05.059 a one -way street. But in VUR, that one -way 00:11:05.059 --> 00:11:07.779 valve is broken. Yes. The valve at the bottom 00:11:07.779 --> 00:11:10.179 of the ureter is incompetent. So when the bladder 00:11:10.179 --> 00:11:12.440 muscle contracts to push urine out of the body, 00:11:12.779 --> 00:11:15.299 some of that urine actually shoots backward up 00:11:15.299 --> 00:11:17.779 the ureters toward the kidneys. It's a backwash. 00:11:17.940 --> 00:11:20.759 A toxic backwash, yeah. And that backwash carries 00:11:20.759 --> 00:11:22.940 whatever bacteria is in the bladder right up 00:11:22.940 --> 00:11:25.620 into the kidneys. And that's why V you are. causes 00:11:25.620 --> 00:11:28.580 pilonephritis, kidney infections. Exactly. And 00:11:28.580 --> 00:11:31.019 repeated kidney infections cause renal scarring. 00:11:31.200 --> 00:11:33.940 And the long -term impact of that scarring is 00:11:33.940 --> 00:11:36.980 huge. It leads to hypertension and even end -stage 00:11:36.980 --> 00:11:39.399 kidney disease later in life. Right. The stakes 00:11:39.399 --> 00:11:42.120 are very high. We are trying to aggressively 00:11:42.120 --> 00:11:44.299 save these kidneys for when the child is 40 years 00:11:44.299 --> 00:11:48.700 old. So how do we spot a UTI in a kid? because 00:11:48.700 --> 00:11:51.460 the baby can't tell you, you know, it burns 1AP. 00:11:51.620 --> 00:11:54.179 This is where age -specific presentation is crucial. 00:11:54.399 --> 00:11:56.600 In a preschooler or a school -age kid, sure, 00:11:56.720 --> 00:12:00.440 you get the classic dysuria, frequency, urgency, 00:12:01.399 --> 00:12:04.039 maybe some belly pain or flank pain. But in an 00:12:04.039 --> 00:12:07.730 infant? It is incredibly non -specific. Fever, 00:12:07.730 --> 00:12:10.009 lethargy, irritability, poor feeding, they might 00:12:10.009 --> 00:12:12.549 be vomiting. A neonate might just present with 00:12:12.549 --> 00:12:15.149 jaundice. So the exam trap is an infant with 00:12:15.149 --> 00:12:18.110 a fever of unknown origin. Yes. If you have an 00:12:18.110 --> 00:12:20.070 infant with a fever and you can't find a source, 00:12:20.350 --> 00:12:22.649 no ear infection, no pneumonia, you absolutely 00:12:22.649 --> 00:12:24.830 have to check the urine. It is a mandatory part 00:12:24.830 --> 00:12:26.450 of the septic workup. And how are we getting 00:12:26.450 --> 00:12:28.769 that urine? I assume we aren't asking a six -month 00:12:28.769 --> 00:12:31.350 -old to pee in a sterile cup. No. And this is 00:12:31.350 --> 00:12:33.149 where the pediatric nurse has to be the bad guy 00:12:33.149 --> 00:12:35.500 for a minute. For a diagnostic urine culture, 00:12:35.759 --> 00:12:38.019 you need a sterile sample. Because we need to 00:12:38.019 --> 00:12:40.720 know exactly what bacteria is growing. Exactly. 00:12:40.879 --> 00:12:43.480 So in a non -toilet -trained child, that means 00:12:43.480 --> 00:12:46.059 a straight catheterization. An in -and -out cath. 00:12:46.220 --> 00:12:49.100 Yes. It's invasive. The parents absolutely hate 00:12:49.100 --> 00:12:51.940 it. The baby screams. But sticking a cotton ball 00:12:51.940 --> 00:12:54.480 in a diaper or using one of those adhesive bags 00:12:54.480 --> 00:12:56.980 just gives you a contaminated sample. You could 00:12:56.980 --> 00:12:59.200 use a bag for a quick screening urinalysis, right? 00:12:59.340 --> 00:13:03.049 You can to look for nitrites or leukocytes. But 00:13:03.049 --> 00:13:05.210 if that's positive and you need to confirm it 00:13:05.210 --> 00:13:07.649 with a culture to prescribe the right antibiotics, 00:13:08.190 --> 00:13:10.710 you have to do the straight cath. OK, so once 00:13:10.710 --> 00:13:13.549 we diagnose it, what's the intervention? Antibiotics 00:13:13.549 --> 00:13:16.450 are first line, and hydration to flush the system. 00:13:16.490 --> 00:13:19.080 And for the view, our part. VUR is graded from 00:13:19.080 --> 00:13:22.059 1 to 5. If it's mild, like grades 1 through 3, 00:13:22.419 --> 00:13:24.740 we often just monitor them closely. We might 00:13:24.740 --> 00:13:27.580 put them on a low -dose prophylactic antibiotic. 00:13:27.740 --> 00:13:29.879 Because many kids actually outgrow it? Yeah. 00:13:29.960 --> 00:13:32.139 As the child grows, the ureters lengthen, and 00:13:32.139 --> 00:13:34.399 the valve often corrects itself. But if it's 00:13:34.399 --> 00:13:37.500 severe, grade 4 or 5? Or if they keep getting 00:13:37.500 --> 00:13:40.080 breakthrough infections despite the daily antibiotics, 00:13:40.639 --> 00:13:44.120 then they might need surgery, a ureteral re -implantation. 00:13:44.480 --> 00:13:46.559 Let's talk about the developmental impact of 00:13:46.559 --> 00:13:49.480 all this. Because having chronic urinary issues 00:13:49.480 --> 00:13:52.340 has to be incredibly tough for a kid socially. 00:13:52.620 --> 00:13:54.960 It's a huge impact. Think about a seven -year 00:13:54.960 --> 00:13:57.899 -old who was completely potty trained. And suddenly, 00:13:58.059 --> 00:14:00.440 they're wetting their pants at school. Because 00:14:00.440 --> 00:14:04.340 of UTI or the bladder spasms from VUR? Exactly. 00:14:04.519 --> 00:14:07.519 It's humiliating for them. It causes severe regression. 00:14:07.700 --> 00:14:09.980 They might start bedwetting again, which is called 00:14:09.980 --> 00:14:13.519 inuresis. It creates a ton of shame and anxiety. 00:14:13.659 --> 00:14:15.539 So what's our nursing action there? We have to 00:14:15.539 --> 00:14:17.620 protect their development. We pull the parents 00:14:17.620 --> 00:14:20.299 aside and reassure the child that this is a medical 00:14:20.299 --> 00:14:22.500 plumbing issue. It is not their fault. They aren't 00:14:22.500 --> 00:14:25.340 being bad. Parent education is a big piece here, 00:14:25.340 --> 00:14:28.259 too, to prevent bounce backs. Critical. Wiping 00:14:28.259 --> 00:14:31.100 front to back for girls is the classic one. No 00:14:31.100 --> 00:14:33.720 bubble baths. Why no bubble baths? The chemicals 00:14:33.720 --> 00:14:36.220 in the soak severely irritate the urethra and 00:14:36.220 --> 00:14:38.500 change the flora, making it easier for bacteria 00:14:38.500 --> 00:14:41.179 to climb up. Also, cotton underwear to let things 00:14:41.179 --> 00:14:43.960 breathe. And treating constipation. This is a 00:14:43.960 --> 00:14:45.620 really interesting link in the source material. 00:14:45.960 --> 00:14:49.960 Yes. What does constipation have to do with a 00:14:49.960 --> 00:14:53.159 UTI? Everything. Right, because the rectum sits 00:14:53.159 --> 00:14:55.440 right behind the bladder. Exactly. So a full 00:14:55.440 --> 00:14:57.700 constipated rectum, we call it a heavy rectal 00:14:57.700 --> 00:15:00.559 stool burden, it physically pushes forward onto 00:15:00.559 --> 00:15:02.539 the bladder. Which prevents the bladder from 00:15:02.539 --> 00:15:04.980 emptying completely when they pee. Right. And 00:15:04.980 --> 00:15:08.320 stasis of urine equals infection. Urine sitting 00:15:08.320 --> 00:15:11.480 in a warm, dark place will grow bacteria. So 00:15:11.480 --> 00:15:14.200 an aggressive bowel regimen is actually a core 00:15:14.200 --> 00:15:17.159 part of UTI prevention. That is exactly the kind 00:15:17.159 --> 00:15:19.360 of need -to -know detail that saves a kid from 00:15:19.360 --> 00:15:21.750 recurrent infections. OK, let's switch gears 00:15:21.750 --> 00:15:24.070 and go back to that swollen child pattern. Nephrotic 00:15:24.070 --> 00:15:26.549 versus nephritic. Right. Let's do nephrotic syndrome 00:15:26.549 --> 00:15:29.330 first. Minimal change disease is the most common 00:15:29.330 --> 00:15:31.250 type in kids, according to the deep dive notes. 00:15:31.470 --> 00:15:33.850 Yes. And remember, our plain language patho here, 00:15:34.110 --> 00:15:37.309 it's the leaky filter. The glomerular basement 00:15:37.309 --> 00:15:40.309 membrane in the kidney suddenly becomes highly 00:15:40.309 --> 00:15:42.970 permeable to proteins. Specifically albumin. 00:15:43.169 --> 00:15:45.269 Right. So the albumin leaves the bloodstream 00:15:45.269 --> 00:15:48.350 and goes straight into the toilet. Yes, and we 00:15:48.350 --> 00:15:50.769 established that albumin acts like a sponge in 00:15:50.769 --> 00:15:53.389 your blood. It provides the oncotic pressure 00:15:53.389 --> 00:15:56.070 that holds water inside the blood vessels. So 00:15:56.070 --> 00:15:58.740 when you lose the albumin sponge... the water 00:15:58.740 --> 00:16:01.120 leaks out of the blood and into the interstitial 00:16:01.120 --> 00:16:03.419 tissues. Which is why these kids present with 00:16:03.419 --> 00:16:06.019 such massive edema. And when you say massive? 00:16:06.200 --> 00:16:09.480 We are talking profound periorbital edema. Their 00:16:09.480 --> 00:16:11.840 eyes might be swollen shut in the morning, a 00:16:11.840 --> 00:16:15.139 sites in the belly, severe scrotal or labial 00:16:15.139 --> 00:16:17.220 edema. An incredible weight gain, right? Yes. 00:16:17.480 --> 00:16:20.279 But it's entirely fluid weight. They might gain 00:16:20.279 --> 00:16:22.539 20 % of their body weight in just a few days. 00:16:22.700 --> 00:16:25.120 So if we are looking at an exam question or assessing 00:16:25.120 --> 00:16:27.440 a patient, what are the top findings for the 00:16:27.440 --> 00:16:30.779 80 -20 core? Number one, massive protein area. 00:16:30.899 --> 00:16:33.799 It'll be plus three or plus four on a urine dipstick. 00:16:34.200 --> 00:16:37.139 Number two, hypoalbuminemia, low blood protein. 00:16:37.559 --> 00:16:39.820 Number three, the generalized edema. And number 00:16:39.820 --> 00:16:43.340 four was hyperlipidemia, high cholesterol. That 00:16:43.340 --> 00:16:45.899 one seems really random to me. It does seem disconnected, 00:16:45.960 --> 00:16:48.460 but it's actually the liver trying to help. The 00:16:48.460 --> 00:16:50.840 liver senses that the blood protein levels are 00:16:50.840 --> 00:16:53.659 dangerously low, so it kicks into overdrive to 00:16:53.659 --> 00:16:56.299 synthesize more proteins, but it also turns out 00:16:56.299 --> 00:16:58.559 a ton of lipids at the same time. So the high 00:16:58.559 --> 00:17:01.240 cholesterol is just a side effect of the liver 00:17:01.240 --> 00:17:03.259 trying to fix the low protein problem. Exactly. 00:17:03.320 --> 00:17:06.680 It's a compensatory mechanism. Fascinating. So 00:17:06.680 --> 00:17:10.559 how do we actually treat the leaky filter? Corticosteroids. 00:17:11.330 --> 00:17:13.990 Prednisone is the absolute gold standard here. 00:17:14.450 --> 00:17:17.029 We hit them with high doses to suppress the immune 00:17:17.029 --> 00:17:19.450 system, stop the inflammation, and seal that 00:17:19.450 --> 00:17:22.109 leak. But high dose steroids for a kid come with 00:17:22.109 --> 00:17:25.329 a lot of baggage. So much baggage. The number 00:17:25.329 --> 00:17:27.849 one critical complication to monitor for in a 00:17:27.849 --> 00:17:30.329 child with Nasodic syndrome is infection. Because 00:17:30.329 --> 00:17:32.269 of the steroids suppressing their immune system. 00:17:32.490 --> 00:17:34.930 Yes, and also because they literally peed out 00:17:34.930 --> 00:17:36.789 their immunoglobulins during the protein leak. 00:17:36.950 --> 00:17:39.650 They have zero defense. A simple cold virus can 00:17:39.650 --> 00:17:42.089 turn into peritonitis or overwhelming sepsis 00:17:42.089 --> 00:17:44.910 very quickly. And from a developmental standpoint, 00:17:45.250 --> 00:17:47.250 steroids are really rough on kids. Extremely. 00:17:47.269 --> 00:17:49.549 We see the classic moon face, that round, very 00:17:49.549 --> 00:17:52.349 puffy facial structure. For a school -aged child 00:17:52.349 --> 00:17:55.359 or an adolescent, suddenly looking drastically 00:17:55.359 --> 00:17:57.920 different like that is devastating for their 00:17:57.920 --> 00:18:00.160 body image. They get teased at school. They don't 00:18:00.160 --> 00:18:02.740 want to see their friends. Plus, steroids cause 00:18:02.740 --> 00:18:06.299 severe mood lability. Roid rage. Roid rage in 00:18:06.299 --> 00:18:09.319 a four -year -old is a real thing. They are irritable. 00:18:09.460 --> 00:18:11.740 They are starving all the time. They can't sleep. 00:18:12.079 --> 00:18:15.930 So as the nurse... You have to do a lot of anticipatory 00:18:15.930 --> 00:18:17.970 guidance with the parents. You have to sit them 00:18:17.970 --> 00:18:20.670 down and say, listen, your sweet calm child might 00:18:20.670 --> 00:18:23.289 become an absolute monster for the next few months. 00:18:23.529 --> 00:18:26.650 It is the medication. It is not your child. And 00:18:26.650 --> 00:18:29.230 it is temporary. That conversation probably saves 00:18:29.230 --> 00:18:31.769 marriages. It absolutely does. All right. Let's 00:18:31.769 --> 00:18:34.849 flip the coin to the other swollen child. Acute 00:18:34.849 --> 00:18:38.740 post -striptococcal glomerulonephritis. APSGN. 00:18:38.819 --> 00:18:41.460 The clogged filter. So this is an immune complex 00:18:41.460 --> 00:18:44.559 disease. Yeah. The child had strep throat or 00:18:44.559 --> 00:18:47.099 maybe a skin infection like impetigo about one 00:18:47.099 --> 00:18:49.220 to three weeks ago. Right. The body did what 00:18:49.220 --> 00:18:51.359 it was supposed to. It made antibodies. It fought 00:18:51.359 --> 00:18:53.640 off the strep. But those antibody antigen clumps, 00:18:53.700 --> 00:18:55.900 they get physically stuck in the kidney filter. 00:18:56.299 --> 00:18:58.539 Yes, they lodge in the glomerulus. It causes 00:18:58.539 --> 00:19:00.940 intense inflammation. And because the filter 00:19:00.940 --> 00:19:04.059 is completely clogged, they can't pee well. Wiguria. 00:19:04.250 --> 00:19:07.569 Low urine output. Exactly. And because they aren't 00:19:07.569 --> 00:19:09.970 peeing, all that fluid just backs up and stays 00:19:09.970 --> 00:19:12.890 in the bloodstream. Hypervolemia. Which leads 00:19:12.890 --> 00:19:15.210 to our number one critical assessment priority 00:19:15.210 --> 00:19:19.009 for APSGM. Hypertension. How dangerous are we 00:19:19.009 --> 00:19:21.509 talking with this blood pressure? It can be severe 00:19:21.509 --> 00:19:23.910 enough to cause hypertensive encephalopathy. 00:19:24.160 --> 00:19:28.099 which means seizures. Yes. So if you have a kid 00:19:28.099 --> 00:19:30.859 with APSGN who suddenly complains of a really 00:19:30.859 --> 00:19:34.619 bad headache or fuzzy vision or dizziness, that 00:19:34.619 --> 00:19:37.059 is a massive red flag. You need to check their 00:19:37.059 --> 00:19:39.019 blood pressure immediately. And the urine color 00:19:39.019 --> 00:19:40.960 here is our other big distinguishing factor, 00:19:40.980 --> 00:19:43.720 right? Yes. It's not frothy like nephrotic. It 00:19:43.720 --> 00:19:47.039 is tea colored or cola colored gross hematuria. 00:19:47.099 --> 00:19:49.500 Because the inflammation damages the capillary 00:19:49.500 --> 00:19:52.400 so much that red blood cells squeeze out. And 00:19:52.400 --> 00:19:54.779 as they squeeze through that inflamed filter, 00:19:54.819 --> 00:19:56.859 they get broken down. That breakdown is what 00:19:56.859 --> 00:19:59.339 turns the urine that dark brown color. So what's 00:19:59.339 --> 00:20:01.079 the treatment? Do we give steroids here too? 00:20:01.279 --> 00:20:03.579 No, because it's not a leaky membrane we need 00:20:03.579 --> 00:20:06.359 to seal. There's no magic pill to dissolve the 00:20:06.359 --> 00:20:09.119 clog. The body just has to clear it over time. 00:20:09.220 --> 00:20:11.549 So it's all supportive care. Strictly supportive. 00:20:11.769 --> 00:20:14.150 We manage the blood pressure very aggressively 00:20:14.150 --> 00:20:17.329 with antihypertensives, things like hydralazine 00:20:17.329 --> 00:20:20.269 or nifidapine. And we restrict their fluids and 00:20:20.269 --> 00:20:22.430 their salt intake so we don't add to the fluid 00:20:22.430 --> 00:20:24.930 overload. Exactly. And we monitor them closely 00:20:24.930 --> 00:20:27.750 for those neurological changes that would signal 00:20:27.750 --> 00:20:31.069 a seizure. Developmentally, I saw that bed rest 00:20:31.069 --> 00:20:34.190 is often required during the acute phase of APS 00:20:34.190 --> 00:20:36.410 -GN. Yeah, especially when that blood pressure 00:20:36.410 --> 00:20:39.430 is sky high. We want them resting quietly. But 00:20:39.430 --> 00:20:41.190 try telling an energetic five -year -old that 00:20:41.190 --> 00:20:42.910 they have to stay in bed all day when they really 00:20:42.910 --> 00:20:45.029 don't feel that sick anymore. It is a constant 00:20:45.029 --> 00:20:47.029 battle. This is where nursing creativity comes 00:20:47.029 --> 00:20:49.750 in. You need heavy distraction techniques. Quiet 00:20:49.750 --> 00:20:52.710 play, coloring books, puzzles. And yes, this 00:20:52.710 --> 00:20:55.170 is a time when unlimited screen time is perfectly 00:20:55.170 --> 00:20:57.289 acceptable. Let the iPad do the heavy lifting. 00:20:57.869 --> 00:21:00.579 Exactly. Okay, moving on to one of the scariest 00:21:00.579 --> 00:21:05.619 acronyms in all of pediatrics, HUS hemolytic 00:21:05.619 --> 00:21:08.059 uremic syndrome. This is the dangerous sequel 00:21:08.059 --> 00:21:10.220 to the hamburger disease. It's usually caused 00:21:10.220 --> 00:21:16.019 by E. coli 0157 HH7, often from undercooked ground 00:21:16.019 --> 00:21:19.339 beef, unpasteurized apple cider, or trips to 00:21:19.339 --> 00:21:21.849 a petting zoo. Petting zoos are a classic board 00:21:21.849 --> 00:21:24.329 question set up for HUS. It sounds like the setup 00:21:24.329 --> 00:21:27.390 to a horror movie. What is the triad we absolutely 00:21:27.390 --> 00:21:30.250 have to memorize for this? Three things. One, 00:21:30.690 --> 00:21:35.029 hemolytic anemia. Two, thrombocytopenia. And 00:21:35.029 --> 00:21:38.789 three, acute kidney injury. Break down that patho 00:21:38.789 --> 00:21:41.390 for us in really plain English. How does eating 00:21:41.390 --> 00:21:43.869 a bad burger cause all three of those things 00:21:43.869 --> 00:21:46.480 to happen? OK, so you. In just the bacteria, 00:21:46.619 --> 00:21:48.799 the bacteria sets up shop in your gut and releases 00:21:48.799 --> 00:21:51.720 a very potent toxin. Sheega toxin. Right. That 00:21:51.720 --> 00:21:53.579 toxin enters the bloodstream and attacks the 00:21:53.579 --> 00:21:55.519 endothelial lining of the small blood vessels, 00:21:55.779 --> 00:21:57.980 specifically the tiny vessels inside the kidneys. 00:21:58.200 --> 00:22:00.819 Damages the vessel wall. Yes. And the body tries 00:22:00.819 --> 00:22:03.059 to fix that damage by sending platelets to plug 00:22:03.059 --> 00:22:04.980 the holes. So you get thousands of these tiny 00:22:04.980 --> 00:22:07.160 little microclots forming all over the kidney 00:22:07.160 --> 00:22:08.880 vessels. And because the body's using up all 00:22:08.880 --> 00:22:11.359 those platelets to make these tiny clots, The 00:22:11.359 --> 00:22:14.279 platelet count drops. Boom! Prombocytopenia. 00:22:14.480 --> 00:22:16.660 OK, that's one. Then your red blood cells are 00:22:16.660 --> 00:22:19.140 circulating. They try to squeeze through these 00:22:19.140 --> 00:22:22.319 narrow, clot -filled kidney vessels. And they 00:22:22.319 --> 00:22:25.079 get shredded on the clots. Like slicing a water 00:22:25.079 --> 00:22:28.019 balloon through a cheese grater. They are mechanically 00:22:28.019 --> 00:22:30.500 destroyed. That is the hemolytic anemia. Hemolysis 00:22:30.500 --> 00:22:33.779 literally means breaking blood. That is a terrifyingly 00:22:33.779 --> 00:22:36.720 clear image. And then the third part, the AKI. 00:22:36.819 --> 00:22:38.940 Well, because the kidney vessels are completely 00:22:38.940 --> 00:22:41.819 clogged with all these time tiny clots and shredded 00:22:41.819 --> 00:22:44.960 red blood cell debris. Blood flow stops. The 00:22:44.960 --> 00:22:49.200 nephrons die. The kidneys shut down. Acute kidney 00:22:49.200 --> 00:22:52.119 injury. Wow. And the critical intervention here. 00:22:52.299 --> 00:22:54.940 The need -to -know safety point is what we talked 00:22:54.940 --> 00:22:57.160 about in the patterns. What do we absolutely 00:22:57.160 --> 00:22:59.740 avoid doing? You do not give antibiotics for 00:22:59.740 --> 00:23:01.839 the initial bloody diarrhea. Because killing 00:23:01.839 --> 00:23:04.660 the bacteria releases a massive wave of that 00:23:04.660 --> 00:23:07.339 Shiga toxin all at once, which just accelerates 00:23:07.339 --> 00:23:09.400 the vessel damage. Exactly. It throws gas on 00:23:09.400 --> 00:23:12.079 the fire. You also do not give anti -motility 00:23:12.079 --> 00:23:14.819 drugs like Imodium. Why not? If they have severe 00:23:14.819 --> 00:23:17.069 diarrhea, shouldn't we stop it? No, you want 00:23:17.069 --> 00:23:19.369 that diarrhea to get the bacteria out of the 00:23:19.369 --> 00:23:21.970 gut. If you freeze the gut with Imodium, the 00:23:21.970 --> 00:23:24.289 bacteria just sit there multiplying and pumping 00:23:24.289 --> 00:23:26.990 more toxin into the blood. So again, it's mostly 00:23:26.990 --> 00:23:29.390 supportive care. Very intense supportive care. 00:23:29.650 --> 00:23:32.329 Many of these kids require temporary hemodialysis 00:23:32.329 --> 00:23:34.549 to let the kidneys rest and clear the toxins. 00:23:34.650 --> 00:23:36.410 And they probably need blood transfusions for 00:23:36.410 --> 00:23:39.859 that severe anemia. Yes. packed red blood cells, 00:23:40.380 --> 00:23:43.339 and strict seizure precautions because the profound 00:23:43.339 --> 00:23:46.079 electrolyte shifts from the kidney failure can 00:23:46.079 --> 00:23:48.500 easily irritate the brain. Let's talk about the 00:23:48.500 --> 00:23:51.500 developmental impact of HUS. It is deeply traumatic 00:23:51.500 --> 00:23:53.819 for the child and the family. It happens so suddenly. 00:23:54.279 --> 00:23:56.519 One day they're at a petting zoo. Three days 00:23:56.519 --> 00:23:59.259 later they are on dialysis in the ICU. And because 00:23:59.259 --> 00:24:01.700 it's fundamentally a foodborne illness, I imagine 00:24:01.700 --> 00:24:04.380 it creates major psychological issues around. 00:24:04.509 --> 00:24:07.609 eating. Massive issues. If a child ends up on 00:24:07.609 --> 00:24:10.490 dialysis, their diet becomes incredibly restricted. 00:24:10.730 --> 00:24:13.750 Low sodium, low potassium, low phosphorus. Which 00:24:13.750 --> 00:24:16.910 means no bananas, no potatoes, no dairy, no processed 00:24:16.910 --> 00:24:19.910 foods. Right. For a toddler who is naturally 00:24:19.910 --> 00:24:22.150 in that picky eating phase where they only want 00:24:22.150 --> 00:24:25.170 mac and cheese and hot dogs, this new diet becomes 00:24:25.170 --> 00:24:28.289 an absolute battleground. It is incredibly stressful 00:24:28.289 --> 00:24:31.349 for the parents. Let's shift gears from the chemistry 00:24:31.349 --> 00:24:33.170 of the kidneys back to the physical plumbing 00:24:33.170 --> 00:24:36.410 structures. Bladder Extrophy. This is a major 00:24:36.410 --> 00:24:38.410 structural defect. This is the one where the 00:24:38.410 --> 00:24:40.349 baby is born with the bladder completely outside 00:24:40.349 --> 00:24:42.930 the body, right? Yes. It is literally inside 00:24:42.930 --> 00:24:46.269 out and exposed flat on the lower abdomen. It's 00:24:46.269 --> 00:24:48.769 a failure of the abdominal wall to fuse during 00:24:48.769 --> 00:24:50.930 fetal development. So when the baby is born, 00:24:51.089 --> 00:24:55.769 you just see this bright red, moist, mucosal 00:24:55.769 --> 00:24:57.910 tissue sitting on their stomach. Yes. What is 00:24:57.910 --> 00:25:02.079 the immediate day one nursing? priority in the 00:25:02.079 --> 00:25:04.079 delivery room. You have to protect that nukosa. 00:25:04.299 --> 00:25:07.140 You cover the exposed bladder with spiral plastic 00:25:07.140 --> 00:25:09.680 wrap or a specialized non -adherent dressing. 00:25:09.819 --> 00:25:11.920 Why plastic wrap? Because you have to keep it 00:25:11.920 --> 00:25:13.920 perfectly moist. You do not want it to dry out 00:25:13.920 --> 00:25:16.000 and you don't want it to stick to a regular gauze 00:25:16.000 --> 00:25:18.759 pad. If that delicate tissue dries out, it cracks, 00:25:19.059 --> 00:25:21.740 it bleeds, and it gets infected instantly. And 00:25:21.740 --> 00:25:23.920 we mentioned the strict latex rule for these 00:25:23.920 --> 00:25:27.079 kids earlier. Mandatory latex avoidance from 00:25:27.079 --> 00:25:29.190 the second they are born. They're going to have 00:25:29.190 --> 00:25:31.950 multiple massive reconstructive surgeries. Their 00:25:31.950 --> 00:25:34.529 exposure risk is just too high. What about the 00:25:34.529 --> 00:25:36.950 post -op care once they start doing those reconstructions? 00:25:37.049 --> 00:25:40.410 He will have catheters, stents, suprapubic tubes 00:25:40.410 --> 00:25:43.769 everywhere. A major, major issue post -op is 00:25:43.769 --> 00:25:46.480 bladder spasms. Because the bladder muscle is 00:25:46.480 --> 00:25:48.359 angry that it got cut and sewn back together? 00:25:48.539 --> 00:25:51.180 Exactly. And those spasms are excruciatingly 00:25:51.180 --> 00:25:53.579 painful. What's worse is that a strong spasm 00:25:53.579 --> 00:25:55.880 can actually pop the delicate surgical stitches 00:25:55.880 --> 00:25:58.579 or push a stent right out. So how do we prevent 00:25:58.579 --> 00:26:01.849 that? We give them oxybutynin. It's an antispasmodic 00:26:01.849 --> 00:26:03.990 medication. We'll cover the details in the med 00:26:03.990 --> 00:26:06.349 module, but it basically paralyzes that smooth 00:26:06.349 --> 00:26:09.069 muscle so it can heal. Let's touch on hypospadias 00:26:09.069 --> 00:26:11.210 next. This is much more common than excessstrophy. 00:26:11.269 --> 00:26:13.829 Very common. It's the ventral placement of the 00:26:13.829 --> 00:26:16.710 urethral metis. The hole is on the underside 00:26:16.710 --> 00:26:19.210 of the penile shaft instead of right at the tip. 00:26:19.329 --> 00:26:22.069 And again, the golden rule. No circumcision in 00:26:22.069 --> 00:26:24.900 the newborn nursery. Saved the foreskin for the 00:26:24.900 --> 00:26:27.420 urologist to use for the reconstruction. When 00:26:27.420 --> 00:26:29.700 do they usually do that surgery? Usually around 00:26:29.700 --> 00:26:32.299 6 to 12 months of age. Is there a developmental 00:26:32.299 --> 00:26:36.130 reason for picking that specific window? Absolutely. 00:26:36.349 --> 00:26:38.710 We want to complete the reconstruction before 00:26:38.710 --> 00:26:41.450 the child's window of body image awareness really 00:26:41.450 --> 00:26:44.309 opens up. Castration anxiety is a real psychological 00:26:44.309 --> 00:26:47.230 phase, right? It was. Around age two or three, 00:26:47.230 --> 00:26:49.309 they become very protective of their genitals. 00:26:49.829 --> 00:26:52.190 Surgery, then, is much more psychologically traumatic. 00:26:52.369 --> 00:26:55.210 Plus, you absolutely want this fixed before you 00:26:55.210 --> 00:26:57.170 attempt toilet training. Right, because you can't 00:26:57.170 --> 00:26:59.690 potty train a little boy who has to sit down 00:26:59.690 --> 00:27:02.150 to pee if all his friends are standing. Or if 00:27:02.150 --> 00:27:04.890 his urinary stream shoots off at a strange downward... 00:27:04.809 --> 00:27:07.190 angle. It sets them up for failure and shame. 00:27:07.509 --> 00:27:10.910 Now there is a very specific almost strange nursing 00:27:10.910 --> 00:27:14.809 procedure for these babies post -op. Double diapering. 00:27:15.029 --> 00:27:16.750 Can you explain that to listener who has never 00:27:16.750 --> 00:27:19.250 seen it done? It sounds weird but it's brilliant. 00:27:19.450 --> 00:27:21.509 It is exactly what it sounds like. You have a 00:27:21.509 --> 00:27:24.009 baby who just had urethral surgery. They have 00:27:24.009 --> 00:27:26.230 a delicate little stent coming out of their penis 00:27:26.230 --> 00:27:28.589 to keep the new urethra open while it heals. 00:27:28.869 --> 00:27:31.609 Okay. You absolutely have to keep stool away 00:27:31.609 --> 00:27:34.849 from that stent to prevent a catastrophic infection. 00:27:35.069 --> 00:27:37.150 So how does double diapering do that? You take 00:27:37.150 --> 00:27:40.130 a small diaper, like a preemie or newborn size. 00:27:40.490 --> 00:27:42.849 You cut a hole in the front of it. OK. You put 00:27:42.849 --> 00:27:45.690 that small diaper on the baby. But you gently 00:27:45.690 --> 00:27:48.190 pull the penis on the stent through that hole 00:27:48.190 --> 00:27:50.309 so they're resting on the outside of the diaper. 00:27:50.609 --> 00:27:52.710 So the penis is completely separated from the 00:27:52.710 --> 00:27:55.109 area where the baby poops. Exactly. That inner 00:27:55.109 --> 00:27:58.039 diaper catches all the stool. Then you take a 00:27:58.039 --> 00:28:00.759 much larger diaper, maybe size two, and you put 00:28:00.759 --> 00:28:04.000 it on over the whole thing. Ah. And that outer, 00:28:04.140 --> 00:28:06.339 larger diaper catches the urine draining from 00:28:06.339 --> 00:28:08.940 the stent. Right. It isolates the feces from 00:28:08.940 --> 00:28:12.160 the surgical site. It is a brilliant, low -tech 00:28:12.160 --> 00:28:15.720 way to prevent infection. That is so smart. Okay, 00:28:15.720 --> 00:28:17.759 let's jump into the scrotal and reproductive 00:28:17.759 --> 00:28:19.980 disorders. We talked about testicular torsion 00:28:19.980 --> 00:28:23.660 being a massive emergency. Sudden, severe unilateral 00:28:23.660 --> 00:28:26.460 scrotal pain, usually accompanied by nausea and 00:28:26.460 --> 00:28:29.170 vomiting. And if you assess them, the affected 00:28:29.170 --> 00:28:31.250 side of the scrotum might be elevated and swollen. 00:28:31.710 --> 00:28:34.809 But the absolute key sign you mentioned was the 00:28:34.809 --> 00:28:37.589 absence of the cremasteric reflex. Yes, that 00:28:37.589 --> 00:28:40.470 is the diagnostic hallmark on a physical exam. 00:28:40.650 --> 00:28:42.970 Remind everyone what that reflex is. Normally, 00:28:42.990 --> 00:28:45.109 if you take your finger or a tongue depressor 00:28:45.109 --> 00:28:47.410 and lightly stroke the inside of the patient's 00:28:47.410 --> 00:28:50.490 upper thigh, the testicle on that same side will 00:28:50.490 --> 00:28:53.250 physically pull upward. It's a protective reflex 00:28:53.250 --> 00:28:56.849 against cold or trauma. Right. But in torsion... 00:28:56.809 --> 00:28:59.430 The spermatic cord is twisted so tightly that 00:28:59.430 --> 00:29:01.549 the testicle is essentially locked in place it 00:29:01.549 --> 00:29:03.789 cannot pull up. The reflex is absent. And we 00:29:03.789 --> 00:29:06.210 have a very strict time limit here. Six to eight 00:29:06.210 --> 00:29:09.309 hours maximum from the onset of pain before the 00:29:09.309 --> 00:29:12.069 testicle suffers irreversible necrosis and dies. 00:29:12.170 --> 00:29:14.470 So this kid needs to be NPO immediately and you 00:29:14.470 --> 00:29:16.670 are prepping them for the OR. Don't wait for 00:29:16.670 --> 00:29:18.849 an ultrasound if the clinical picture is obvious. 00:29:19.170 --> 00:29:21.509 Time is testicle. What about cryptorchidism? 00:29:22.210 --> 00:29:24.440 Undescended testicles. Much less of an acute 00:29:24.440 --> 00:29:28.160 emergency, but it has huge long -term implications. 00:29:29.740 --> 00:29:32.500 Normally, testicles drop into the scrotum before 00:29:32.500 --> 00:29:35.039 birth or shortly after. What if they don't? If 00:29:35.039 --> 00:29:37.339 they haven't ascended by 12 months of age, we 00:29:37.339 --> 00:29:39.940 go in surgically and bring them down. That procedure 00:29:39.940 --> 00:29:42.400 is called an orchaeopexy. Why can't we just leave 00:29:42.400 --> 00:29:44.319 them up in the abdomen? Do they really need to 00:29:44.319 --> 00:29:47.230 be in the scrotum? They absolutely do. The internal 00:29:47.230 --> 00:29:49.589 body temperature of the abdomen is simply too 00:29:49.589 --> 00:29:52.710 high. Testicles need to be slightly cooler than 00:29:52.710 --> 00:29:55.150 core body temperature to function properly. So 00:29:55.150 --> 00:29:58.769 the heat damages them. Yes. Long -term exposure 00:29:58.769 --> 00:30:01.970 to that core heat causes permanent infertility. 00:30:02.430 --> 00:30:05.069 It destroys the sperm -producing cells. Wow. 00:30:05.349 --> 00:30:08.230 And even worse, an undescended testicle has a 00:30:08.230 --> 00:30:10.950 significantly dramatically higher risk of developing 00:30:10.950 --> 00:30:13.289 testicular cancer later in life. So we bring 00:30:13.289 --> 00:30:15.690 them down to keep them cool. Preserve fertility 00:30:15.690 --> 00:30:18.430 and lower the cancer risk. Exactly. What about 00:30:18.430 --> 00:30:20.730 fomosis and parafomosis? I always get these two 00:30:20.730 --> 00:30:23.230 confused. You aren't the only one. Fomosis is 00:30:23.230 --> 00:30:25.390 simply a tight foreskin that cannot be pulled 00:30:25.390 --> 00:30:27.430 back. Which is actually completely normal in 00:30:27.430 --> 00:30:30.089 newborns and infants, right? Yes, physiological 00:30:30.089 --> 00:30:33.919 fomosis is normal. You never ever... forcefully 00:30:33.919 --> 00:30:37.359 retract a baby's foreskin. It will tear and scar. 00:30:37.460 --> 00:30:39.859 It naturally loosens over several years. OK, 00:30:39.940 --> 00:30:43.259 so that's phimosis. What is parafimosis? Parafimosis 00:30:43.259 --> 00:30:46.119 is a medical emergency. This is when the foreskin 00:30:46.119 --> 00:30:48.759 has been retract, pulled back behind the head 00:30:48.759 --> 00:30:50.519 of the penis, but then it gets stuck there. It 00:30:50.519 --> 00:30:52.619 can't be pulled back forward. So it acts like 00:30:52.619 --> 00:30:55.039 a rubber band. Exactly. It creates a tourniquet 00:30:55.039 --> 00:30:57.160 effect. It cuts off the venous blood flow. The 00:30:57.160 --> 00:30:59.720 head of the penis swells massively. And if it 00:30:59.720 --> 00:31:02.269 isn't reduced quickly, you get ischemia. Ouch. 00:31:02.849 --> 00:31:06.109 So, phimosis is tight, but usually normal. Paraphimosis 00:31:06.109 --> 00:31:09.230 is stuck and an emergency. Perfect summary. Okay, 00:31:09.250 --> 00:31:11.450 let's talk about the end game for all these kidney 00:31:11.450 --> 00:31:14.750 issues if things go wrong. Renal failure. Let's 00:31:14.750 --> 00:31:19.150 start with AKI, acute kidney injury. In pediatrics, 00:31:19.309 --> 00:31:21.849 the vast majority of AKI is what we call pre 00:31:21.849 --> 00:31:24.230 -renal. Meaning the problem is happening before 00:31:24.230 --> 00:31:26.650 the blood even gets to the kidney. Right. The 00:31:26.650 --> 00:31:29.349 kidney itself is perfectly healthy, but it is 00:31:29.349 --> 00:31:31.309 starving because it's not getting enough blood 00:31:31.309 --> 00:31:33.109 flow. And what's the number one cause of that 00:31:33.109 --> 00:31:36.569 in kids? Severe dehydration, usually from a bad 00:31:36.569 --> 00:31:39.569 case of gastroenteritis. The stomach bug. So 00:31:39.569 --> 00:31:41.750 a kid who has been throwing up for three days 00:31:41.750 --> 00:31:44.740 is at risk for acute kidney injury. Absolutely. 00:31:45.180 --> 00:31:47.660 Because their intravascular volume is so depleted, 00:31:47.880 --> 00:31:50.000 the blood pressure drops and the kidneys stop 00:31:50.000 --> 00:31:52.720 filtering. If they stop paying oliguria and their 00:31:52.720 --> 00:31:55.579 BUN and creatinine start shooting up, that is 00:31:55.579 --> 00:31:58.559 pre -renal AKI. So the priority intervention 00:31:58.559 --> 00:32:01.339 is pretty straightforward, then. Fluid resuscitation. 00:32:01.460 --> 00:32:04.759 Fill the tank. Give them IV normal saline boluses 00:32:04.759 --> 00:32:06.960 to restore that perfusion pressure to the kidneys. 00:32:07.359 --> 00:32:09.420 What is the most dangerous electrolyte imbalance 00:32:09.420 --> 00:32:11.380 we need to watch for while their kidneys are 00:32:11.380 --> 00:32:14.359 shut down? Hyperkalemia. High potassium. Because 00:32:14.359 --> 00:32:16.019 the kidneys are the only way the body gets rid 00:32:16.019 --> 00:32:18.319 of excess potassium. And high potassium is a 00:32:18.319 --> 00:32:21.079 cardiac killer. Yes. It stops the heart. If you 00:32:21.079 --> 00:32:23.740 see a potassium level of 6 .5 or 7 on the lab 00:32:23.740 --> 00:32:25.859 report, you need to act immediately. What are 00:32:25.859 --> 00:32:27.900 the clinical signs of that before the heart stops. 00:32:28.119 --> 00:32:31.240 Weak pulse, severe muscle cramps, and eventually 00:32:31.240 --> 00:32:33.779 cardiac arrhythmias on the monitor. Peaked T 00:32:33.779 --> 00:32:36.319 waves are the classic early sign. OK, moving 00:32:36.319 --> 00:32:39.500 from acute to chronic. End -stage kidney disease 00:32:39.500 --> 00:32:43.720 or ESKD. The focus here shifts from quick fixes 00:32:43.720 --> 00:32:47.539 to lifetime management. Yes. The kidneys are 00:32:47.539 --> 00:32:49.839 permanently failing. What are the big developmental 00:32:49.839 --> 00:32:53.519 hits for a child with ESKD? The most profound 00:32:53.519 --> 00:32:56.380 impact is on their physical growth. Because kidneys 00:32:56.380 --> 00:32:59.059 do more than just filter pee. Right. They are 00:32:59.059 --> 00:33:02.059 actually vital endocrine glands. The kidneys 00:33:02.059 --> 00:33:04.680 produce a hormone called erythropoietin, which 00:33:04.680 --> 00:33:07.019 tells the bone marrow to make red blood cells. 00:33:07.339 --> 00:33:10.980 So kids with ESKD are chronically severely anemic. 00:33:11.140 --> 00:33:14.250 Yes. They are exhausted all the time. The kidneys 00:33:14.250 --> 00:33:17.049 also activate vitamin D, which is essential for 00:33:17.049 --> 00:33:19.089 absorbing calcium and building strong bones. 00:33:19.210 --> 00:33:21.529 So without that active vitamin D, their bones 00:33:21.529 --> 00:33:23.509 become weak. They develop a condition called 00:33:23.509 --> 00:33:26.410 renal osteodystrophy, or renal rickets. Their 00:33:26.410 --> 00:33:28.809 bones literally demineralize. So between the 00:33:28.809 --> 00:33:30.670 anemia and the bone disease, they just stop growing. 00:33:30.769 --> 00:33:32.650 They fall completely off the growth chart, they 00:33:32.650 --> 00:33:34.910 end up profoundly short in stature, and their 00:33:34.910 --> 00:33:37.069 puberty is severely delayed. How do we treat 00:33:37.069 --> 00:33:40.730 that? Aggressively. We give them synthetic erythropoietin 00:33:40.730 --> 00:33:44.000 injections to fix the anemia. We give them active 00:33:44.000 --> 00:33:46.839 vitamin D, and we often have to give them daily 00:33:46.839 --> 00:33:49.339 human growth hormone injections just to try and 00:33:49.339 --> 00:33:51.460 keep them somewhat near the normal growth curve. 00:33:51.759 --> 00:33:54.160 That is a massive medical burden for a child. 00:33:54.410 --> 00:33:57.150 And then there's dialysis. Right. To keep them 00:33:57.150 --> 00:33:59.089 alive until they can get a kidney transplant, 00:33:59.369 --> 00:34:03.150 they need dialysis. But in pediatrics, we strongly 00:34:03.150 --> 00:34:06.309 prefer peritoneal dialysis over hemodialysis 00:34:06.309 --> 00:34:08.889 whenever possible. Why is PD better for kids? 00:34:09.210 --> 00:34:11.329 Because of the developmental and psychosocial 00:34:11.329 --> 00:34:13.809 impact. Hemodialysis requires them to go to a 00:34:13.809 --> 00:34:15.909 clinic, right? Yes. Three or four days a week 00:34:15.909 --> 00:34:18.500 for three to four hours at a time. They are hooked 00:34:18.500 --> 00:34:21.440 up to a massive machine. It makes them feel very 00:34:21.440 --> 00:34:24.260 sick, washed out, and most importantly, it severely 00:34:24.260 --> 00:34:26.360 interferes with their ability to attend school. 00:34:26.559 --> 00:34:28.639 They miss out on being a normal kid. Exactly. 00:34:29.000 --> 00:34:31.420 They lose their friends. They fall behind academically. 00:34:31.679 --> 00:34:34.280 And peritoneal dialysis avoids that. Peritoneal 00:34:34.280 --> 00:34:36.980 dialysis can usually be done at home by the parents, 00:34:37.360 --> 00:34:40.019 overnight while the child is sleeping. Oh, wow. 00:34:40.400 --> 00:34:42.900 The machine just cycles the fluid in and out 00:34:42.900 --> 00:34:45.139 of their abdominal cavity while they are in bed. 00:34:45.300 --> 00:34:47.400 Right. So during the day, they're disconnected. 00:34:47.599 --> 00:34:49.500 They can go to school, play with their friends, 00:34:49.579 --> 00:34:52.500 and have a relatively normal social life. It 00:34:52.500 --> 00:34:54.980 gives them back their independence. That makes 00:34:54.980 --> 00:34:58.539 total sense. But PD must have its own risks. 00:34:59.019 --> 00:35:01.800 The biggest one is peritonitis. Infection of 00:35:01.800 --> 00:35:04.380 the peritoneal cavity. The parents have to be 00:35:04.380 --> 00:35:06.940 absolutely meticulous with their sterile technique 00:35:06.940 --> 00:35:10.929 when they connect and disconnect the bags. The 00:35:10.929 --> 00:35:14.230 classic sign is the effluent. The dialysate fluid 00:35:14.230 --> 00:35:16.570 that drains out of the belly into the waist bag 00:35:16.570 --> 00:35:19.309 should be clear, like light urine. If it looks 00:35:19.309 --> 00:35:21.670 cloudy, like someone poured milk into it, that 00:35:21.670 --> 00:35:24.469 is peritonitis. Cloudy effluent means go straight 00:35:24.469 --> 00:35:27.630 to the hospital. Do not pass go. They need IV 00:35:27.630 --> 00:35:30.230 antibiotics immediately. OK, we have covered 00:35:30.230 --> 00:35:33.550 a massive amount of disease patho. Let's do the 00:35:33.550 --> 00:35:35.809 medication module. This is where we cross -reference 00:35:35.809 --> 00:35:37.869 everything. Let's do it. I am going to throw 00:35:37.869 --> 00:35:40.599 a drug name at you from our source list. I want 00:35:40.599 --> 00:35:42.539 you to give you the rapid -fire need to know, 00:35:42.860 --> 00:35:45.059 the mechanism of action, and most importantly, 00:35:45.639 --> 00:35:49.239 the pediatric -specific pearl. Ready. First up, 00:35:49.659 --> 00:35:54.059 desmopressin, DDAVP. Okay, class is synthetic 00:35:54.059 --> 00:35:57.800 antidiuretic hormone, ADH. What's the main pediatric 00:35:57.800 --> 00:36:01.159 indication? Nocturnal inuresis, severe bedwetting. 00:36:01.340 --> 00:36:04.050 How does it work? It acts directly on the kidneys, 00:36:04.110 --> 00:36:06.309 telling them to reabsorb water and concentrate 00:36:06.309 --> 00:36:08.889 the urine, which significantly reduces the volume 00:36:08.889 --> 00:36:11.130 of urine produced overnight. In the pediatric 00:36:11.130 --> 00:36:13.329 pearl, the big safety warning. You must treat 00:36:13.329 --> 00:36:16.789 DDAVP almost like a strict do -not -drink order. 00:36:16.889 --> 00:36:19.250 Why? Because the medication is telling the kidneys 00:36:19.250 --> 00:36:21.690 to hold on to all the water. If you give a kid 00:36:21.690 --> 00:36:23.789 this nasal spray at bedtime and then they chug 00:36:23.789 --> 00:36:26.949 a massive liter of water or Gatorade, their body 00:36:26.949 --> 00:36:29.150 will retain every drop of it. Which leads to 00:36:29.150 --> 00:36:31.769 fluid overload. Worse, it leads to water intoxication. 00:36:31.630 --> 00:36:34.889 and severe hyponatremia. The sodium in their 00:36:34.889 --> 00:36:37.690 blood gets diluted so much that it causes cerebral 00:36:37.690 --> 00:36:40.650 edema and seizures. So the parent education is 00:36:40.650 --> 00:36:43.250 absolutely crucial here. Give the med at bedtime 00:36:43.250 --> 00:36:46.630 and strictly restrict fluids after dinner. Yes. 00:36:46.949 --> 00:36:51.710 Next med, oxybutynin, brand name Detrovan. Class 00:36:51.710 --> 00:36:54.869 is anticholinergic and antispasmodic. We talked 00:36:54.869 --> 00:36:57.590 about this one for bladder spasms after hypospadias 00:36:57.590 --> 00:37:00.489 or extastrophe surgery. Right. Or for kids with 00:37:00.489 --> 00:37:03.050 a neurogenic bladder from spina bifida. A mechanism 00:37:03.050 --> 00:37:05.210 of action. It relaxes the smooth muscle of the 00:37:05.210 --> 00:37:07.929 detrusor, the bladder wall, stopping the spasms. 00:37:08.030 --> 00:37:09.909 And what's the pediatric parole we need to look 00:37:09.909 --> 00:37:12.449 out for? Anticholinergics draw you out. The classic 00:37:12.449 --> 00:37:15.130 adult phrase is can't see, can't pee, can't spit, 00:37:15.250 --> 00:37:17.070 can't stool. But how does that affect a child 00:37:17.070 --> 00:37:19.900 differently? The big pediatric safety risk is 00:37:19.900 --> 00:37:23.340 heat intolerance. Oxybutynin severely impairs 00:37:23.340 --> 00:37:26.320 the body's ability to sweat. Oh, wow. So if a 00:37:26.320 --> 00:37:28.980 child is on this medication and they are running 00:37:28.980 --> 00:37:31.179 around on a hot playground in the middle of July, 00:37:31.539 --> 00:37:34.219 they cannot cool themselves down. They can overheat 00:37:34.219 --> 00:37:36.780 and develop heat stroke very rapidly. That is 00:37:36.780 --> 00:37:38.679 a great safety point. What about the can't stool 00:37:38.679 --> 00:37:41.800 part? Constipation is a huge side effect. And 00:37:41.800 --> 00:37:44.380 remember our plumbing loop. Constipation leads 00:37:44.380 --> 00:37:47.820 to urinary stasis, which leads to UTIs. So if 00:37:47.820 --> 00:37:50.360 they get constipated from the oxybutynin, it 00:37:50.360 --> 00:37:52.500 defeats the whole purpose. So they need to be 00:37:52.500 --> 00:37:54.599 on a bowel regimen while taking it. Yes. All 00:37:54.599 --> 00:37:59.119 right, third medication, corticosteroids, specifically 00:37:59.119 --> 00:38:01.619 prednisone. Indication is nephrotic syndrome. 00:38:01.980 --> 00:38:04.980 We use high doses to induce remission and stop 00:38:04.980 --> 00:38:07.340 the massive protein leak. We talked about the 00:38:07.340 --> 00:38:09.039 side effects, the moon phase, the roid rage. 00:38:09.480 --> 00:38:12.119 What is the critical safety pearl for the exam? 00:38:12.230 --> 00:38:15.170 Infection risk is huge, obviously, but the biggest 00:38:15.170 --> 00:38:17.690 one is that it completely masks the normal signs 00:38:17.690 --> 00:38:20.309 of infection. Because it suppresses the inflammatory 00:38:20.309 --> 00:38:23.690 response. Exactly. A child on high dose steroids 00:38:23.690 --> 00:38:25.929 could have a raging, life -threatening infection, 00:38:26.190 --> 00:38:28.829 but they will not mount a fever. You cannot rely 00:38:28.829 --> 00:38:30.969 on a thermometer. You have to look for subtle 00:38:30.969 --> 00:38:33.610 signs like lethargy or behavior changes. And 00:38:33.610 --> 00:38:35.730 there's a hard rule about stopping the medication, 00:38:35.789 --> 00:38:38.030 right? And never ever stop prednisone abruptly. 00:38:38.449 --> 00:38:41.150 It causes an acute adrenal crisis. Because the 00:38:41.150 --> 00:38:43.409 body's own adrenal glands have essentially gone 00:38:43.409 --> 00:38:46.130 to sleep while taking the pills. Right. You have 00:38:46.130 --> 00:38:48.929 to taper the dose down very slowly over rinse 00:38:48.929 --> 00:38:51.550 to wake the adrenal glands back up so they start 00:38:51.550 --> 00:38:53.949 making their own cortisol again. Next on the 00:38:53.949 --> 00:38:57.849 list, intravenous albumin. Indication is severe 00:38:57.849 --> 00:39:01.030 refractory edema, usually in nephrotic syndrome. 00:39:01.110 --> 00:39:03.889 Mechanism of action. It massively increases the 00:39:03.889 --> 00:39:06.369 intravascular oncotic pressure. It acts like 00:39:06.369 --> 00:39:09.869 a giant... Super sponge. So it rapidly pulls 00:39:09.869 --> 00:39:12.489 all that third space fluid out of the puffy tissues 00:39:12.489 --> 00:39:14.530 and sucks it right back into the blood vessels. 00:39:14.809 --> 00:39:17.590 Yes. And the pediatric pearl. You have to monitor 00:39:17.590 --> 00:39:20.150 them incredibly closely during the infusion because 00:39:20.150 --> 00:39:22.989 you can easily overload their small hearts. Because 00:39:22.989 --> 00:39:25.309 you are pulling so much volume into the vascular 00:39:25.309 --> 00:39:27.929 space so quickly. Exactly. You watch for signs 00:39:27.929 --> 00:39:30.929 of sudden fluid overload, pulmonary edema. If 00:39:30.929 --> 00:39:32.909 they start coughing, if you hear crackles in 00:39:32.909 --> 00:39:35.190 their lungs, or if they have sudden respiratory 00:39:35.190 --> 00:39:37.599 distress, you stop. the infusion. And this leads 00:39:37.599 --> 00:39:40.619 right into our final medication, furosemide or 00:39:40.619 --> 00:39:43.380 LASIX. The classic loop diuretic. Indication 00:39:43.380 --> 00:39:46.659 is fluid overload like an APS -GN or to help 00:39:46.659 --> 00:39:49.099 clear the edema in nephrotic syndrome. Right. 00:39:49.380 --> 00:39:51.340 And there is a specific double -hit protocol 00:39:51.340 --> 00:39:54.139 we use in nephrotic syndrome. We usually give 00:39:54.139 --> 00:39:57.300 the IV albumin first. To pull all water from 00:39:57.300 --> 00:39:59.500 the tissues into the blood vessels. Exactly. 00:39:59.940 --> 00:40:02.280 And then, once the water is in the blood, we 00:40:02.280 --> 00:40:04.820 hit them with a dose of fibi -lasix. To force 00:40:04.820 --> 00:40:06.880 the kidneys to pee all that extra fluid out. 00:40:07.000 --> 00:40:09.780 It is a highly coordinated sequential attack 00:40:09.780 --> 00:40:12.400 on the edema. What are the safety pearls for 00:40:12.400 --> 00:40:15.619 lasix in kids? It is severely potassium wasting. 00:40:15.940 --> 00:40:18.719 You must monitor for hypokalemia, look for muscle 00:40:18.719 --> 00:40:21.280 weakness or leg cramps. So they might need a 00:40:21.280 --> 00:40:24.480 potassium supplement or a diet high in bananas 00:40:24.480 --> 00:40:28.059 and leafy greens. Yes. And the second major safety 00:40:28.059 --> 00:40:31.960 point is ototoxicity. Hearing loss. Yes. If you 00:40:31.960 --> 00:40:35.420 push IV Lasix too fast into a small child's vein, 00:40:35.900 --> 00:40:38.599 it can cause permanent damage to the eighth cranial 00:40:38.599 --> 00:40:41.300 nerve. You must push it very slowly. OK, this 00:40:41.300 --> 00:40:43.460 has been an absolutely massive synthesis. Let's 00:40:43.460 --> 00:40:45.639 try to bring it all together in a final cross 00:40:45.639 --> 00:40:47.900 -linking summary. We can really see how all these 00:40:47.900 --> 00:40:50.059 disparate diseases connect now. Right, like the 00:40:50.059 --> 00:40:51.960 structural infection loop. If you have a plumbing 00:40:51.960 --> 00:40:55.159 problem like VUR or an obstruction, you get urinary 00:40:55.159 --> 00:41:00.139 stasis. Stasis leads to UTIs. UTIs cause. pilonephritis 00:41:00.139 --> 00:41:03.239 and renal scarring. And scarring leads to hypertension 00:41:03.239 --> 00:41:06.019 and chronic kidney disease later in life. So 00:41:06.019 --> 00:41:08.639 the overarching goal is to fix the structural 00:41:08.639 --> 00:41:11.480 plumbing early to save the kidney tissue. Perfect. 00:41:11.619 --> 00:41:13.739 Then there's the nephrotic management loop. You 00:41:13.739 --> 00:41:16.239 start with a leaky filter which causes massive 00:41:16.239 --> 00:41:20.000 edema. You use IVL Bumin to pull the fluid back 00:41:20.000 --> 00:41:22.960 into the vessels and Lasix to pee it out. Well, 00:41:23.000 --> 00:41:25.480 simultaneously giving high dose steroids to plug 00:41:25.480 --> 00:41:28.039 the leak in the filter. But those steroids create 00:41:28.039 --> 00:41:30.360 a massive infection risk. It's an incredibly 00:41:30.360 --> 00:41:33.239 delicate physiological balancing act. And finally, 00:41:33.420 --> 00:41:35.619 the growth and development loop. Any chronic 00:41:35.619 --> 00:41:39.139 kidney issue, like ESKD, means the child lacks 00:41:39.139 --> 00:41:42.199 erythropoietin and active vitamin D. Which causes 00:41:42.199 --> 00:41:44.840 severe anemia and bone demineralization, leading 00:41:44.840 --> 00:41:47.679 to stunted growth. So you absolutely must treat 00:41:47.679 --> 00:41:49.860 the growth and nutrition deficits aggressively 00:41:49.860 --> 00:41:51.920 with hormones to protect their developmental 00:41:51.920 --> 00:41:54.559 trajectory. It all connects. The physical plumbing 00:41:54.559 --> 00:41:57.179 dictates the chemistry. and the chemistry directly 00:41:57.179 --> 00:41:58.980 dictates the child's growth and development. 00:41:59.219 --> 00:42:01.599 Exactly. That is the holistic pediatric view. 00:42:01.960 --> 00:42:05.119 Okay. We are coming to the end of our deep dive. 00:42:05.579 --> 00:42:08.039 We have covered the swollen child, the plumbing 00:42:08.039 --> 00:42:11.139 emergencies, the kidney failures, and the meds 00:42:11.139 --> 00:42:13.420 that fix them all. We really have covered a lot 00:42:13.420 --> 00:42:15.780 of ground today. But before we sign off, I want 00:42:15.780 --> 00:42:17.860 to leave everyone listening with a final, more 00:42:17.860 --> 00:42:19.860 provocative thought. I love these. Let's hear 00:42:19.860 --> 00:42:22.280 it. We just spent an hour talking deeply about 00:42:22.280 --> 00:42:25.380 pee, anatomy, catheters, and bowel regimens. 00:42:25.820 --> 00:42:29.320 But I want you to step back and imagine being 00:42:29.320 --> 00:42:31.159 an eight -year -old child going through this. 00:42:31.320 --> 00:42:34.760 That is a tough age. It's the age of deep modesty. 00:42:35.760 --> 00:42:38.219 You are just becoming truly aware of your body 00:42:38.219 --> 00:42:41.420 and your privacy. And suddenly your most private 00:42:41.420 --> 00:42:44.059 parts are the subject of daily medical rounds. 00:42:44.300 --> 00:42:46.739 10 different strangers coming in to inspect your 00:42:46.739 --> 00:42:49.019 surgical sites. Exactly. Constant inspections, 00:42:49.260 --> 00:42:51.840 invasive catheters, multiple reconstructive surgeries. 00:42:51.960 --> 00:42:55.059 It is a profound loss of control. It is. Medical 00:42:55.059 --> 00:42:57.739 trauma isn't just about physical pain. It is 00:42:57.739 --> 00:43:00.440 often about a severe loss of dignity. So my thought 00:43:00.440 --> 00:43:02.400 for you to take into your next clinical shift 00:43:02.400 --> 00:43:07.280 is this. How do we as health care providers intentionally 00:43:07.280 --> 00:43:10.500 protect that child's dignity in a hospital system 00:43:10.500 --> 00:43:13.039 that is designed purely for clinical efficiency? 00:43:13.389 --> 00:43:16.429 That is a great question. Are we exposing them 00:43:16.429 --> 00:43:20.090 unnecessarily during an exam? Right. Are we explaining 00:43:20.090 --> 00:43:22.389 what we are going to do to them, using words 00:43:22.389 --> 00:43:24.510 they understand, or are we just talking over 00:43:24.510 --> 00:43:26.530 their heads to the parents while we prep the 00:43:26.530 --> 00:43:29.110 catheter tray? The clinical skill of preserving 00:43:29.110 --> 00:43:32.210 privacy is just as important as the actual physical 00:43:32.210 --> 00:43:34.889 skill of placing the catheter. I really believe 00:43:34.889 --> 00:43:38.130 that. Treat the whole child. Protect their mind, 00:43:38.369 --> 00:43:41.210 not just their bladder. That is a very powerful 00:43:41.210 --> 00:43:43.489 place to end. Thanks for taking this deep dive 00:43:43.489 --> 00:43:45.750 with us today. Keep those master patterns in 00:43:45.750 --> 00:43:48.429 your head for the exam. Frothy versus T -colored. 00:43:48.849 --> 00:43:51.789 Torsion is time. No antibiotics for HUS. You 00:43:51.789 --> 00:43:53.750 guys got this. See you on the next deep dive. 00:43:53.889 --> 00:43:54.349 Bye, everyone.