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Hello. Um We just give the phone a couple of minutes to uh make sure everyone's d joined and then more kick off. Uh If someone can let me know in the chat, if they can hear me and see my screen, that would be terrific. Hello, just checking, hear me. I see my screen. Hello. Hello, just checking. Can anyone hear me? I'll see my screen. Ok, great. Um It's five past uh seven hours. So we'll, we'll kick off now and anyone who joins can just join in as we're going along. Um So my name is uh Doctor Anil Sangera. Um a little bit quick background about me. Um I'm currently working as a local pediatric sho um in a variety of different hospitals for an agency. I've been doing this position for almost uh a year and a half now. Uh So actually in my F four here, that's actually a thing. Um And so that's about about me and today we're gonna be talking about um some common pediatric uh presentations and asked to see the patient Pediatric edition. Um So our objectives today hopefully are to gain some confidence in dealing with common pediatric presentations and to understand how to assess the common pediatric presentation and the kind of the approach we'll take towards that and then to understand how we initiate the management of common pediatric conditions. So it's gonna follow kind of two case studies um throughout the teaching session. Um, and we'll go through the cases and we'll explore kind of how we deal with these different scenarios um to help you to go along, you kind of need um something to write on to look at your computer to type some bits and bobs that on or a pencil and paper. Um It's completely our preference. Um But just to give us some bits, some, some questions I'm going to ask as we go along. Um So just a bit of a quick quiz to start us off with about some um some of the topics we're going to discuss in the um talk today. So, in your own time, I'll give you guys a couple of minutes to go through these um questions, um and try and answer them the best you can if you can't think of an answer, that's absolutely fine. Um That's kind of the point in this presentation today is that we're going to go through all these points and by the end, you should have 100% confidence that you can answer every one of these. Um So question one, if a child weigh 23 kg would be the daily requirement of fluids. And at what rate would you give that? At? Question two, what is the most acceptable range of saturations for most Children with bronchiolitis? Question number three. What concentration of glucose is used? Uh IV glucose in hyperglycemia. Question number four. What volume of fluid bolus would be given to a 10 kg child? Question number five. How does high flow work to improve a patient's ventilation? So I'll give you guys a couple of minutes to kind of jot down any answers to that, please. And at the end of the presentation, we'll go through all the answers and we'll kind of talk for everything again. But like I said, it doesn't matter if you don't know the answers to them. Now, that's the whole point of the presentation. We'll go through all the answers and the rationale to all of them throughout the cases that we're going to do. Um feel free to message in the chat throughout the presentation if you have any questions or don't understand something I've said. Um and I'm happy to go back through things and explain. I'll try to make it as interactive as possible. Terrific. So we will move on to the next bit. Um So for our first case, um you are the Fy one C in a pediatric assessment unit and your registrar has gone to A&E to see a patient requiring difficult access. The nursing team has just informed you that the um a patient of the measure up to the area has come in from the GP uh They are for your patient presenting with diarrhea and vomiting. Um You're busy finishing a discharge letter for patients on the ward who's ready to go home. And um, we need to ask ourselves, um, what we need to do um in the meantime, whilst we're doing that letter or what might be beneficial for us to do whilst we're doing that letter um to get started with patient management and, and assessment of the patient. So if you message on chat, if you have any ideas, what this might be, it's quite a common thing we do in pediatrics for anyone with similar symptoms. Any ideas at all? Ok. Um Oh, perfect. Thank you very much. Yeah, so perfect. So we're going to a fluid challenge. Um So the purpose of a fluid challenge um is to see if a child can tolerate kind of small and frequent amounts of fluid. Um I'm recording that input and output during this period of time. So practic in practical terms, what this really is is giving a child kind of a volume of 5 to 10 mils via a syringe um every kind of 5 to 10 minutes um whilst they're waiting to be seen. Um So this has got um a number of great benefits to it. So um this can really demonstrate and give an objective measure to see that you have a prolonged period of time where the child has been on the assessment unit and been able to tolerate or not been able to tolerate uh or fluids. Um So it can really help support your decision making, especially when you're thinking about kind of what management plan you want to go over with this child. And with that needs to be um supporting your discharging and your rationale for your discharge or supporting your rationale for admission and uh start of any treatments. Um We usually say the best kind of um fluid to give at these points in time is usually an oral rehydration solution. Um but in practicalities, a lot of the time it might just be kind of juice or squash. Um but ideally something with kind of salts and sugars in to make sure that um needs are most accurately met um because we don't want that kind of a hypoglycemia happening. That's fantastic. Um So in our first case, we have um a four year old girl called Debbie. Um Debbie weighs 15 kg and is coming in with mum and she's coming in with diarrhea and vomiting. So um I'll give you guys a minute. But what, what I want you to do is to kind of think about five things we might want to ask in our focus, focus assessment. Um and kind of what three differentials we might be thinking about at this point in time and trying to focus your questions towards excluding some of those differentials. So, like I said, I'll give you a couple of minutes to just kind of jot down anything you want there. That's five things you want to ask further and three differentials at this point in time and then I'll go through some of the common differentials and then we'll go through a full history as well. Ok, fantastic. We will move on. Um, so some of the differentials you might have at this point, you might be considering things like a gastroenteritis. You might be considering uh differentials like um Celiac disease, Crohn's ulcerative colitis. Um potentially might be considering things like malrotation or um appendicitis even or even you could be considering something like a constipation with features of overflow as well. So those are some of the more common differentials you might be thinking about at this point in time. So the rest of the history of the present complaint is mum reports that Sarah's had diarrhea for six days now and vomiting for four days, she's passing up to six stores of watery consistency a day with no blood and no mucus. She's passed urine once today. And prior to this, you put open bar is normally with a type four stool. She's been having some abdominal pain intermittently but been unable to describe this any further. She's been lethargic, she's been parial, there's no preceding history of any illnesses or foreign travel. Prior to this illness, she's up to date on all of her scheduled vaccinations. She has no relevant birth history and otherwise have been developing well and gaining weight, tracking along her centiles. One of my siblings at home has been unwell with similar symptoms but less severe. So, what might, uh, most likely differential will be at this point? And I'll just pop a pole into the group for this one here. Fabulous. Yeah. Um, so our most likely differential at this point is probably going to be gastroenteritis. Um So a lot of things in this history to kind of support that even before we've done our examination. Um So things to spot this. So prior to this, um to this episode, she's been having normal stools. So that means it's unlikely to be elements of constipation with overflow. There's no foreign travel or um to suggest that there might be kind of a parasite involved in the case, um or other endemic organisms. Um She's fully vaccinated. Therefore, um she's less likely to have kind of a rotavirus. Um No birth history means that there's kind of no history of any uh necrotizing enterocolitis. So there's no short bowel syndrome or issues regarding that, the fact that she's gaining weight along her centile and this is a very acute presentation means it's less likely to be kind of a ulcerative colitis Crohn's or Celiac presentation because you usually have kind of a failure to five features in each of those. Um Aporia makes her less likely to have appendicitis and the fact that her sibling at home has similar symptoms, kind of makes her a differential of an infected nature much more likely. That's kind of our rational thinking here. We'll move on to her observations. So we've got a temperature of 37.2 heart rate of 120 respiratory rate of 28 BP of 90/60 saturation is 90% in there and no additional workup. You. So relatively normal observations, a slightly elevated heart rate for her age group. So then next, we've got our examination. Um So when we're approaching a child, um and this goes for, for every case that you'll see, we want to take an A to e examination like you will do in, in adults as well. Um So the initial approach is quite similar in that in an acute scenario, you don't move on from A until you've solved A and you don't move on from B until you solve B. So in this case, we've got um the airways Payton and her own still, she's got a clear chest, um equal air injury bilaterally, no wheezes, no crackles, no increase work of breathing. Her heart sounds are normal and her cap refill time is slightly prolonged. So it should be less than two seconds essentially and proliferate. And here we've got kind of equal to two seconds centrally and equal to three seconds peripherally. So, slightly prolonged there other features of dehydration, we've got is kind of cracked lips and sunken eyes and these are really common in Children as well. Um Other things we can look for is kind of skin turgor and other signs of dehydration like that. In younger ones, we can look at the anterior fontanelles. So this is the soft spot on the top of the head, um which usually closes by about 18 months old in most Children. Um So really useful in, in Children, younger than that age group if it hasn't already closed. Um And what a dehydrated child might have a sunken or depressed anterior fontanel. Um So that's a sunken or depressed anti might indicate um dehydration as well. But we're just kind of both in this picture of the patient to see as much evidence as we can to support our decision making. Um But the abdomen is soft, nontender, there's no signs of peritonism, no organically, no abdominal masses palpable. So here we've got an example of this child's uh fluid challenge. This is exactly how you might see it recorded in some places. Um It's very simple. It will just have times and the fluids um and the amount and the actual liquid that was given uh and any outputs at the time. So here we can see what she's had, they initially tolerated the first kind of 1520 meals, but then had to vomit. She refused uh one afterwards that and then had a second vomit afterwards. So she's in this case, in this um case, um she's not really tolerated that fluid challenge at all. Um So we need to think about kind of next steps. So with that in mind, uh I've got another second poll for us to go through about what's the next best steps for this patient's management. So we've got cyclizine IV fluids or NG feeds. So that's fab. So yeah. Um um first line of antiemetic in uh Children is usually on Dansetron. Um, we could consider IV fluids in this patient. You've got justifications to it, given that you've got feature of dehydration. I think it's sensible to try a or antiemetic in this patient as they're not unwell to the point where we be considering cannulation right now and we kind of avoid that as much as we can in pediatrics. It can be quite distressing for Children. Um, and for parents involved. So we'll do our best we can to avoid that. Um So the ones are usually our first line an, like I mentioned, but we could consider IV fluids and it wouldn't necessarily be wrong to be considering that at this point in time. Um, we can think about some other investigations to kind of support, um, what we might do next. So we can think about kind of doing a blood gas, um, doing a, a, um, BM, doing a urine dip or a stool MC NS to kind of support our next steps. Um, but in this instance, we're going to do a blood gas. Um, so this could be, uh, usually done from a capillary sample in, um, someone in this age group. Uh, I really commonly used in pediatrics, not as commonly used in kind of adult medicine as we tend to go for uh BBg S and ABG S to uh get eye glasses instead. Um, but we can usually do this from a kind of small toe or, or finger uh in the pediatric populations. Um One thing to note is that um sometimes we can see uh potassium and lactate values be kind of raised as a result of this because when we're taking the samples from the capillary, um we've often got to squeeze um the sample a little bit as well, especially in a dehydrated child. Uh and that might see an artificially raised potassium and lactate as a result of this. But in this gasp, we've got a ph of 7.38 pt two of 4.8 um A lactate of 1.6 a sodium of 148 potassium of 3.2 and it will increase of 4.5. So what we're seeing here is kind of features of um the case here. So uh sodium is slightly high um at 1.8. Um and this can be as a result of the dehydration that we might be experiencing. So that kind of reinforces that um our potassium is a little bit lower than normal. Our reference range is at 3.5 lowering the potassium. Um And this can be a result of kind of the the losses that we got. So that's the intenible losses of vomiting and diarrhea, which are rich in potassium and, and chloride. And our blood glucose here is 4.5. So um our normal reference range for for glucose, um this age group is above four. So we're happy with that blood glucose as well. But what if our blood sugar was 3.1? Um So if our patient had a glucose of 3.1 and still not able to keep anything down orally at the moment, um what would be the most appropriate way to correct this patient's hypoglycemia? So it's a little po for you guys um about what's the best way to treat this patient's hyperglycemia? Ok. Fantastic. Um This is a bit of a trickier question. Um Just because um I've written all the answers to sound very similar. Um um But in an acute scenario, this is um definitely something that we should be aware of. Um So the correct answer is to have give IV glucose 10% at 2.5 mL per kilogram. So that's IV glucose 10% at 2.5 mL per kilogram. So that's um as part of guidelines and the nice guidelines um in the UK um in this scenario, if we didn't have IV access we might be considering things like giving a buckle um dextrose gel in the meantime, or you could consider things like Im Glucagon if you don't have access or you're struggling to get access in a child. Um So that would be I A IV glucose at 10%. Uh 2.5 mils per kilo. I am Gluco or Dextros buck. Ok. So we're prescribed to for the child, but they're still vomiting after this and you want to prescribe some IV fluids for the patient. Patient weighs 15 k. So we're going to some um food prescriptions here. So I'll pop into a pole into the group. But at what rate of fluid would you prescribe for regular maintenance fluids for this child? We'll go through all the answers for both these and the kind of rationale after we did them both, but we'll just go for this. Now, I'll give you guys a minute to, to figure it out, feel free to use a calculator. Fantastic. And then what fluid would we give? And like I said, we will go through exactly the answers to this in the next slide. Fantastic. Ok. So for our first question, we got a 15 kg child. So the model we work off is 100 mills per kilo for the 1st 10 kg, 50 mils per kilo for the 2nd 10 kg and 20 miles per kilo for the remaining weight. So for a 15 kg child, our 1st 10 kg would be 100 miles per kilo, making that 1st 10 kg equal to 1000 mils. Our second five kms that we have would be measured at 50 mils per kilo. So that would be 250 mils. So that's 1000 at 250 gets us to 1250 divide that by 24 to get our rate for our maintenance fluids, um will give us 52 meals per hour. So again, just to go through that with a different example that we've got on the screen here. So for a child with 23 kg, at 1st 10 kg would be equal to 1000 mils. Our 2nd 10 kg would be equal to 500 mils because that's at 50 mils per kilo. And then our remaining weight is 20 kg 20 mg per kilogram. So that's an additional 60. So we get a value of 1560. And again, divide that by 24 to get the rate over the day. Um some of our examples on the screen, but for a child who's kind of 800 kg, we times that by 100 miles per kilo. So that's 800 mg uh milliliters, sorry. Um over the day to divide by that by 24 to get our rate. Um for our type of fluids, we want to make sure we're giving something with glucose and we're giving something with potassium, especially considering on our gas, our potassium was a little bit low. We're having continual losses. So we're going to be continually losing for the diarrhea and the vomiting still and those losses will be high in potassium anyway. So we want to get the naught 0.5 naught 0.9 sodium chloride, 5% glucose and 10% 10 millimoles of K cl per bag. We might consider giving kind of 20 millimoles, but this would be kind of in conjunction with a discussion with a senior. I would most likely to start at um 10 millimoles um for the first bag. Um But again, yeah, this would depend on the kind of clinical scenario at the time and the further trends of your potassium. Um Trying to remember kind of our daily fluid requirements for patients. Patients need kind of 50 to 100 g of glucose per day, one minimal of sodium and potassium to kind of maintain the um normal balance of electrolytes. Um But obviously, we've got diarrhea and vomiting. So we might also consider replacing glasses as well. Um But we not go into that kind of, we're not delve into that today. Um Not at this level anyway, um if our child was showing signs of more severe dehydration, so they might be showing any signs of kind of prolonged competitive refill time of 4 to 5 seconds. Further increase in the heart rate, a decrease in BP, sunken eyes dried cracked lips, reduced skin tiger. We might be considering kind of giving the child a bolus of fluid. Um So what volume of food bo might be given for a 15 kg child? Um My po for this has disappeared. So just have a think about um what um b you might give and I'll give you guys a second and then I'll talk for the answer. OK? Um So for a fluid bolus um we want to be giving 10 mL per kilogram. So in a 15 kg child, we will be getting 100 and 15 meals. Um So this was recently kind of updated in the last five years or so from the cancer guidelines, all guidelines said that it was a 20 mils per kilo bolus. Um But we've moved to kind of a 10 mL per kilogram bolus um with repeated doses rather than giving the initial 20 just to prevent um any overload complications. So 10 mL per kilogram and then reassess. So 100 and 50 mils and then reassess and give a fair about 100 and 50 mils if you think it's required at that point in time. Great. Um So our take points for our first case um will be our fluid challenges. So, initiating a fluid challenge for anyone you feel that might be dehydrated uh early is always beneficial. Um Just so you have the objective measure of how they're performing on the unit. So you can safely use that to discharge or start unjustified. Any further investigations you want to do trying all Ondansetron for a child to make sure we're avoiding um more invasive procedures. Um So avoiding doing buds in Children, um just to, just to avoid that distress, it causes them are fluid calculations for maintenance and for boluses. So again, that's that 100 mils per kilo for the 1st 10 kg, 50 mils per kilo for a 2nd 10 kg and 20 for the remaining weight. Um And then our bolus at 10 mils per kilogram and then repeat it if you require. Um I apologize if I'm just kind of repeating the same points again. But um just a really key take 10 point here for this presentation and then uh hypoglycemia um for a vomiting child. Again, that's 10% glucose at 2.5 mils per kilo. Some trusts might do two meals per kilo. Um But usually it's 2.5 but you'll have to check your own trust guidelines for that. We'll move on to the second case. Um So again, you are the fy one clerk in in the pediatric assessment unit. The nursing staff inform you that a patients come up from A&E appears to be working hard and ask you to review them. So this patient is called Blake. Um They are six months old. They weigh 6.8 kg, again, accompanied by mum and their chief complaint is an increased work of breathing and Blake's name was changed to Emily. I apologize for that. Um, but, um, Emily's found a report to the PD unit with a two day history of reduced feeding and coughing. She's been born full term and has been well before this illness over the last 24 hours, she appears to be working harder with her grieving and so her parents brought her to the assessment unit. Um, so at this point, um what are kind of if you wanna take a few minutes to jot down what three differentials you might be thinking about at this point in time. So that's three differentials you might be thinking about at this point in time. Uh Yes, I've just seen the chart now. So that is yes, 10 mL per kilogram over 15 minutes. So three differentials we might be considering at this point in time might be um sepsis, um pneumonia, uh bronchiolitis. Um So those are the most kind of common things you might be thinking about at this point in time. Um Probably the most common out of those will be kind of the sepsis. And so um child had a two day history of cries and cough with a one day history of working harder with her breathing mom report. She's had decreased feeds today and taking only four ounces over the day. She denies any vomiting, any diarrhea or pyrexia. She had no past medical history was born at time with no neonatal issues up to date with her vaccinations and no concerns regarding her development. Um So first I wanna know is um we need to be able to calculate her fluid that she's had today accurately. So mom's given it to us in ounces. So how many mils are in an ounce? This is gonna sound like it sounds like a very mean question. Very Google question. But in PS it's just a good rough number to know. Um because parents will often tell you how much their child's had in terms of answers and that's f so it's approximately kind of 30 mils. It's actually kind of 28 mils per ounce, but 30 is absolutely terrific. Um And so again, just to, to go over what we've been talking about before um Blake weighs 6.8 kg. So what is his milk requirement for the day? And so that is Blake we 6.8 kms. What is his milk requirement for the day? So, yeah, fantastic. Um So that is 10 sorry, that's 100 mils per kilo for the 1st 10 kg. That is 680 mils throughout the day. Um So we move on to um the observations of this case. So we've got a respiratory rate of 60 breaths per minute. A heart rate of 140 BPM that are 92% on room air temperature is 37.5 with a mild to moderate work of breathing and the BP has not been recorded. Um So our reference range for um, little ones can be up to 60 minutes but not in kind of a six month old. We're looking at more kind of neonatal at that point in time and that heart rate is slightly high, but not to the point where we're too concerned about things at this point in time. Ok. And so on our examination, our airway again in an A to E approach. So our airway is patent and own the chest has got equal area of artery. There's bilateral crackles with some transmitted sounds, no wheeze some mild subcostal recessions and a moderate to our heart sounds are normal. A week for time is less than two seconds are bilateral femoral pulses. Um So this is something we often do impedes, which isn't done in adults is to check their bilateral femoral pulses for any signs of kind of reduction in that volume or asymmetry in the pulses. Um but they are normal um in this case, um and then we have a soften tear of Pontana which is not depressed. Um The child is alert and active. Um the abdomen is soft, nontender with no organomegaly and no kind of rashes. So at this point, um in our case, our most likely differential is probably um a bronchiolitis. So if we think about kind of initiating um further steps and kind of what we want to do Next, we would want to kind of do a um nasopharyngeal aspirate or an MP to kind of try and identify what common organisms might be caused um causing the bronchitis. Um So that tests for things like R SV adenovirus, Rhinovirus and the whole um bunch of other ones including COVID. Um and potentially you might be thinking about doing a gas in this patient as well. So, um explaining what bronchiolitis is to a patient is something that you'll commonly have to do and to commonly kind of give that reassurance to patients about what's going on. So it's good to have a good definition of what bronchiolitis is and to kind of prepare them for things. So, bronchiolitis is a common viral infection of the small airways, which mainly affects Children under two years old. It typically worsens over the course of the initial presentation of 3 to 5 days before improving after that. So it's good to warn parents that their child might get worse before you see them getting better. Um And to give that kind of clear understanding of our expectations and their expectations of what should be happening over the next couple of days. So um next poll coming up now is what are our target saturations in an uncomplicated bronchiolitis. So this is a bronchitis where we have not got any features of preterm, they're not less than one unfold and they've got no kind of past medical history in terms of chronic lung disease or anything that might be impacting on their respiratory system in terms of recurrent infections. So, what are the target saturations in an uncomplicated bronchiolitis? So, um there's been some recent change in these uh guidelines due to COVID. So we can accept a saturation target of anything above 90% in most cases of bronchiolitis. So that's 90% in most uncomplicated bronchiolitis and that recently changed um in COVID um due to the anticipation in the increased number of patients that we would have. Um but it's been carried on since then. So most departments will accept any, any reference range of above 90% in air. Um One important thing to not with this is just because your child is saturating fine when they're awake. Children have this annoying habit of um dipping their SATS when they're asleep and it will often require kind of ventilation um support during this period at the time. So ways we can kind of give respiratory support um in patients is via a kind of nasal cannula um via face mask oxygen. Um and that whether that be kind of wafting oxygen or having the face mask actually on their faces. Um depending on how old the child is and how well they're tolerating the the masks. Um We can give kind of high flow oxygen, we can give CPAP, bipap and obviously in duration of ventilation in severe cases, what you'll probably most commonly see on the ward is a mixture of nasal cannula oxygen and high flow oxygen being used. Um So it's important to understand kind of the different ventilatory methods. Um So, um she got a quick question on how does high flow support our ventilation? Um And I promise this is the last poll that we're going to do today. So how does high flow um helps improve our ventilation? So that's great. Um So um high flow delivers a constant peak. So that is a peak and expiratory pressure and preventing the collapse of bronchioles. So, correcting the collapse of the lower smaller airways. Um and that works by um ensuring the patients that need to use as much pressure and develop as much pressure to um keep the um volume of that long for. So each breath they take that have to generate that initial pressure by giving them a continuous peak. Um And I'll go through this a little bit more on the next slide when we have a, a diagram to explain it as well. Um It's often kind of described in terms of liters per flow per kilogram and we usually start this at 2 L per kilogram. Um Other sports we can give is kind of feeding support. Um So we do this kind of by reducing the feeds, giving frequent smaller feeds. Um And we can give energy feeds and fluids and TPN if we need to. Um But when we were kind of talking about, we're talking about a, probably an intubated and ventilated child who are not expecting to be able to tolerate anything orally for kind of five days, at least. Um, so often we'll, um, start babies on a feed of kind of 100 mills per kilo. Um, and if we're concerned about their breathing and everything, they're working kind of moderately to severely hard, that feed will probably be a continuous feed. And as we think they're kind of progressing and weaning down the ventilatory support, we can give those feeds and kind of boluses. Um So we'll start at hourly feeds and kind of stretch it out to two hourly feeds and three hourly. And before we start trying kind of oral feeds again. Um, so let's go through um our um mechanism of high flow and how it works again. We've just got a simple kind of diagram of a pressure volume graph here. So you'll see kind of along the bottom. We've got pressure on the um wi axis, we've got um volume. So you'll see in the initial um, initial pressure that is required to generate um, the volume that you initially get, require quite a large amount of pressure to produce just a small amount of volume. And so by introducing a peep which keeps that pressure from dropping um to, to a low value, um, we make sure that the airways kind of stay open so that the patient only has to produce the small amount of pressure that's on um the higher gradient of that inhalation to um ensure that they get the amount of gas exchange in the lungs and to make sure they have the right amount of volume exchange going on. Um So what we're trying to do is to keep that uh peak and expiratory pressure up to prevent that collapse from happening um and support their lungs in that way to allow them to have the rest that they need. Um Whilst the illness is going on. Um So again, that's to keep the initial peak and exposure pressure up to prevent this initial collapse of the smaller airways and allow the patient to have just the high gradient all grasped um for the inhalation to prevent less pressure that needs to generate in order to have a greater volume um exchange. So take home points for the second case. Um More things about fluid assessments. Um So again, we've got that 100 mils per kilo for the 1st 10 kg that 50 mils per kilo for the 2nd and 20 for everything after that. Um And remembering that kind of one ounce is 30 mils. Um so we can do some quick calculations um for when parents give us um feed volumes in terms of ounces. Um We've talked about our mechanism of action of high flow and supporting uh patients ventilation and uh how that kind of works in particularly in bronchitis and preventing the collapse of the smaller airways preventing them to have to generate that initial pressure, which requires so much energy. And then we've briefly spoke about kind of feeding support in, in bronchitis as well in terms of NG feeding and how we can practically start that at 100 M per kilo or less if we need to. Um and starting that as kind of continuous feeds um or giving them both feeds kind of every 1 to 3 hours as we require them. Um So we'll go back to as we started with our poster presentation knowledge quiz. So this is the same questions that we saw at the beginning. If anyone's joined us since the beginning, we didn't quite um get a chance to do these initially, I'll give you a second to kind of read through the questions now, um before we go through each one of them and I kind of explain the rationale for each of them. Um Yeah, so I'll just give you guys a minute if anyone who was here at the beginning to scribble on science studies. Great. So um for our first question, if you had a child who weighs 23 kg, what would the daily requirement of fluid be? So we got uh 100 mils per kilo for the 1st 10 kg. So that's 1000 mils, we've got 50 mils per kilo for the 2nd 10 kg. So that's 500 mils and then further 20 MS per kilo for the remaining weight, which is 3 kg, which is 60 mils. So that's 1560 mils for that daily period requirement. And then to calculate the rate for that, we would just divide that by 24 um which is 65 mils per hour um for the acceptable range of saturations for most Children with bronchiolitis. We're looking at saturations above 90%. And again, we're remembering that these saturations will often drop um when the child goes to sleep. So perfectly reasonable decision making to consider keeping a child for observation overnight, should the kind of saturations be borderline? 90 91% and you're worried about the child. Um What concentration of glucose are we giving for an IV glucose in hyperglycemia? Um So we're gonna give 10% and we're gonna give 2.5 mils per kilo um in our boss for hyperglycemia IV glucose versus, and again, we're gonna remember that we can give kind of buckle um um glucose in certain situations. Uh We can give Iron Glucon if we're struggling for IV access. Um And we can give obviously our 2.5 mils per kilogram of 10% glucose if we need to in hypoglycemia. What volume of fluid boats we give to a 10 kg child. So um we said it's a 10 mils per kilogram bolus. So that is 100 mils per ki um for this child. So 100 mils every 15 minutes and then we'd reassess the child and we can give a further 100 mils if we need to at that point. So it's a 10 mil per kilo bos and that would be 100 mils in this patient. And then how is high flow work to improve patients ventilation? So he said it's maintaining the peak. So maintaining that peak end expiratory pressure to prevent the collapsing of these smaller airways. So I hope that has been useful for everyone. Um, feel free to kind of contact me by email for any further questions or suggestions. We've got, I'll pop anything in the chat now. Um, and I'll check the chart in just a second, um, on anything you'd like to see. Uh, my email is on the screen. Um, and don't forget to fill in the feedback form which I'll send in the chat as well in the next five seconds or so. Um, because you won't get your certificate of attendance until you've done. So I'll also put a link in the chat for the session for next week. Um, so everyone can get on to that. Um, and I think next week's topic is on headaches. Um If you have anything you want me to cover in future sessions, I'm more than happy to go through anything, uh, different. Um, just drop me an email of what you want to see. Um, and I'm happy to cover it. Um, as long as it's related to peds and neonates. Um, because that's my kind of area of interest. Um, we're just in here in the c if a child is dehydrated with a 5% deficit, we'd do a fluid deficit and main some fluid. Yes. Um, I haven't had time today to go through kind of fluid deficit but that if that's something you're interested in me going through, I'm very happy to go through that on a and the next session I think land in a couple of weeks next. So drop me an email if that's something you want me to go through and we can go through um how to calculate um everyone's fluid deficit as well. Um So I'll hang around for the next kind of five minutes or so and see if anyone's got any other questions and pop them in the message chat. But otherwise thank you very much for attending and I hope it's been useful.