Case Report Summaries

•Index Patient: Fluid Overload

7-month-old female with complicated intestinal and feeding problems - presented with refractory anasarca. Transferred for CRRT. Rx with 15 ml/kg over 1 hour. Diuretic stopped. Second dose at 12 hrs. 

• Diuresis of 780 ml. weight decreased by 0.8 kg at 26 hours.

•Anasarca resolved completely. Albumin increased from 1.9 to 2.4 and maintained that level.

•Patient 2. Sepsis and fluid overload

3-month-old male Infant with complicated intusseption resected cecum and distal ileum.

• Bolus 20ml/kg of NS x2 prior to surgery.

•Post operatively two 20ml/kg boluses NS given.  

•A “second look” operation was performed.

•Three boluses of 20ml/kg NS were given for low urinary output.

•1ST post operative day, patient massively fluid overloaded and diuretic refractory. 

•Rx 15 ml/kg TNS yielded improved perfusion and increased urine output.

•Day 2 a second dose of TNS 15 ml/kg given plus diuretic resolved the fluid problem.

•Despite Klebsiella growth patient was afebrile and showed prompt recovery.

•Patient 3. Sepsis and fluid overload

Complex pt with multiple cystic hygroma presented with abdominal pain and rt pleural effusion.

•Patient already on ventilatory support (?ARDS) left pleural effusion and ascites.

•Anasarca gradually developed despite TPN and diuretics.

TNS dosed 20 ml/kg q 12hours for a total 4 doses. Fluid overload resolved.

•Patient 4. Low grade sepsis and anasarca

17 year old male with hx of abdominal pain. Free air in abdomen and biliary tree.

•Given 2500 ml NS prior to surgery.

•Aspiration occurred during anesthesia induction.

•At operation pneumatosis intestinalis and obstruction was noted and relieved.

•Rx Tazobactam and piperacillin.

•Hypotension and decreased perfusion along with severe  third spacing was expected therefore  Pt rx-d with TNS 1000 ml q12 hours plus normal maintenance fluids.

•Post operatively  patient had no fever. Blood pressure remained normal and perfusion was normal.  Albumin levels were not recorded.     

•Patient 5. Urinary septic shock  

23 year-old male with sepsis from urinary tract infection.

•Developed tachycardia, hypotension, decreased perfusion and pedal edema. 

•Patient treated with 600 ml of TNS with decreased  heart rate, increase in BP and perfusion & decreased edema of his feet.

•Albumin increased from 1.4 gm/dl to 2.4 Gm/dl

•Patient 6. Enterococcus faecalis sepsis, Candida sepsis, Herpes G infections

7 year-old male with Acute Lymphocytic Leukemia  with neutropenia and sepsis (?possible line sepsis)

• HR 180, BP 90/39 supported with Dobutamine due to myocardial dysfunction .

•TNS 15ml/kg  over 2 hours redosed at 12 hours.

•Clinical improvement with decreased HR, increase BP and perfusion.

•Albumin 1.9 gm/dl to 2.5 gms/dl.

•Patient 7  Neonatal Septic shock, severe with coagulopathy and thrombocytopenia.

42 day old male with anemia and bowel obstruction. Status post non-operated necrotizing enterocolitis.

•Emergency operation to resect portions of ileum, cecum and portion of sigmoid colon.

•Hgb 5.0, Bolus with NS intraoperatively.

•Post operatively bolus NS 20 ml/kg then 15 ml/kg to stabilize postop BP and perfusion.

•Developed severe thrombocytopenia  of 7,000, Glucose >325mg/dl.

•Treated with Insulin drip platelet transfusion and IVIG for platelet anti bodies causing thrombocytopenia.

•Albumin 1.5gm/dl

•Treated with TNS 15ml/kg over 2 hours every 12 hours for 3 days (6 doses)

•Albumin increased to2.6 gradually over 5 days. Clinical course unusually stable.

•Patient 8 Stage 4 Hepatoblastoma, ARDS and restrictive thorax with Ascites

2 year-old female with massive inoperable hepatoblastoma

•Underwent open biopsy with bleeding.

•Intubated with diffusion block and restrictive thoracic capacity due to tumor. Ventilator on High setting and 50\dl FiO2.

•Patient had poor response to furosemide and  possible abdominal compartment syndrome.

•TNS 20 ml/kg  given led to decreased abd size and better ventilation.

•Patient 9 Septic Shock ARDS Multi-organ failure

15 month-old with testicular Myelois Sarcoma admitted for chemotherapy developed acute sepsis, ARDS, fluid overload with multiorgan failure required pressors and large amount of voluime as normal saline. Difficult to ventilate despite sedation and paralysis.

•Started on TNS 15 ml/kg q12 hours for 6 doses.

•Diuresed 2kg fluid

•Resolved sepsis

•resolved fluid overload weaned off ventilator at two days.

•Resumed chemotherapy.

•Patient 10  Peritonitis with gangrenous cecum and ileum, multiple peritoneal abscesses and prolonged ileus

13year old male who had severe abdominal pain for four days, dehydration with acute appendicitis and peritonitis.

•Surgery requiring cecal and ileal resection.

•Pt treated with standard protocols, of NS fluid support.

• reoperation x3 very slow recovery over 10 days with prolonged Ileus, despite infection control ileus persisted.

•Low serum albumin treated with TNS 15 ml/kg over 2 hours every 12 hours for 2 doses

•Albumin increased to 3.1 gm/dl.

•Ileus resolved and patient discharged.

•All patients successfully treated and discharged from from Hospital.

•No side effects no complications from additional treatment.