I just was wondering if I could get some feedback on the care of a pt. I am not a pedi nurse, but occasionally take pedi overflow on my floor. Usually it's pedi postop's, or CP kids with aspiration pnuemonia that are now stable. Unfortunately the pedi unit was bursting at the seams, so I was recieving pt's with dx and conditions I am not so familiar with. Usually we do a swapout (Pedi nurse to my floor, one of my floor's nurses to pedi to take the bigger kids), but the pedi unit was short, so it was me and a float nurse from ortho.
I was admitted a 10 year old from the ER with a dx of asthma. Per ER report, pt was now "stable". However had recieved back to back albuterol neb tx, oral prednisone 30 mg, IV roceph and clinda??(can't remember the second abx at this time). No IV fluids were administered. Pt on 4 liters O2 via nasal cannula, spO2 at 95%. ER nurse stated she had NOT auscultated the lungs, "I just took over this pt an hour ago, I can't tell you what her lungs sound like, ".
When I recieved my pt, she was satting 86% on 4 liters, wheezes and rales to all lung fields, nonproductive cough. I got the pedi resident up there stat, and paged RT. O2 titrated to 5 liters and humidified, back to back neb tx's given, 500ml normal saline bolus given, then IV fluids were set for 150% maintenance. Pt placed on continuous pulse ox. SpO2 up to 89-92% after all that. Recieved orders for xopenex nebs q 2 hours.
Then after 3 hours, she started to decompensate again, and even trends into the mid 70's after ambulating to bathroom. xopenex d/c'd by resident, placed on albuterol nebs q1 hour. Resident states she is not comfortable giving solumedrol because the pt recieved oral prednisone earlier. Pt becoming more congested, placed on O2 by mask 5 liters. spO2 will not stay above 89%.
Finally after the resident, his upper level, the fellow all quit scratching their heads, the head of the asthma team is called in at 0100, because there are NO PICU beds and NO ICU beds, and Pedi is still full, and we are the only hospital in 100 miles capable of taking care of this kid, and he orders solumedrol q6 hours. After first dose, cough became productive, and we started chest percussion with hourly albuterol nebs. By the time I left at 0800SpO2 was at 94% on 5 liters, and mucinex added to regimen.
If I ever encounter an asthmatic kid like this again, what else can I do or suggest to the team. I hate not knowing what to do. And the mom had to leave, there was a sick sibling at home and no childcare, so I was spending a great deal of time calming the pt down and talking her through breathing and distracting her from the monitors ( every time she looked at her sats, she'd get nervous and desat more), that I didn't really have time to do any research with the manuals at work.
Nov 25, '06
For asthma kids most of our docs order something like this. Solumedrol IV early on, along with Atrovent and Xopenex in neb once, then Xopenex alone every 15 mins times 2. Then usually continuous neb treatments for 4 hours if still hypoxic. Obviously we don't wait 4 hours to see if cx nebs are working. If that doesn't work then consider PEEP. If child still hypoxic consider intubation depending on lots of other factors.
Your patient may have benefitted from continuous neb tx's. The majority of the time this brings sats up. That sound like it was a difficult situation that you handled really well. She probably should have been in PICU.
Nov 26, '06
elthia, with status asthmaticus subcu epi could have been given or mag sulfate iv. itsybitsy spider, what do you mean PEEP? how was it used?
Nov 26, '06
Here is an article on status asthmaticus in kids:
eMedicine - Status Asthmaticus : Article by Adam Schwarz, MD
Helium is an inert gas that is less dense than nitrogen. The administration of a helium-oxygen mixture (heliox) reduces turbulent airflow across narrowed airways, which can help to reduce and, thus, relieve the work of breathing. This, in turn, can result in improved gas exchange and improve pH and clinical symptoms. It does not improve the caliber of the narrowed airways. Some data suggest that nebulized-size particles may be more uniformly distributed in the distal airways when nebulization treatments are administered via heliox than with a standard oxygen-nitrogen mixture.
Heliox can be administered via a well-fitting face mask at flows high enough to prevent entrainment of room air. The effectiveness of heliox in reducing the density of administered gas and improving laminar airflow is dependent on the helium concentration of the gas—the higher the helium concentration, the more effective the result. Therefore, an 80:20 mixture of helium-oxygen is most effective, and heliox loses most of its clinical utility when the FiO2 is greater than 40%, reducing the percentage of helium to less than 60%. Therefore, the limitation to the use of heliox is the amount of supplemental oxygen the patient with status asthmaticus requires to maintain an adequate oxygen saturation. Heliox has also been used to drive mechanical ventilation with lower dynamic peak inspiratory pressures."
We have used heliox with good results. It should only be used in a monitored setting though. It seems to me that this child should have been in the ICU or stepdown unit. If that wasn't possible, then she should have been 1:1 care.
Nov 26, '06
Unfortunately we didn't have any ICU beds available at the time. Thanks for the feedback everyone.
Nov 27, '06
Sounds like you handled it well. Agreeing with the above, probably continuous aerosols, and they should have stayed in ER until a PICU bed was available or found elsewhere if you didn't have PICU beds available. Absolutely no reason they should be on a floor without the appropriate resources, especially on an adult floor without specialized peds nurses familiar with asthma protocols.
Nov 27, '06
We do albuterol/atrovent, then albuterol x2, in the meanwhile they've already rec'd steroids. If they aren't much improved after the 3rd albuterol, some will try another albuterol and give a prolonged tx. If that doesn't work, they get Mag and cont tx's. We do use heliox sometimes. Status is a definite PICU admit. If your facility didn't have the capacity, sounds like the pt should've been transferred. Sounds like you did everything you could for the child on the floor.
Dec 22, '06
Could they consider a terbutaline drip on this child?