Patient Scenario and D/C home

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I work in the Emergency Department and am a fairly new grad, 6 months out of school. I had a patient come in this past weekend and I just can't stop thinking about what I could have done differently as I am usually very, very hard on myself.

Here's the scenario:

Parents bring their 4 year old child in to the ED with chief complaint of fever and abdominal pain for the past three days. They deny any other symptoms except three episodes of emesis over the course of the three days he has been sick.

I medicate him for his 102.1 fever with Tylenol, draw some blood, give him some fluids and anti-nausea medication. Pt is vitally stable, crying but consolable, and sleeping on bed with mom as it is 3 am. Send urine to lab, it is dark in color.

Once all the results come back, he is diagnosed with "fever in children, vomiting in children, UTI, and renal insufficiency". His BUN was 39 and Cr. 1.6. Pt is discharged and parents are given instructions to follow up with PCP and urologist.

Fast forward to the next night, pt is brought back to ED by parents stating that his abdominal pain has not decreased, but parents now state that en route to ED, child began having difficulty breathing. Pt ends up satting at 84% on RA, and gets admitted to hospital with a diagnosis of pneumonia as well as the diagnoses that were given the night before.

Long story short, pt ends up getting intubated as soon as he arrives to PICU. The pt was mine the first night, but I saw him come into triage the second night.

I guess my question is was the doc wrong in discharging a 4 year old with renal insufficiency? Are the two diagnoses related? What causes a 4 year old to even have renal insufficiency? I guess I'm mostly just looking for reassurance, when the pt was mine, he was totally stable and there wasn't even an indication for a chest x-ray or any respiratory related exams. I just feel bad that we maybe could have prevented all this from happening. I'm not as familiar with pediatric patients as I should be, but am hoping I can get some advice/words of wisdom from you more experienced nurses out there

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I don't know peds but renal insufficiency in a little one seems like it would be a big deal.

Admission criteria has gotten absurd but I wonder why they didn't at least keep him for observation?

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Specializes in Emergency & Trauma/Adult ICU.

Was the patient's PCP consulted?

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Specializes in orthopedic/trauma, Informatics, diabetes.

Sounds like AKI and child needed more fluids before being d/c'd. A dose of IV antibiotics for UTI maybe? Someone dropped the ball if the child was brought back and ended up intubated. Glucose levels????

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As far as I remember glucose levels were within range

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Specializes in Pedi.

A fever that high would have bought the child blood cultures, urine cultures and a CXR when I worked in a pediatric hospital. You said his urine was dark- what was his spec grav? He probably needed more fluids and labs rechecked before being discharged. Discharging a child with that BUN/Cre without known kidney disease seems inappropriate to me.

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Specializes in Trauma, Orthopedics.

I don't work peds or ED but my first thoughts were no fluids/lab recheck after? I'm a little shocked he wasn't admitted for obs at the least.

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I agree with the other posts...I would've anticipated at least an observation stay for this patient given the BUN/Cr levels (if there were no known kidney issues that would've explained the labs)

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I agree with you all. I just wish I pushed the doc harder to keep him. He wasn't having it though :(

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Specializes in Vents, Telemetry, Home Care, Home infusion.
I agree with you all. I just wish I pushed the doc harder to keep him. He wasn't having it though :(

Lesson learned: you will put your foot down FIRMLY next time similar incident occurs in future.

HUGS to you for caring so much!

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Overview of Kidney Disease in Children - National Kidney and Urologic Diseases Information Clearinghouse

Here's a general link for some sort of cause analysis. 102 temp with a UTI could also suggest a sepsis. If the child aspirated vomit, that also could cause a pneumonia. I would also think about a strep infection.

I am surprised that the patient's PCP wasn't consulted as to how to proceed with this patient. And the parents to be advised that a follow up with the PCP should occur the next day. Perhaps something to consider going forward if you have ER docs sending kids home that are not quite there yet. To cover yourself, I would ALWAYS remind a patient/parents to bring the child back if there's no resolution or if there is worsening at any time, and to follow up with the PCP on the following day. And perhaps that needs to be policy.

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Great read, thanks so much for posting it!

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