Pediatric resp distress

[Lbu]

Hey guys,

I haven't been nursing very long and I recently started off in pediatric intensive care. I'm slowly getting the hang of it but I'm wondering what you would do if your patients on room and and say your patients O2 says suddenly drop significantly. Obviously with intubated patients you would bag ventilate them, or increase the O2.

Would you just call for help or is there certain steps you go through.

Thanks!

[MunoRN, RN]

17 hours ago, murseman24 said:

Why?

As Peak and Wuzzie pointed out, you're not going to do better than the vent, it isn't going to fix any of the common issues that should be assessed first, yet it can potentially cause further harm.

Even with a PEEP valve, changing over to a bag will result in alveolar decruitment, there's the potential to cause barotrauma, particularly in kids where volumes are so critical, and if not excessive volumes then insufficient volumes are just as likely, and you loose your I:E ratio as well. Basically, it's switching from a finely tuned ventilation therapy to a sloppy less effective ventilation.

[PeakRN]

4 hours ago, Wuzzie said:

And don't forget those cardiac kids. Their plumbing is all jacked so giving them too much O2 or TV or PIP or PEEP or just looking at them cross-eyed will cause issues. We had a cardiologist who was in the habit of telling nurses "you just killed that baby" if she saw a SaO2 >80 on some of the kids. Yikes!

For anyone following who is interested this is a phenomenon present when patients have a large communicating shunt between the pulmonary and cardiac circulation. We tend to think of this in our most of our un-corrected or un-paliated diseases that have what we call a single ventricle pathology, and occasionally if we place a shunt in something like a pulmonary atresia. Commonly we think of patients that have very large uncorrected shunts like a massive VSD, AV canal defects, HLHS, and so on. Kids who are single ventricle pathology and have a Glenn are at lower risk, those with a fontan are at even less risk (as they should be pretty at this point, and even with a fenestration should not have that much communication).

The pathophysiology is that our lungs will mimic much of our fetal circulation pathology and in utero kids run hypoxic and a bit acidic. This keeps the foramen ovale and ductus arteriosus open. It also constricts the pulmonary vasculature resulting in relatively low pulmonary blood flow. As a result the patient has pulmonary hypertension and 90ish percent of their blood flow goes to their body.

After birth when the baby is exposed to higher amounts of oxygen and normalize their acid base balance they close their ductus arteriosus and foramen ovale, the large amount of oxygen causes dilation of the pulmonary arteries resulting in increased increased pulmonary blood flow.

Thus kids who still have a relativly large and patent shunt who become more hypoxic (typically below 70-75 sao2) will begin to favor their systemic circulation. Certainly we don't want these kids to stay hypoxic, but generally being 10% low is much safer than being 10% high.

Kids who are high sating dialate and favor their pulmonary blood flow. In the case of shunted hearts they can then potentially just end up pumping around the pulmonary side and have almost no systemic circulation. Of course this causes insult to the brain, kidneys, liver, mesentery, and so on; more importantly it does not peruse the coronary arteries and can result in cardiac arrest. We calculate Qp:Qs on all of our fresh or unstable hearts who present this pathology.

Many heart kids don't present with this concern, it really depends on each kids disease process. It is important to remember that ventilation includes many gases, and that simply withholding ventilation isn't appropriate. These kids really need to be transferred to a pediatric cardiac hospital as soon as possible by a pediatric cardiac trained transport team.

[raemcclain]

Always look at the patient first! Is the kid acting like he can't breathe? What is his color? Is he flailing his extremities? Unable to cry?? All the above are
great suggestions. usually something simple before the complex issues will resolve the problem. My friends who worked in the ER said the greatest
sound in a pediatric ER is crying!!! I always remembered that. I loved
peds but they are not tiny adults. They have separate physical issues.

Throat collapses easier. Unable to tell us they are in distress until they
are really in distress so we need to keep a close eye on them. Especially
for things like RSV, croup, bronchiolitis. Things that seem 'simple' but
in an infant or young toddler...not so. Or the asthmatic that is not
well-controlled. Maybe parents do not understand the importance of
preventative care at home, or have issues with cost of meds. Sounds
like I am going too far, but I am not. If the latter issues are present,
treat the immediate problem then contact Social Services for further
help. Pass it on to the next shift and continue to follow up until you
are satisfied that all issues are solved.