This is an offshoot of another thread that strayed far off its path.
I will be posting questions that spring from situations I see on my quaternary level PICU to test your knowledge of critical care topics that apply to children. As we know, children are not small adults and the reasons they are admitted to ICU are very different from those of adults. For example, PICUs see virtually NO life-style related comorbidities such as COPD from a 2 pack-per-day cigarette habit, cardiovascular disease from a 10 Big-Mac-per-week habit or end-stage cirrhosis from a 6-drink-per-day habit. Congenital anomalies, trauma (accidental and non-accidental), metabolic disorders, ingestions and respiratory infections are our biggest offenders.
Question #1:
Name the 4 main treatments for JET (junctional ectopic tachycardia).
Specializes in NICU, PICU, PCVICU and peds oncology.
Coags are within normal limits although the INR is borderline on the high side. Carbamazepine level is therapeutic.
Her fluids are at 120% of maintenance. You've started norepinephrine at 0.05 mcg/kg/min and her BP is now stable. You have a morphine infusion at 40 mcg/kg/hr started andhave given two boluses of 2 mg each. There's an order for IViG, a dermatology consult, an ophthalmology consult and standing orders for blood products within certain parameters.
Plastics and dermatology have determined that her blistering has not yet peaked even though the lesions now cover 60% of her skin surface. Skin biopsies have been obtained and are pending. They recommend protective isolation, daily dressings of bacitracin-coated gauze held in place with Kerlix, Polysporin eye drops to both eyes QID and to continue with the chlorhexidine mouthwash.
Thus far her cultures are all negative except for a UTI. So the piperacillin-tazobactam is discontinued. But her glucose is now 300 so an insulin infusion is started.
What complications can you foresee in the next week or so?
Ok, so I'm a NICU nurse, not a PICU nurse...but just a side question. 40 mg/kg/hr of morphine sounds like A LOT to me! Was that a typo or is that the real dose? We're talking about 2400 mg/hr of morphine! Just curious...
Ok, so I'm a NICU nurse, not a PICU nurse...but just a side question. 40 mg/kg/hr of morphine sounds like A LOT to me! Was that a typo or is that the real dose? We're talking about 2400 mg/hr of morphine! Just curious...
That's just the infusion rate. You've only given two 2mg boluses.
I think TEN and SJS are the same things, so that's not it.
I'm glad the piperacillin was d/c. I would be watching for infection (also wondering about plasmapheresis) watch cultures and ESR, GFR and total renal failure is where she's headed, those values were bad to begin with, so redo all the kidney functions to check for progressive deterioration, set up dialysis and really stay on top of fluid status.
That's just the infusion rate. You've only given two 2mg boluses.
Is that really what you meant Jan? That doesn't make sense based on Jan wrote. That would calculate to "infusing" your morphine over 1-2 seconds, which is just IV push.
Specializes in NICU, PICU, PCVICU and peds oncology.
It was a typo, littleneo. I meant (and have edited to reflect!) 40 mcg/kg/hr, which is a common dose for our unit.
TEN and SJS are NOT the same thing although they are similar. SJS is limited to a BSA of [/u] 30%. Histopathologically and etiologically they're different entities. Necrotic keratinocytes with full-thickness epithelial necrosis and detachment is consistent with the diagnosis of TEN. Another feature is Nikolsky's sign, that the lesions wrinkle, slide laterally and separate with the slightest pressure.
TEN has an overall mortality rate of 30-50%. Based on the SCORTEN severity-of-illness score this patient socres a 4 of 7, which carries a predicted mortality of 48%.
Plasmapheresis hasn't been demonstrated to be any more effective than corticosteroids, chemotherapy, TNF alpha inhibitors or IViG. There has been no uniformly successful treatment modality identified.
This patient subsequently recovered fully without dialysis. She was in PICU for a month, undergoing daily burn dressing changes. After the first week, she was successfully weaned from her pressors and was extubated part way through week three. I transferred her out to the peds ward on a low airloss bed; I wasn't aware at the time that the bed didn't have a backup battery and when I unplugged it the mattress deflated around the poor kid. We all laughed about that later. I ran into her and her mom in the hallway about a month after that and was astounded to see that she had healed without a single sign of how sick she had been. Her skin was flawless! Totally amazing.
Specializes in NICU, PICU, PCVICU and peds oncology.
It was indeed TEN, and carbamazepine was the culprit. She never had any need for plastics other than on a consultative basis. I had only been working in the PICU for a month when she came in and this case has stayed with me. Recalling the daily dressing changes in that hot, tiny isolation room she was in, with all that equipment, and all the people needed to get the job done reminds me that we do some of our best work in the most difficult of settings. And we ROCK IT!
I'm putting together another case for y'all... another interesting one. See you after my night shift.
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
Coags are within normal limits although the INR is borderline on the high side. Carbamazepine level is therapeutic.
Her fluids are at 120% of maintenance. You've started norepinephrine at 0.05 mcg/kg/min and her BP is now stable. You have a morphine infusion at 40 mcg/kg/hr started andhave given two boluses of 2 mg each. There's an order for IViG, a dermatology consult, an ophthalmology consult and standing orders for blood products within certain parameters.
Plastics and dermatology have determined that her blistering has not yet peaked even though the lesions now cover 60% of her skin surface. Skin biopsies have been obtained and are pending. They recommend protective isolation, daily dressings of bacitracin-coated gauze held in place with Kerlix, Polysporin eye drops to both eyes QID and to continue with the chlorhexidine mouthwash.
Thus far her cultures are all negative except for a UTI. So the piperacillin-tazobactam is discontinued. But her glucose is now 300 so an insulin infusion is started.
What complications can you foresee in the next week or so?