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).
With chronic hypoventilation and acute pneumonia, I don't think that blood gas looks too bad. I would want to know what the pt's baseline CO2 level is. I think they would either titrate the bipap a bit or check another one in six hours. Sounds like what the pt really needs long term is a trach and vent, though.
Specializes in NICU, PICU, PCVICU and peds oncology.
Compensated respiratory acidosis. I believe the CO2 was elevated as part of the central hypoventilation with exacerbation and the bicarb is elevated as compensation.
Or... could it be the other way around? That the CO2 is high to compensate for the high HCO3-?? To determine which came first, what intervention would be employed?
With chronic hypoventilation and acute pneumonia, I don't think that blood gas looks too bad. I would want to know what the pt's baseline CO2 level is. I think they would either titrate the bipap a bit or check another one in six hours. Sounds like what the pt really needs long term is a trach and vent, though.
I didn't think it was that bad either! One of the issues is that no one knows what the baseline CO2 is. In the interim, between working on correcting the HCO3- and checking the ABG in a few hours, the BiPAP settings were increased from 16/+6 to 20/+8. Respirology suggested the addition of dornase alfa to the treatment regime despite no evidence the patient has CF. Any ideas on the rationale?
If the bicarb was high to begin with, wouldn't the PH be be elevated or high normal and not on the lower end of normal? It's too low to be overcompensated, isn't it? I just think given the pt's symptoms and history, and the electrolytes being relatively normal that it looks more like a respiratory acidosis.
We use pulmozyme to break up secretions, especially on ex preemies with BPD and kids with neuromuscular disorders with a weak, ineffective cough who aren't candidates for cough assist.
My guess for this kiddo would be to help break up secretions that may be contributing to his pneumonia?
Specializes in NICU, PICU, PCVICU and peds oncology.
What about the hypochloremia? There IS a component of respiratory acidosis, but a high bicarb and a low chloride are a little confounding. So how would we know if the bicarb is high to compensate for the high CO2 or if the CO2 is high to compensate for the high bicarb? What can we do to figure that out?
JanF - quick question. It sounds like more ventilation was what this baby needed, no doubt. Were her pressures high on the vent? Did they increase her RR on the vent to help blow off the CO2, and if so did it help? It's hard to know what we're treating without knowing what her baseline CO2 level is. She could be chronically acidotic from hypoventilation.
What about the hypochloremia? There IS a component of respiratory acidosis, but a high bicarb and a low chloride are a little confounding. So how would we know if the bicarb is high to compensate for the high CO2 or if the CO2 is high to compensate for the high bicarb? What can we do to figure that out?
Is that deficit enough to contribute to such profound compensation values? What about sodium chloride replacement, either via fluid or PNG? The pt's sodium was borderline, too. The bicarb is high on ABG, but what about giving a dose and see what happens to the ABG?
What other issues does the pt have? Is the central hypoventilation caused by some other neuro defect?
P.S. Was the pulozyme being used off label for something?
Specializes in NICU, PICU, PCVICU and peds oncology.
That's the whole thing... no baseline anything! CBGs for 5 days, the suspicion that there's more to the situation than meets the eye...
She received 6 doses of acetazolamide over 36 hours to see if dropping her bicarb would also drop her CO2, and there was a significant change in both. Intubation was required for airway clearance; airway pressures weren't unusually high, O2 requirements were minimal and her gases approached normal. Long-term airway management will be needed. The Pulmozyme? No real explanation for why it was ordered, and it was quickly discontinued.
Okay, here's a quickie:
You have a patient on peritoneal dialysis. Dialysate is Dianeal 4.25% with KCl 3 mmol/litre. Cycles are 60 minutes, with a 5 minute fill time, 45 minute dwell time and 10 minute drain. Serum K+ begins to climb, going from 4.1 to 6.3 in 12 hours. Patient is NPO and already has diarrhea. What can you do to fix the K+?
Specializes in NICU, PICU, PCVICU and peds oncology.
Patient has diarrhea so will be unable to hold in the Kayexalate enema.
Insulin and D25 are already going as infusions but the K+ is still rising.
No response to loop diuretics although there's still some renal function. Medical staff are reluctant to go to hemodialysis. (It's a Friday night, someone would have to come in to place a line, the HD staff aren't all that anxious to come in either.)
The fellow's suggestion is to change the frequency of PD fills and to remove the KCl from the dialysate. So what should the new dwell time be?
would you want to decrease dwell time to say 30 minutes? i think the amount of waste products diffuse more quickly at the beginning of the dwell when the concentration gradient is steepest. Isn't it rare to have hyperkalemia with PD? I had a very similar patient with diarrhea on PD who had hypokalemia. I'm a newbie so i'm just going out an a limb here...
NeoPediRN
945 Posts
With chronic hypoventilation and acute pneumonia, I don't think that blood gas looks too bad. I would want to know what the pt's baseline CO2 level is. I think they would either titrate the bipap a bit or check another one in six hours. Sounds like what the pt really needs long term is a trach and vent, though.