Test your PEDS critical care knowledge

[NotReady4PrimeTime]

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).

[NotReady4PrimeTime, RN]

Good answer! It seems a little contradictory to decrease the dwell time since equilibration of electrolytes across the membrane is about 70% in 60 minute cycles and only about 55% in 30 minute cycles. But shorter cycles pull more potassium because much of the clearance occurs in the first part of the dwell. How efficient this strategy is when the fill volumes are large (taking more than 5 minutes to fill or drain) during short cycles is unknown.

It is indeed rare to have hyperkalemia with PD, but that's only true for chronic PD. For patients receiving PD in the short term, some interventions such as ACE inhibitors or ARAs for their underlying illness, the presence of hemolysis or high potassium diet will cause this problem. PD doesn't provide a quick fix.

[Rookie12]

did decreasing the dwell time work or did the patient end up needing hemodialysis?

[NotReady4PrimeTime, RN]

No hemo... in fewer than 48 hours it normalized and stayed within the desired range. The workload was significant because the PD was done manually.

[Double-Helix, BSN, RN]

I'll share a quick senario:

11 yo female with pmh of cerebral palsy, severe scoliosis, reflux and Failure to Thrive. Admitted to PICU post operatively for a routine fundoplication with GT-placement. Had an uneventful post-op course for two days, feeds were started via G-tube and patient was sent to the general floor. Two days later the patient was noted to have frequent diarrhea and a temperature of 104. Pt was admitted back to PICU, acetaminophen and antibiotics were started. Blood cultures and labs were sent. Py remained febrile with diarrhea and, a day later, the patient crashed: respiratory distress, hypotension and eventually became bradycardic as well. She was subsequently intubated, a central line was started, and the patient was started on dopamine, norepinephrine, epinephrine and milranone before stabalizing.

What happened to this patient?

[umcRN, BSN, RN]

Post-op septic shock? I have seen kids crash with sepsis post a "routine" gtube/fundo :-(

[NotReady4PrimeTime, RN]

It certainly looks like septic shock. But it's a bit late for it to be directly related to the original OR. I think it's probably peritonitis/abdominal sepsis from a leak at the GT site. The symptoms didn't begin until 2 days after the feeds were initiated. The onset of shock was on POD 5, which is consistent with peritonitis.

I've seen a very similar situation where a child's GT hadn't properly healed post-op. The stoma appeared to be normal but the stomach wall hadn't been adequately sutured to the fascia so when feeds were started they leaked out of the stomach into the peritoneal space and caused unimaginable problems. The child died.

[Double-Helix, BSN, RN]

janfrn is too good! That's exactly what we found happened with this child. Surgeons found a large fluid leak into the peritoneum and had to place multiple drains to evacuate the fluid. We all thought that since she was on so many vaso-active drugs that she was going to die as well, especially with her pmh and malnourished state before surgery, and it didn't look good for several days. She surprised us though. In the next week we were gradually able to wean some of her vaso pressors. About three-four weeks later we were able to extubate. Gradually she recovered strength and we are in the process of advancing tube feeding again and stopping the TPN. Her stay with us has lasted nearly two full months, and in the next week or so she'll probably be discharged home.