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).
Well we know he likely has hyponatremic encephalopathy, right? The question is, is there another process on top of that. He's third spacing a lot of the volume so his neuro sx won't improve until his Na levels are up, right? What's his WBC count? Any bands? Are they doing anything other than fluid restriction to get rid of the ascites/third spacing?
Specializes in NICU, PICU, PCVICU and peds oncology.
No, the hyponatremia has been corrected. Remember, we're now three days post admission. WBC remains lowish - he's immunosuppressed as he's had a liver transplant... but yes, there are bands. We know he's septic and is being treated; actually, he has abdominal wall cellulitis and peritonitis. He's not fluid-restricted; they're replacing his losses 1:1 on top of 100% maintenance. However, his renal function is still mildly abnormal. In an effort to minimize the ascites he has been receiving 25% albumin followed by a Lasix chaser. He has no obvious peripheral edema at this time. Recall that in the initial history we were told that he had lost 6 kg of fluid weight in 5 days.
His father and siblings have arrived. The family lives about 1000 miles from your hospital and the boy and his mom had been there alone until this crisis. Since his condition remains very critical, the family needs to be together.
Specializes in NICU, PICU, PCVICU and peds oncology.
Okay, I won't keep you in suspense any longer.
The repeat CT showed 3 separate areas of infarct in his brain, the largest being at the temporoparietal junction in the vicinity of Broca's area roughly the size of a walnut. The smaller ones were a left frontal area the size of a dime and the third also the size of a dime at the central sulcus near the interhemispheric fissure. Later an MRI revealed a left basal ganglion hemorrhage of indeterminate age. Because the damage was not visible on the first CT it was decided that the infarcts were thrombotic strokes caused by dehydration and hyperviscosity. Careful questioning of his mother revealed that the boy had been complaining of a headache for several days prior to his collapse, and that he had "lost his balance" two days prior while sitting unsupported in bed watching television. At the time neither of these had been deemed significant.
His stay in the PICU was complicated by ongoing sepsis, fungemia, funguria, pneumonia, pleural effusion, acute renal failure progressing to total anuria and liver failure. It was necessary to hold his immunosuppressants for several days when it reached a toxic level. A liver biospy was suggestive of chronic rejection and his condition was such that he could not be relisted. 3 weeks after his readmission to the PICU he suffered a circulatory collapse and required aggressive resuscitation. He also had sanguinous drainage from his peritoneal drain that led to a laparotomy. 4 days later he had a seizure. The following day the PICU attending, the multidisciplinary team and his primary physician met with the mother, the rest of the family having returned home, to discuss her wishes. After hearing from all parties the mom decided that if his renal function deteriorated to defined limits, the team would withdraw life-sustaining therapies. 27 days after his admission he suddenly began to make urine; his BUN and creatinine peaked just below the threshold that had been set at the meeting. 11 days after that, he was transferred out of the PICU.
By six months post infarcts he was sitting unsupported, feeding himself and attending school. He is now nearly 27 years old, still living with that transplanted liver and in excellent health. He is my son.
Wow! That's what I love about kids, you can never underestimate them. Thanks for sharing your story and reminding us once again that we can never stop believing that a child might just turn around and surprise us all.
Specializes in NICU, PICU, PCVICU and peds oncology.
The day I started telling his story on this thread (March 5) was the 21st anniversary of his readmission to the PICU. It was such a long time ago but the details are still so fresh. I can clearly remember the neurologist telling me that if he survived that first night he would certainly never be aware of his surroundings or even know he existed. That couldn't be farther from the truth. He loves life with such vigor!
I can also clearly remember one of his nurses telling me, "When you've been doing this (PICU nursing) for as long as I have you get this sixth sense that tells you when the person is 'still in there', and he's still in there." Now that I've been doing this for 14 years, I know exactly what she meant. It was an amazing thing when she came to visit us last fall and got to see him as he is now; the last time she had seen him was the day he was transferred to the ward, a silent little boy who couldn't even hold up his head. There he was, watching Transformers and drooling over Megan Fox...
Wow Jan! I have been busy working and other such things and have been away from the thread for some days, but I just read to catch up. Thanks for sharing your story!
NeoPediRN
945 Posts
Did he have a shunt?
No meningitis right?