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).
Could she have thrown clots elsewhere from the endocarditis? Could this be a sign of valve rejection or the new valve not functioning properly?
If a clot's not the cause of her renal failure, and it's not due to insufficient perfusion from the heart, then I'm stumped. Would they do an UD of kidneys?
Lack of perfusion at times could also explain her level of mental alertness/function right? Especially since her supplemental 02 needs are increasing.
Now I'm really stumped. Couldn't find much on the WWW to help either.
Specializes in NICU, PICU, PCVICU and peds oncology.
Nope, no clots anywhere. The mitral valve wasn't replaced, it was repaired so there's nothing to reject. And we know there's regurg. But you're on the right track in looking at endocarditis. Think about signs and symptoms, physiologic effects and cascades.
Lack of cerebral perfusion isn't the problem. She's been given a number of drugs for chest tube placement both before and at the beginning of your shift - fentanyl and ketamine. You notice that she's particularly out of it for some time after the chest tube insertion, then gradually has become more appropriate, but still not completely coherent. She is oriented to person but not to place or time. And she doesn't remember your name, even though you've reoriented her each time she rouses.
Specializes in infection control, peds, home infusion.
You mentioned the pt. received ketamine w/ fentanyl prior to the chest tube insertion. Could this combinations, specifically the ketamine have something to do with her varying mental status?
Specializes in NICU, PICU, PCVICU and peds oncology.
Dingdingdingdingding! But why? Aren't both ketamine and fentanyl relatively short-acting? Why is she still really loopy a couple of hours later? And what will solve her main issue?
she still has endocarditis. This explains the mitral regurg and CHF as well as the poor kidney function. She's still disoriented because due to the reasons mentioned above, she isn't metabolising and excreting the fentanyl and ketamine properly.
I think reducing the inflammation in her heart will help resolve her main issue. So my guess is that some sort of corticosteriod will be ordered.
Specializes in NICU, PICU, PCVICU and peds oncology.
Partly correct. She has been receiving corticosteroids since the beginning, since it's becoming first line therapy for shock unresponsive to fluid resus, which was the case when she was admitted. (Remember, we're 4 days into her admission.)
The renal failure is acute tubular necrosis related to prolonged ischemia during the hours and days preceding her admission. ATN in children is often unresponsive to loop diuretics, so that explains the lack of diuresis with Lasix. The confusion and disorientation are partly related to significant uremia as well as delayed metabolism of fentanyl and ketamine as both drugs are mainly excreted in the urine... and she doesn't have any. However, she's about to get another big dose of both. The decision to initiate continuous renal replacement was made for hemofiltration to remove solutes such as urea and those two drugs, and to remove fluid excess. So she will have a hemocath inserted percutaneously.
HVVHDF is initiated mid-afternoon. You tell her mom that within a few hours, hopefully before midnight, she'll be much more like herself. Suprisingly, by the end of your shift, she's already improving rapidly. Her urea has fallen by 2/3 and she's awake, coherent and cooperative. Her mom is so happy she gives you a big hug before you leave.
She's not out of the woods yet though; she'll need hemodialysis for several weeks once she's stabilized while her kidneys recover. And she'll need a valve replacement soon. But she's going to be fine.
I'll think about our next scenario. Watch this space.
WOW! Hopefully one day (hopefully soon) I'll be good enough to pick up on all those things. I long for the days where I can be a resource to others as others are to me. :)
Thanks for givin up the answer. I was held in suspense.
Specializes in NICU, PICU, PCVICU and peds oncology.
You're welcome. If you pay attention, ask questions and research things that are new to you, you'll soon be picking up on all kinds of things you're not catching yet. I've got many years of observation behind me, and I have a suspicious nature, so I'm never quite satisfied that it all is as it appears!
Specializes in MICU for 4 years, now PICU for 3 years!.
It's been a while since this thread's had any activity... I was wondering if we could bring it to life again? I'm a new PICU nurse and have learned so much reading this! :)
rn4lyfe08
141 Posts
Could she have thrown clots elsewhere from the endocarditis? Could this be a sign of valve rejection or the new valve not functioning properly?
If a clot's not the cause of her renal failure, and it's not due to insufficient perfusion from the heart, then I'm stumped. Would they do an UD of kidneys?
Lack of perfusion at times could also explain her level of mental alertness/function right? Especially since her supplemental 02 needs are increasing.
Now I'm really stumped.
Couldn't find much on the WWW to help either.