Presenting a Difficult PICU Patient Practice Case
Presenting a Difficult PICU Patient Practice Case
Using the resident's guide to presenting patients during PICU morning rounds, the following is an example of presenting a difficult PICU patient on morning rounds.
Chart Summary
HD 1
14-year-old male admitted from the OR to PICU. Rectal pull through procedure performed under general anesthetic. Extubated and breathing easy in room air with 02 Sats of 93%, awake with good perfusion. Monitored in PICU because of continuous epidural for pain relief. Claforan periop. Family request no blood products for religious reasons.
HD 2
Continuous epidural discontinued. Hemoglobin 12.7, BUN 5, Creatinine 1.3. Transferred to general pediatric area.
HD 3
Tmax 38.5. Abdominal tenderness. Pain meds adjusted. Ceftriaxone.
HD 4
Tmax 39.3. WBC 17,200. Right sided abdominal pain. Upright Chest X-ray shows free air in the abdomen.
HD 5
Tmax 39.5. Peritoneal signs. Exploratory Lap, drainage of intra-abdominal feces, excision of rectal mucosa, repair of anastomotic leak, descending colostomy with Hartman's pouch, placement of left subclavian catheter. JP drains. Thirteen liters of fluid required in the OR. Returned to the PICU intubated; ventilated with need for increasing tidal volumes and PEEP; requiring 9 liters of fluid post op and amrinone 10 mcg/kg/min, dopamine 10 mcg/kg/min to maintain a mean blood pressure of 58. Metabolic acidosis, hypocalcium and hypomagnesmia corrected. Vancomycin, cefotaxime and flagyl IV. Zantac IV prophylaxis. Fentanyl and vecuronium infusions.
HD 6
High frequency oscillator required for hypoxemia. Bilateral loss of lung volumes as well as pleural effusions. Bilateral 8.5F pigtail chest tubes placed. Persistent metabolic acidosis requiring frequent sodium bicarbonate and THAM supplements. Septic shock, Acute Lung Disease, myocardial dysfunction, oliguric renal failure, disseminated intravascular coagulation, liver failure. Echocardiogram shows poor filling secondary to decreased intravascular volume despite continued fluid resuscitation. Continues on amrinone 10 mcg/kg/min, dopamine 10 mcg/kg/min and now epinephrine 0.1 mcg/kg/min. Fentanyl, versed and atracurium infusions. Vancomycin and timentin now for antibiotic coverage. NPO. Receiving central dextrose 5gm/kg/day, amino acids 1.2 gm/kg/day and 20% intralipd at 0.5 gm/kg/day. H/H 8/24. Request to give blood products denied. Erythropoetin begun. Platelets 163,000,PT 27,PTT 59. Creatinine rising from 1.7 to 2.9. Albumin 0.9, lactate 3.7, SGOT 297. Weight 70.7 kg
Increasing abdominal distention leads to exploratory lap, debridement of intra-abdominal pus and silastic patch closure of abdominal wall. Femoral venous and arterial catheters placed and Continuous Arterial Venous Hemofiltration (CAVH) begun without heparinization. Additional femoral artery catheter placed for blood pressure monitoring.
HD 7
Switched from oscillator to conventional ventilation because of improved compliance and oxygenation. CAVH continues, now requiring active heparinization. BUN 56, Creatinine 5.1. SGOT 4274, LDH 3974.
Gram negative rods from blood and peritoneal cultures. Vancomycin, timentin, gentamycin. Continued metabolic acidosis. Insulin added to TPN solution.
HD 8
WBC 38,800. Hematocrit 15. Exploratory lap to drain abscess. Pulmonary artery catheter placed for better monitoring. Blood products refused.
HD 9
This morning CAVH changed to Continuous Arterial Venous Hemofiltration with Dialysis. Ultrafiltrate replaced cc per cc with replacement fluid without potassium. Dialysate running at 1000 cc/hour with KCL and NaPhosphate. GI and chest tube drainage replaced. TPN adjusted up.
The following is available today at 0630 for more detailed review of the patient's status as you prepare for morning rounds.
▪ Clinical exam
▪ Chest X-ray
▪ Pediatric Intensive Care Daily Flow Sheet
▪ Patient Care Kardex
▪ Continuous infusion worksheets
▪ Respiratory Care Ventilator Flow Sheet
▪ Hemodynamic calculations
▪ Lab results
▪ Emergency Drug Sheet
Example of Presenting this Patient during
PICU Morning Rounds
This is the 9th PICU day for John DOE, a 14 yr old 74.3 kg male remains in the PICU for ongoing support of multiorgan dysfunction after an abdominal abscess complicated his initial repair of newly diagnosed Hirshbrung disease.
Post op day # 8 for
Rectal pull through procedure
Post op day # 4 for
Exploratory lap, drainage of intra-abdominal abscess, excision of rectal
mucosa, repair of anastomotic leak, descending colostomy with Hartman's
pouch, placement of left subclavian catheter
Post op day #5 for
Exploratory lap, debridement of intra-abdominal pus and silastic patch
closure of abdominal wall
Post op day #1 for
Exploratory lap, drainage of abscess
His main problems are:
1. Gram negative peritonitis and sepsis
2. Acute Lung Injury (ARDS)
3. Bilateral pleural effusions
4. Septic shock
5. Severe Anemia, Hbg 4.4 gms/dl
6. Disseminated Intravascular Coagulation
7. Oliguric Renal Failure
8. Gastrointestinal and Liver dysfunction
9. Nutritional compromise
10. Hypo-ionizedcalcemia
11. Hypoalbuminemia
12. Hyperglycemia
13. Hyperphosphatemia
14. Technical difficulties with PA Catheter (low light indicator; CVP reading high when cordis infusing with solutions).
System Review:
• Airway
7.5 cuffed oral endotracheal tube, taped at 22 cm, secure, patent with minimal leak and appropriately positioned on CXR exam. Thick green-tan secretions are present on day 11 of intubation.
Plan: Maintain endotracheal tube patency, suction frequently
• Oxygenation/Ventilation
This is day 6 of ventilatory support, 3 of which required high frequency oscillator support for hypoxemia.
Presently, while still paralyzed and sedated, a volume controlled velor hamilton is providing adequate oxygenation (Pa02 160mmHG and Sa02 100%) and ventilation (PaC02 36, pH 7.49) on non-toxic Fi02 of 40%, PEEP 5 with some concern about low grade on-going baro-volutrauma (PIP 44, TV 11ml/kg).
Pleural effusions have resolved with bilateral 8.5F pigtail chest tubes, day #10. 200-500ml /shift chest tube drainage with no air leaks.
Plan:
Maintain ventilator support, attempt to decrease TV to 6ml/kg and PIP < 35, as long as pH > 7.2 (with or without NaHC03 or THAM) and this doesn't interfere with cardiovascular or neurologic function
Maintain chest tubes
CPT q4hr
• Cardiovascular
Ongoing septic shock with poor oxygen delivery and oxygen consumption.
Plan:
- Volume expansion (NSS. Refuses blood and albumin)
- Resume dobutamine 10 mck/kg/min
- May need mild vasopressor after fluid expanded
- PRBC to raise Hbg to 40-45 (refuses blood products)
- Replace calcium, 10% calcium chloride 10-20mg/kg slow push over 1 hour, increase calcium in fluid
- Continue sedation/paralyzation to minimize oxygen consumption
Continue PA catheter monitoring, following oxygen delivery/consumption and Sv02 as make therapeutic changes to maximize oxygen delivery to meet the metabolic needs of the patient.
Change oximetric PA catheter - technical problems
Check for availability and efficacy of blood substitutes to improve oxygen delivery
Appropriate Emergency Drug Sheet at bedside
• Hematologic
Increasing anemia, ongoing caogulopathy and systemic heparinization for CRRT with evidence of ongoing blood loss:
- Serosanguinous drainage chest tubes
- Serosnaguinous drainage JP drains
- Gelatinous red/dark brown drainage from rectal penrose drain
Plan:
- PRBC (refused) or blood substitute if available
- Continue erythropoietin (day 10 (8000u daily IV, 113u/kg/day))
- Iron Dextran
- Vitamin K
- FFP(refused)
- Use just enough heparin to avoid the CRRT filter from clotting(Presently,11u/Kg/hr)
- Avoid blood draws if possible
• Neurologic
Suspect borderline cerebral perfusion and oxygen delivery
Because he requires continued paralyzation and sedation with atracurium 15 mcg/kg/min, fentanyl .03 mcg/kg/min and ativan .05 mg every 4 hours IV to support cardiopulmonary systems, unable to fully evaluate for ICP, focal neurologic problems or seizures
Plan:
- Continue efforts to improve global perfusion pressure and oxygen delivery
- Peripheral nerve stimulator to titrate parylytic to minimum needs (allow synchronization with vent and decrease oxygen consumption)
- If clinically safe, stop paralytic to grossly evaluate neuro status more clearly.
- Adjust fentanyl and ativan to pain/sedation needs - appears adequate at present
- Lacrilube opthalmic ointment
• Gastrointestinal
Continued peritonitis, gastrointestinal and mild liver dysfunction with continued increased fluid loss from abdominal dressing and colostomy.
Plan:
- It is not felt safe to begin trophic feeds today.
- Carafate 1000mg q6hr NG (56 mg/kg/day)
- Aluminum hydroxide and Magnesium hydroxide 30 ml via NG for gastric pH ................
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