PICU

Question 1

Pathology of a stress ulcer

Answer 1

Stress, splanchinc hypoperfusion, gastric mucosal breakdown and impaired gastric motility, leading to prolonged gastric acid exposure.

Question 2

What are some regmens for stress ulcer

Answer 2

PPI’s… max effect not until 48 hrs
H2 antagonists, quicker onset of action but less effective
*neither of these demostrated decreased mortality, ICU stay, rate of HAP/VAP, or rate of ulcers on meta analysis

Question 3

What are you supposed to use if there is a stress ulcer and a risk of thrombocytopenia?

Answer 3

PPI’s

-use if Plt <50,000… cimetidine inhibits cytP450 (this is a problem with PPI useage)

Question 4

Incidence of DVT in kiddos compared to adults

Answer 4

10x lower

Question 5

main ICU risk factor for DVT?

Answer 5

CVL (central line?), the other risk factors are what you think they are, immobility etc…

Question 6

Does a negative U/S rule out a DVT?

Answer 6

absolutely not because it has low sensitivity

-so, if you have high suspicion, treat until able to confirm with contrast CT or venogram (gold standard)

Question 7

What do you do for DVT ppx in kiddos?

Answer 7

TEDs or pneumoboots, rarely LMWH

• no benefit of ppx in trauma pts <13 yo or with warfarin in pedi-onc pts w/ CVL
• Bottom line: consider ppx for adult sized pts with significant risk factors (long term immobiliation, CVC, malignancy)

Question 8

What is a good way to decrease catheter related blood stream infections?

Answer 8

• CVC care bundle whatever that is… (ask them on rotation)
• decrease insertion time and use of parenteral nutrition??
• only use chlorhexadine prep if child is older than 6 months

Question 9

Oral to IV equivalents of analgesics

Answer 9

Morphine 30 to 10

Dilaudid 7.5 to 1.5

Question 10

Which analgesic has the quickest onset of action?

Answer 10

fentanyl (look at book for dosing cuz it’s nutzo)

Question 11

Peds dosing of dilaudid

Answer 11

0.015 mg/kg/dose q3-6h prn

Question 12

dosing for morphine

Answer 12

0.05 mg/kg/dose, usual 0.1-0.2 mg/kg /dose q2-4 h prn (max 15 mg/dose)

Question 13

Define respiratory failure

Answer 13

Failure of xygenation, ventilation, gas exchange or airway protection

• PaO2 <60
• PaCO2>50
• pH< 7.35
• if chronic resp innsuff, acute hypercarbia is an increase in PCO2 20mm Hg above baseline

Question 14

workup for resp failure

Answer 14

ABG (VBG to r/o hypercapnea), CXR (r/o PNA, edema), consider CBC (anemia), CT (if suspect PE), ECHO, BNP (if suspect shunt or CHF)

Question 15

Oh god… calculation for the A-a gradient

Answer 15

PAO2-PaO2 - (FiO2 x 713)- (PaCO2/0.8)

Question 16

What is the normal value for the A-a gradient?

Answer 16

about 2.5 + (0.21 x age in years)

Question 17

What is PaO2/ FiO2 ratio used for?

Answer 17

this is called the oxygenation index and it’s used to measure severity

• normal >300
• ALI: 201-300
• ARDS <200

Question 18

How does one measure PaCO2?

Answer 18

just think about CO2 production/ alveolar ventilation

• the equation is k x (VCO2/ (RR x VT x (1-VD/VT)))
• so, use this to watch out for hypercapnea (increased PaCO2)

Question 19

What are the different etiologies of Hypoxemia (decreased Pa O2)

Answer 19

• Hypoventilation
• O2 delivery/consumption imbalance
• True Shunt
• VQ mismatch

Question 20

What is specific about a true shunt,

Answer 20

it does NOT correct with O2

Question 21

What etiology of hypoxemia DOES correct with O2

Answer 21

VQ mismatch suckaaaaa

Question 22

What is the actual difference between CPAP and BiPAP?

Answer 22

• CPAP: continuous PEEP. Useful for HYPOXIA (Atelectasis, edema, OSA, HMD)
• BiPAP: Pt-triggered PIP + CPAP. Useful for HYPOVENTILATION (CF, NM disease)

Question 23

What are the invasive options for mechanical ventilation?

Answer 23

• Support (PS/VS)
• Assist/control (AC)
• SIMV
• HFOV

Question 24

What is support mechanical ventilation

Answer 24

spont breaths assisted to reach goal pressure (P) or volume (V)

• no set rate, pt MUST initiate breaths. Pt determines inspiration time
• less efficient if ETT leak

Question 25

What is AC with regards to mechanical ventilation?

Answer 25

• Assist/control (AC): vent delivers minimum # of supported breaths (synch to pt effort) with add’l pt-initiated breaths getting full assist to reach goal P or V 2. controlled inspiration time
• downside: uncomfortable, dyssynchrony and auto-PEEP (breath stacking)

Question 26

What is SIMV (mechanical ventilation)?

Answer 26

Vent delivers minimum #of supported breaths (sync to pt effort) but add’l pt-initiated breaths get no assist. May add PS to assist spont breaths (SIMV + PS)
*downside: inc resp effort (pt must overcome circuit resistance during spont breaths)

Question 27

What is HFOV (mechanical ventilation)?

Answer 27

Rapid oscillatory breaths given at set frequency (Hz); manipulate MAP and change in Pressure

• downside: can easily hypervent. Vent change may take longer to equilibrate on blood gas
• used when conventional ventilation fails
• initial trials supporting HFOV over conventional vent strategies were done before ARDSNet low TV protocols, which appear to have the same mortality. They are likely equal but HFOV may be an easier way to obtain the same result (Crit Care 2005)

Question 28

What do you do with acute desaturation in pts w/ artificial airway on mechanical ventilator?

Answer 28

Think DOPE

• Dislodgement (ETT)
• Obstruction (musuc plug)
• Pneumothorax
• Equipment failure
• remember that oxygenation depends on mean airway pressure and ventilation depends on minute ventilation and dead space

Question 29

What parameters does conventional ventilation increase?

Answer 29

RR, FiO2, PEEP, PIP, inspiration time (though it should not be first line for this)

Question 30

What parameters does HFOV increase?

Answer 30

MAP and change in pressure

Question 31

What 3 parameters will increase the pCO2?

Answer 31

RR, PIP, and change in pressure

Question 32

What are the extubation readiness criteria?

Answer 32

• Pt awake 2/ intact airway reflexes (cough, gag), hemodynamicall stable, manageable secretions, acceptable gas exchange, P2 requirement <40%
• Air leak: used to predict upper airway obstruction (swelling) after extubation… presence of audible leak around ETT @ <25 cm H20, consider steroids if no leak (role unclear, may decrease risk re intubation), negative inpiratory fice: strenght of resp muscles in pts w/ neuomuc weakness (NIF > 30 mm Hg.. not validated in children… unreliable
• Spontaneous breathing trial (CPAP or PS + PEEP) prior to extubation

Question 33

What dose of steroids do you give a kid who does not have an audible leak from ETT when considering extubation?

Answer 33

decadron 0.5 mg/kg q6h x 6, 12 hr prior to extubate (crit car med 1996)