PICU General Flashcards
8 questions (2 neuro drug, 1 DKA, 3 Ped Asthma, 2 application of procedure (ie. LVRM)
- Review slide 13…its horrible
- Review slide 19 for responsibilities
What are complications that come with Diabetic Ketoacidosis (DKA)?
- ABG?
- Breathing?
- Core issue?
Not ideal to intubate because it is not a respiratory problem.
- Need to correct glucose (but not too quickly)
- Kussmauls breathing
- Low pH and high CO2
Why shouldn’t you intubate or take over the breathing for a patient with Diabetic Ketoacidosis (DKA)?
DKA will be accompanied with Kussmaul breathing patterns from the patient which would be more efficient at ventilating than what we could support.
- Kussmaul patterns have big vt, rapid breathing, and big minute ventilation
- Intubation could also suppress the pts respiratory drive
What are some issues with Ketamine?
- Slow onset
- Sedation suppresses cough
- Stimulation to vocal cords on conscious Pts could cause laryngospasm
What safety equipment should be kept on hand when sedation agents like ketamine are administered?
Bagger (CPAP/PEEP) and Succinylcholine to paralyze them right away
- succinylcholine is kept on hand incase additional muscle relaxation is needed (that ketamine can’t provide) rapidly, espesially when worried about laryngosapsm
- 5 minutes?
What is the max allotted time that Propofol should be administered on a pediatric patient?
- Why?
No longer than 24 hours
- Causes lactic acidosis via propofol infusion syndrome
What is propofol infusion syndrome (PRIS)? (4)
When prolonged use of propofol leads to:
- Severe metabolic acidosis,
- Rhabdomyolysis (breakdown of muscle tissue -> releases myoglobin into blood stream = kidney damage)
- Hyperlipidemia (elevated levels of fat in the blood)
- multi-organ failure
What presentation may change ventilation strategies in pediatrics on initial assessment?
Distended abdomen
What pressures are used for pediatric patients receiving a LVRM procedure? (3)
- <10kg @30cmH2O
- 10-20 @35cmH2O
- > 30 @40cmH2O
What patients group would benefit from LVRM?
- Cerebral palsy patients/Neuro disease pathologies
- SCI and chest wall disorders
- COPD Patients
- Prolonged/vent depdenant pts
What is the goal of LVRM?
Open up as many alveolar units as possible with a high inspiratory pressure
- LVRM also aides in secretion clearance
- Stacks breaths, needs to be correlated w/patient
Is LVRM performed with a bagger or a ventialtor?
Both can be used. Use them to essentially stack pts breaths.
- Bagger is preferred in pediatrics
- Clamping the ETT before switching is best practice to prevent loss in PEEP
Indications for LVRM? (4)
- After vent circuit disconnect
- After suctioning
- CXR shows atelectasis
- Prior to initiation on HFO
What are absolute contraindications for LVRM?(3)
- Pulmonary air leaks (recent/active pneumothorax, PIE), BP-fistula
- Hemodynamic instability (low BP)
- Obstructive lung disease
What are relative contraindications for LVRM? (5)
- Unilateral lung disease
- Head injury (increased ICP)
- COPD complicated by ARDS
- Pregnancy
- No artline in place
When is PEEP said to be optimal?
- oxygenation is maximized
- minimal end-expiratory atelectasis
- minimal end-inspiratory over distension
Interpretation of Oxygen Index (OI) values:
- What are normal values
- What do high values indicate?
- OI calculation?
A lower OI indicates better oxygenation and less severe respiratory compromise.
- OI 5-10 = mild to moderate respiratory distress.
- OI 10-20 = moderate to severe respiratory distress.
- OI >20 is considered severe respiratory failure.
LVRM manual procedure?
LVRM ventilator/Servoi procedure?
What are 4 things that must be met before extubation can proceed (assuming SBT has passed)
- Ensure cuff leak
- Cough and gag
- Sedation off
- NPO 4 hours prior
What parameters should be met for the Extubation Readiness Test (ERT)
- FiO2 < 0.5
- [PSV Delta8/+5] or [Delta6/+5 if ETT dependent] for 30-120 mins
- Settings dependent on Pt need, some are extubated right to NIV.
When would you discontinue Extubation Readiness Test (ERT)?
- vitals?
- Supporative parameters?
Generally, 20% increases in any parameters or complete apnea/RR
- If RR increases by 20% (or no RR)
- Vt <5 ml/kg
- Increased EtCO2 of 15
- Increased FiO2 >0.5
- HR 20% or Increased WOB
What equipment should be ready during extubation?
- Extubate off bagger
- Suction ready
- Re-intubation equipment outside room
What are indications for Nitric Oxide (iNO) for pediatric patents? (3)
- suspicion of pulmonary hypertension that cannot be explained by significant pulmonary disease
- RV failure (RV>45) secondary to myocarditis or cardiomyopathy
- Demonstrated significant (R->L) shunt causing systemic hypoxemia
- What is maintenance algorithm for Nitric Oxide (iNO) use?
- How soon do you assess vitals after initiating cardiac iNO?
- How soon do you assess vitals after initiating non cardiac iNO?
- Assess after 1 hour after initiation
- Assess after 30-60 mins after initiation
What are indications of improvement from Nitric Oxide (iNO)?
- Improved RV function via echocardiogram
- Improved cardiac stability
- Improved mixed SvO2
- Decreased (R->L) shunt w/improved SaO2>10%