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%
What would indicate improved cardiac stability?
- Improved BP
- Decreased Lactate
- Improvement in SvO2
- Improvement in CVP
What is the starting dose of Nitric Oxide (iNO)?
- Rescue dose?
- Maintenance dose?
Start @20 ppm
- Maintenance = 5-20 ppm
- Rescue = 40-80ppm
How is Nitric Oxide (iNO) weaned?
Weaned by 5 ppm every 30 minutes until d/c
How would non-cardiac iNO improvement be observed? (3)
- Increased PaO2>20mmHg
- Increased SaO2 >10%
- Improved hemodynamic stability
What drugs are used for conscious sedations?
- Ketamine for smaller kids
- Propofol for teens and up
What is PRAM?
A score that assess asthma severity
- Asthma protocol is based off of PRAM
What is Asthma Protocol for mild Asthma?
- Range?
- Treatments?
- mild range = 0-4
- Treated w/Ventolin
What is Asthma Protocol for moderate Asthma?
- Range?
- Treatments?
- Moderate = 5-8
- Treated w/Ventolin, Atrovent, and Dexamethasone
- (SABA+SAMA+ICS)
What is Asthma Protocol for Severe Asthma?
- Range?
- Treatments?
- Range = 9-12
- Treated w/nebs for O2 requirement and respiratory failure
Atrovent dose for Asthma Protocol?
Ipratropium (Atrovent) 4 puffs or 750mcg
Salbutamol (ventolin) dosage for asthma protocol?
- Pts <20kg = 5 puffs or 7.5mg neb
- Pts >20kg = 10 puffs or 15 mg neb
Dexamethasone dose for asthma protocol?
0.3mg/kg
- Comes in 4mg/ml PO liquid
- Corticosteroid
What is asthma protocol for pharmalogical administration?
Back to Back (B2B)
- Puffs q20mins x3
- Should take about an hour
- Reassess and stretch as tolerable
What are common causes of Hypovolemic shock in pediatric patients?
- Hx of vomiting and diarrhea
- Underlining sepsis
Treatment/steps to manage Hypovolemic shock for pediatric patients (4)
- 20ml/kg normal saline bolus until improvement in BP
- Once fluids are no longer working, switch to an inotrope (after 3 x 20mL/kg boluses in succession)
- Think about antibiotics early in sepsis
- reassess perfusion and cardiac function
What is Alberta Children’s Hospital Early Warning Score (ACHEWS)?
Score calculate 7 vitals to assess need for STEP (transitional personal for decompensating pts) activation
- RR, WOB, SpO2, O2, HR, Cap refill, BP
Which ACHEWs scores indicate the need for different personal?
- A score of ≥9 is an automatic STEP activation
- A score of 5-8 or change by 4 may involve RRT to assess patient
What drug is most commonly used in PICU for Seizure control?
Midazolam
Why are asthmatic patients generally contraindicated for intubation?
- What is used instead?
Its hard to get pediatrics off of ventilation
- Air trapping, Auto PEEP and acidosis are common complications
- NIV is used to avoid intubation
- Which neuromuscular blocker spares potassium?
- Which neuromuscular blocker does not spare potassium?
- Rocuronium is a non depolarizing agent that protects potassium
- Succinylcholine causes concern if pediatrics will have potassiu missues
What is Milrinone used for?
CVS medication used for long term CHF
- Increases myocardial contractility and decreased preload and afterload
Why are Asthmatic kids who’ve been intubated difficult to manage?
- Difficult to ventilate
- Sedation causes mass vasodilation and myocardial depression
- Poor venous return caused by air trapping will cause the Pt to be hypotensive
Why is ketamine used to intubate kids?
Doesn’t cause hypotension while retaining bronchodilator effects
What ventilation mode is used for kids?
PRVC or PC. not VC
How do you check for auto peep?
Expiratory hold
How does sedation lead to mass vasodilation in kids?
- How is vasodilation and subsequent hypotension managed?
Sedatives depress natural catecholamines like norepi, epi, and dopamine.
- hypotension needs to be kept in check with fluid bolius and resus dose of epi at bedside
What are death spells?
When patient get agitated, they bare down vagaling themselves
- HR and SpO2 drop rapidly
- Must bag, suction, and use paralytics
Vent strategies for RSV/Bronchiolitis?
Similar to asthmatic strats.
- Long Te
- Maintain adequate PEEP
- Will often have death spells
Vent strategies for asthmatic pediatrics?
Allow for long Te while maintaing PEEP to prevent derecruitment.
Treatments for RSV/Bronchiolitis for pediatrics?
- Supportive care
- Suction nares
- +/- nebs and epi nebs if needed
- Vent as last resort (kid desats)
Traumatic brain injury (TBI) parameters and management for pediatrics? (6)
- low normal CO2 35-40mmHg
- PaO2 >80mmHg
- Trendelenburg
- Sedation bolus before ongoing procedure like suction or position change
- manage ICP (CPP >60, ICP ideally <20)
- Watch for Cushing triad
What is CPP comprised of?
ICP and MAP
What drugs can help manage ICP?
Mannitol and 3% saline bolus
- barely used in kids
What are SpO2 goals for cyanotic heart defects?
SpO2 goals 75-85%
- Don’t be afraid if these patients look blue. They are just shunting.
Ventilation goals for (R->L) shunts?
- Need to fact check, don’t worry about this slide for now.
High CO2s w/pH 7.20
- Lowest PO2 possible (keep SpO2 75-80) to keep PVR high
- the goal is to strike a balance in the system before operations
What are the 3 classic signs associated with Cushing triad?
- Systolic hypertension (widening pulse pressure)
- Bradycardia
- Irregular/abnormal respirations (Cheyne-stokes Breathing)
What does Cushing’s Triad reflect about patient condition?
Reflects life threatening increase in ICP.
- 3 signs of Cushings triad is the bodies attempt to maintain sufficient blood flow and oxygenation to the brain despite increased pressure in the skull
Why does LVRM assist in restrictive conditions and/or post op/SCI injury patients?
LVRMs help maintain lung volume, prevent atelectasis, and improve airway clearance.
- The above conditions reduce inspiratory effort and inability to take deep breaths = under inflated lungs
Why would post op patients be at risk of atelectasis?
Post op pain leads to shallow breaths and risk of atelectasis due to pain/immobility
- LVRMS post op can assist in reexpanding alveolar units and prevent post op complications by improving oxygenation
