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.
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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:
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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
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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 barovolutrauma (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
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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
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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
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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
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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 <5.0
- Ranitidine 1mg/kg/day in TPN.
- Discuss replacement of colostomy and abdominal dressing losses
with surgery and nephrology
- Surgery continues to monitor peritonitis and continued surgical needs
Example of Presenting this Patient during
PICU Morning Rounds (continued)
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Infectious/Immune
Continued systemic inflammatory response syndrome from gram negative sepsis
and peritonitis
Plan:
- Maintain antibiotics (renal failure doses but may need adjustment
since on CRRT)
- Clavulanate-ticarcillin 3.1G q12h (88 mg/kg/d)
- Ciproflaxin 400 mg IV daily (5.6mg/kg/d)
- Metronidazole 500 mg MG q6h (7mg/kg/d)
- Fluconazole 100 mg IV daily (1.4mg/kg/d)
- Sulfadiazine cream to abdominal wound QID with dressing
changes
- Peritoneal cultures pending from last operation, adjust as needed.
- CRRT may be removing "unwanted" cytokines but may also be
removing "good" cytokines. However, consider increasing ultrafiltrate
rate since there is some evidence of improvement in systemic
inflammatory symptoms with increased ultrafiltration rates
- Consider blood, tracheal aspirate, urine cultures today- monitoring
for nosocomial infections
- Monitor for recurrent abscess collection intra-abdominally
- Investigate if there are any systemic anticytokines, free radical
scavengers, monoclonal antibodies to endotoxin, etc. that are available
to assist in subduing the SIRS.
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Orthopedic/dermatologic
Stable
Plan:
Ostomy care
- While paralyzed and heavily sedated
- Passive range of motion to extremities
- OT/PT - Sneakers to feet to avoid foot drop
- Dynamic air bed (rotates/CPT every 2 hours)
Renal, Fluid/Electrolytes/Endocrine (*Maintenance IV rate for weight
would be 104ml/hr, 2496ml/day)
- Continued oliguric renal failure with total body overload but
suspected decreased intravascular volume
- Mild hyperglycemia (252)
- Hypoalbuminemia(3.0)
- Hypochloridemia (97)
- Hypertriglceridemia (283)
- Hyperuricemia (7.5)
- CRRT day 4 using an
- Amicon 20 Filter, intact
- Femoral Arteriovenous CAVH (9 days), CAVH-D (day 1)
- Dianeal Impersol 1.5% Dextrose at 1000 ml/hr for dialysis
- Ultrafiltrate replacement fluid of 0.45 NACL with 60 mEq/l NaHC03
and 3.5 mEq KCL/L, replace ultrafiltrate cc/cc every hour, post filter
(average 500-600ml/hr)
- Ultrafiltrate collection bag 18 inches below filter, adjusting height to
maintain ultrafiltration rate, averaging 400-600 ml/hr
- Heparin 25,000 u/25ml, 800u/hr pre-filter.
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Total Ultrafiltrate Replacement Fluid= 9225ml
TPN = 2175ml
Lipids = 414ml
Atracurium infusion = 172ml
Fentanyl infusion = 38ml
Aline = 71ml
PAP = 70ml
CVP = 71ml
Heparin = 134ml
Flushes/meds = 996ml
(4141ml/day above maintenance)
(Total input without replacement = 172ml/hr)
Total In = 13,366
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Total Ultrafiltrate = 9700ml
U.O. = 292ml
Colostomy = 1840ml
Abdominal dressing = 1320
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NG = 450
JP = 28ml
Chest tubes = 1021ml
Peritoneal = 28ml
(total patient output = 207ml/hr)
Total out = 14,679
Net negative 1313 ml/24 hr
Plan:
After feel intravascular replete today, in order to assist with oxygen
delivery, will adjust ultrafiltrate replacement fluid to allow slow daily
negative balance that helps to reduce total body overload slowly but
maintains adequate filling pressures for oxygen delivery needs.
Adjust dialysis solution and rate with nephrology input to allow optimal
nutrition while kidneys have time to heal
Hourly adjustment of ultrafiltrate replacement depending on clinical
status with above plans
Monitor electrolytes, glucose, PO4, Mg.ionized Ca, BUN, Cr BID
Adjust UF replacement fluid as needed to maintain above.
Adjust medications because of renal failure and CRRT; ask
pharmacology for assistance
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Nutrition
Nutritionally compromised
Presently
NPO
with central nutritional support of
Novamine 3.5gm% with 20% Dextrose and 20% Intralipid
Received:
36 ml/kg/day (1.03 x maintenance)
37 cal/kg/day
32 NPC/kg/day
Total calories 2611: 56% carbohydrate, 32% fat, 11.6% protein.
NPC:N ration 190:1
CHO 6.16 gram/kg/day, 4.27mg/kg/min
Fat 1.17 gm/kg/day
Protein 1.07gm/kg/day
Na 4.3 mEq/kg/day
K 0.6 mEq/kg/day
Mg .07 mEq/kg/day
Ca 0.6 mEq/kg/day
Acetate 3 mEq/kg/day
Cl 1 mEq/kg/day
PO4 0.6 mMol/kg/day
ZnCl 90 mcg/kg/day
MTE-4 .06ml/kg/day
MVI-12 0.14 ml/kg/day
Ranitidine 1mg/kg/day
Iron Dextran 0.7 mg/kg/day
Vitamin K 0.14 mg/kg/day
Insulin,human 1.2u/kg/day (.05u/kg/hr)
Receiving 1u insulin/hr for every 5 grams of glucose an hour
Plan:
Goals: Metabolic Cart from yesterday suggested 4800 R.E.E.
Maximize central TPN calories to come as close as possible to 4800
cal/day, help with tissue repair, assist immune system, improve renal
recovery using
- Maximum Glucose concentration of 20% to avoid clots, but increase
glucose load to 15-20gm/kg/day, keeping glucose calories around 50%
of total IV calories.
May need to titrate insulin (1u insulin/hr per 5 grams of glucose/hr) to
avoid hyperglycemia but this is common with sepsis (glucose
intolerance).
Watch for evidence of C02 overload from glucose load as try to wean
ventilator.
- Maximum lipids 3-4gm/kg/day over 24 hours, keeping fat calories at
40% total IV calories, although some believe you need to limit the
amount of IV lipids during sepsis.
Triglycerides are moderately elevated, common in sepsis. Monitor.
- Maximize protein to 2-2.5gm/kg/day, total protein calories about
10% total IV calories and NPC:N ratio 150:1 or better.
CRRT will minimize BUN rise.
- May need more fluids to deliver this caloric goal but CRRT can be
used to adjust total fluid balance.
- Increase Cl, decrease PO4, increase insulin in TPN ( 1u insulin/hr for
every 5 gram glucose /hr)
- If use 20% Dextrose, 3.5% AA solution at 147 ml/h and 20% lipid at
40ml/hr x 24 hours, this will provide:
63ml/kg/day fluid
4813 cal/day (68 cal/kg/day)
61 NPC/kg/day
CHO 50%,Fat 40%,Protein 10% calories
NPC:N 217:1
CHO 9.98 gm/kg/day, 6.9mg/kg/min
Fat 2.7 gm/kg/day
Prot 1.75 gm/kg/day
Adjust electrolytes,trace minerals, insulin for new rate.
Medication Review
Type
Dose/kg/day
Duration of medication
Needed?
Clavulanate-ticarcillin
Metronidazole
Ciprofloxacin
Sulfadiazine cream to wound
Fluconazole
Lacrilube to eyes
Fentanyl
Atracurium
Lorazepam
Sucralfate
Ranitidine
Aluminum hydroxide & magnesium hydroxide
Heparin
Erythropoietin
Iron Dextran
Vitamin K
Insulin, human
Patient comfort/pain management/withdrawal support measures
in place?
Yes
Lines, catheters
Type
Location
Duration
Needed?
7.5 cuffed oral endotracheal tube
NG
7.5 F oximetric PA catheter, left subclavian
Bilateral 8.5F pigtail chest tubes
Peritoneal catheter
JP drains x 2
Colostomy
Foley
Penrose drain, rectum
Femoral arterial line, bilaterally ( one for BP monitoring,
one for CRRT)
Right femoral venous line
Monitoring
Type
Adequate?
Cardiac monitor
Continuous arterial pressure
Continuous CVP, PAP
Intermittent CI, PCWP, O2 delivery, O2 consumption
Oximeter
Sv02 monitor
End tidal C02 monitor
Leonardo respiratory mechanics monitor
Adding: Peripheral nerve stimulator
Changing: Oximetric PA catheter to new one
Radiology and lab standing orders
Needed?
Daily CXR
Labs as per system plans
Primary caregivers
Parents have been updated on clinical care
Blood products discussed.
Social service and pastoral support in place
Discharge planning and teaching is on hold because of
seriousness of illness
Parents updated on clinical course
Referring physician updated?
Referring physician will be called today. She called yesterday
for update.