Pediatric scenario

[Carlos Danger]

if all we have is an LTV1200 and adult vent circuit, what can we do here to successfully get this patient on the machine? Settings/tips & tricks?

I missed in the original post about the adult circuit.

The main problem with the larger circuit is that with their increased volume, they are effectively much more compliant than the pedi ones. This means that both the "space" and the "stretch" of the tubing can effectively "absorb" pressure and volume differently from breath to breath, and confuse the ventilator's flow sensor and manometer into thinking it is delivering more or less volume than it actually is. In adults it isn't an issue because the compliance changes amount to a very small fraction of what is being being delivered. In a small ped though, it is a much larger part of the desired tidal volume and can potentially cause significant over- or under-ventilation. Even with ped tubing, this kid is right at the lower limit of what the LTV1200 is supposed to be used for (IIRC, 10kg is the smallest?)?

As far as tricks, I don't know if increasing the bias flow (can you even do that on the LTV?) would help, or would that make the vent even more sensitive to the circuit? I imagine adding more PEEP than you otherwise might, and keeping them relaxed and using VCV would probably minimize breath-to-breath changes and the influence that the additional circuit volume and compliance has on what the vent senses. This might work OK on a healthy kid who is ventilating easily, but a kid like the one described here just needs to be carefully hand ventilated if you don't have the proper equipment.

 

[E tank]

Good to know, thank you. That said, isn’t 140-150 indicative of appropriate cardiac compensation for a 2yr-old? If you’re running Epi or Dopamine to try to inc C/O, what’s your upper HR limit?

A single number doesn't really mean anything out of the context of the situation. A HR of 150 without pulses.....but like I said, an inopressor is only appropriate when you've done everything else you're supposed to be doing, ie, volume/rbc's or as a stop gap while you do those things. My upper limit in a situation like this is any perfusing number with a p wave.

And don't lets get started on giving NS to a cold, acidotic patient in shock....Still trying to figure out the levophed too...

 

[Peak]

CPR, .11 mg epi IV, consider electricity. We could do an antidysrhythmic if he is refractory, although I'd hate to tank his already fragile pressures. Repeat labs if possible, I suspect that he is still profoundly anemic and his ABG is probably getting worse and that this is the root cause of his dysrhythmia; I would plan on pushing blood in fast and giving at least another dose of bicarb. Goal of a hgb of at least 6 and a crit of 20, if he is a splenic sequestration this does place him at risk of being in overload down the road but he just isn't perfusing now. Goal PH of at least 7.1. Continue my previous plan of care otherwise.

Do you know what his underlying pathology ended up being?

 

[TXmed]

So this patient suffered from several things.

This patient was suffering from spleenic sequestration that ruptured when given fluids to quickly.
Her renal arteries infarcted as well as her bowel. She was in DIC with an INR >10.
The BGL read 10 at the receiving. The Potassium was 7.8 at the receiving, 3 something at the sending. so you can add hypoglycemic & hyperkalemic.

I was not nearly as knowledgeable about the critical care aspects of sickle cell anemia prior to this call as what i probably should have been. This was definitely one i learned from. Thanks for yalls input.

 

[VFlutter]

Good scenario, thank you for sharing

This is one of those situations when you do the best you can knowing it will probably not be good enough. The patient is going to die at the referring facility and the only viable chance of survival is a more capable facility. You fix what you can and go.

 

[Peak]

This kid sounds incredibly sick. The amount of resources he needs for any kind of positive outcome are going to be astronomical, and having a referring doc who is playing games isn't going to help any. Like Vflutter said, this is a case where you do the best you can and hope it's enough to get to a referral facility. Even if you didn't know everything about the pathology you clearly know your stuff if you managed to keep this kid alive until you got to the PICU.

From an education standpoint this kid is sick beyond the general guidelines, but if you ever want to look up information CHOP (not my hospital) publishes their clinical guidelines and UpToDate is always a good quick read. If you want any more information that what you have already found feel free to send me a PM.

 

[NPO]

Thanks for posting this scenario. This patient encounter was WELL beyond my level of training and experience, but as I prepare for higher education and more critical care training, I read these and absorb what I can.

It sounds like this kid was very sick, and the sending facility was not equipped to deal with it, and the provider was not helping either.