BCC4: Lockie on Little Adults
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Frank Lockie, paediatric intensivist, discusses how kids are just little adults at Bedside Critical Care Conference 4 (Cairns, 2013) The podcasts accompanying these slides will be uploaded onto www.intensivecarenetwork.com and libsyn.
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BCC4: Lockie on Little Adults
- 1. Kids: Just Little Adults? Dr Fran Lockie MedSTAR Paediatric Emergency, Women’s and Children’s Bedside Critical Care, September 2013
- 2. Scope • Case • Why are we scared? • Structured approach – Airway, – Breathing – Circulation • Can we do better?
- 3. 15 month old male with fever • • • • • NVD at term, BW 2.7kg Previously fit and well No meds, NKDA Immunisations UTD Family all coryzal
- 4. Country Hospital • At triage (17:30) – Alert and playful – Temp 39, Hr 160, Rr 40 – Good central perfusion – Mottled peripherally
- 5. 18:45 Seen by RMO • Given panadol with resolution of fever, HR never < 170 since triage • Bloods – VBG pH 7.15, BE -10, B/C 10, lact 5, CO2 25 – BSL 6 • Urine NAD
- 6. URTI focus for fever identified • 2 small vomits in waiting room, then a small area of petechiae
- 7. 21:00 Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes
- 8. 22:00 • • • • • A Maintained, No O2 B RR 60, marked increased resp effort C peripheral CRT: absent, central >5 secs D alert, talking to mum 24g PIV tissued, further attempts unsuccessful
- 9. Rapid deterioration – AVPU – Increasing respiratory distress – HR >200, Only femoral pulse palpable – IO sited – Aggressive filling – DA started
- 10. Ketamine, sux, adrenaline bolus
- 11. PEA Arrest • Filling, filling, filling • Dopamine started at 20mcg/kg/min • Filling, filling, filling – 4% albumin – Blood products (packed cells, plts, FFP, cryo) • Noradrenaline, Adrenaline, infusions commenced • Stat dose hydrocortisone
- 12. 6hrs later….still PEA / ROSC • • • • • Maximal inotropic / pressor support multiple dextrose, Ca, Mg boluses Total fluids 180ml/kg Sustained bradycardia, worsening acidosis Massive pulmonary haemorrhage
- 13. • Parents present throughout • RIP, 03:00
- 14. We are scared of kids! • Kids need early aggressive treatment • Failure to diagnose shock • Failure to resuscitate – Early access – Early fluids – Early Abx – Early inotropes (peripheral is OK!) – Early intubation – Evaluate our actions: lactate and physiology
- 15. • Audit of 17 PICU’s • 107 patients with septic shock • 8% received care c/w ACCM guideline – 21% not given >60ml/kg despite ongoing shock – 15% not given dopa/ dobu despite fluid refractory shock – 23% not given catechol for dopa/ dobu refractory shock – 30% not given steroid despite catechol resistant shock Arch Dis Child 2009
- 16. • FAILURE TO DIAGNOSE SHOCK • 3 factors – Not looked after by a paediatrician – Lack of supervision – Failure to administer inotropes BMJ 2005
- 17. Early Resuscitation of Children with Moderate to severe TBI • 299 kids with mod-severe TBI • 39% became hypotensive – Of these only 48% were treated • 44% became hypoxic – Of these 92% were treated Pediatrics 2009;124;56
- 18. • • • • • ED staff Anaethetics Theatre staff Standardised scenarios Causes of error Resuscitation, in Press 2013
- 19. 75 Simulations 12.4 doctors / nurses per session 194 incidents of subobtimal care Resuscitation, in Press 2013
- 20. We are Solutions… scared of kids!
- 21. Train together! • One Base • Adult teams – ED – Intensivists – Anaesthetists • Paediatric and neonatal teams • Special operations paramedics
- 24. • • • • • • Teamwork Leadership Crew Resource Management Resus drills Intubation drills Competency frameworks
- 27. Ann Emerg Med. 2012 Kids have smaller FRC Greater VO2 than adults Rapid desaturation (with stress and apnoea)
- 28. Ann Emerg Med. 2012
- 29. Ann Emerg Med. 2012
- 30. Levitan: Dentition, disruption, disproportion, dysmobility
- 31. Levitan: 4Ds
- 32. “Doctor, He’s Tiring!” • Diaphragmatic exhaustion • Lacks type 1 muscle fibres • Decompress the stomach – Often results in dramatic improvement! • Know your vent: wt limits – Generally TV 4-6 ml/kg
- 33. • • • • • 95 patients Mean age 5.5 95% success 10 seconds or less Pain score 2.3 Pediatr Ermerg Care 2008
- 34. SAFE study Sepsis resuscitation (FEAST) Trauma resusitation / massive transfusion
- 35. Is administering inotropes peripherally safe? Inotrope
- 36. • 73 of 1133 treated with vasoactive agents by peripheral IV • Primarily Dopamine monotherapy (90%) or Dop + Ad (7%) • 11/73 (15%) developed infiltration – all resolved without significant intervention • Longer duration • Higher dose of dopamine Pediatr Emerg Care 2010
- 37. Sugar and temperature • • • • Large SA: body wt (2-2.5 x BW) Thin skin and subcut fat (less insulation) No shivering Immature thermoregulatory center • Sugar ALWAYS goes down in critical illness…
- 38. Lancet 2011; 377: 1011–18 • Listen to the physiology!
- 39. Lancet 2011; 377: 1011–18
- 40. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? I
- 41. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? No, but sepsis often masquerades as respiratory disease in kids I
- 42. If you still can’t explain it… • Always assume ingestion • Always assume inflicted injury
- 43. Smaller but the same • Train together?? • Golden rules – – – – – – PEEP NGT VBG + Physiology Early inotropes Ingestion / inflicted Pink, warm and sweet
Editor's Notes
- ----- Meeting Notes (22/09/13 00:55) ----- We want kids to be well! bias Let's not forget critical illness is rare! Vast majority of material is extrapolated from adult literature: I'd like to add one or two caveats to this and we'll address them in our structured approach ----- Meeting Notes (22/09/13 15:02) ----- changing with PECARN, PERC, PREDICT
- Lives with me and affects the way I practice medicine on a daily basis
- Sad & Unfortunate case Most of us agree there were opportunities lost where time critical interventions may have altered the outcome for this little child Key are: Missed diagnosis Failure to diagnose shock Failure to aggressively resusitate Good news is they will survive!
- How good are we at implementing ACCM guidelines. C/W ACCM guideline NOT timeline! Replicated in other setting including surviving sepsis campaign audit’s.
- Case controlled study INDEPENDENTLY ASSOCIATED WITH INCREASED RISK OF DEATH
- This study from UTAH worried me a lot OBJECTIVES: Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary UTAH brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during “early” (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge. METHODS: This was a retrospective study of 299 children with moderate- to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care. RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of “early care.” Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension. CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes
- Examples of scenarios Knowledge Clinical skills Leadership Communication Resourse utlisation Anticipation and planning Situational awareness
- Examples: Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus This is not just in paeds This is the (hopefully present)
- This really tells the main story of do I think kids are small adults. At medstar we run joint scenarios. Day in and day out we are amazed at how the similarities outweigh the differences! Particularly in the vital areas of clinical decision making, CRM, leadership and teamwork
- Limited AP expansion, limited lateral expansion. Ventilation depends on the diaphragm: fatigues easily, lacks Type 1 muscle fibres. Any restriction of diaphragm movement results in resp difficulties Ie stomach inflation due to forced inflation Lung compliance 5ml/cm H2O, 1/12 adult value, chest compliance 260ml/cm H2O (5x aduly value. High risk of barotrauma Small lung vol rel to body sizeSmall FRC: high RR to maintain the FRC Under GA anaesthesia FRC declines by 10-25% in health adults and 35-45% in 6-18yo. Stress: ratio of MV to FRC is doubled, FRC is diminished and desat occurs PEEP important in kids <3, essential in infants <9m. Mean pee to respore FRC to normal: Infants < 6 months 6, children 6-12 Higher O2 consumption 6-7ml/kg, adults 3-4 ml / kg Rapid desatiration Smaller FRC Greater VO2 per unit weight than adults Critical hypoxia rapid after apnoea Consider 1 month old no pre-oxygenation = 90% sats in 15 seconds Pre –oxygenation for 1 min = 90% sats in 90 seconds
- Mapleson F, Jackson-Rees modification to the Ayer’s T-piece. Cildren under 20KgCompact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation Disadvantages The bag may get twisted and impede breathing High gas flow requirement Uses Children under 20 kg weight
- Mapleson F, Jackson-Rees modification to the Ayer’s T-piece. Cildren under 20KgCompact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation Disadvantages The bag may get twisted and impede breathing High gas flow requirement Uses Children under 20 kg weight
- Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients. Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications. Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4. Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
- Pediatr Emerg Care. 2010 Aug;26(8):563-6. doi: 10.1097/PEC.0b013e3181ea71e1. The use of vasoactive agents via peripheral intravenous access during transport of critically III infants and children. Turner DA, Kleinman ME. Source Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC 27710, USA. david.turner@duke.edu Abstract OBJECTIVES: Many experts recommend that vasoactive agents be infused via a central venous line (CVL) because of the potential risk of infiltration, but CVL placement in pediatric patients is often challenging. We hypothesized that it is safe to administer vasoactive infusions via peripheral intravenous (PIV) line in critically ill infants and children during interhospital transport. METHODS: We retrospectively reviewed the medical records of 1133 neonatal and pediatric patients transported to the intensive care units at Children's Hospital Boston from May 2004 through June 2006 to identify patients treated with vasoactive medications via PIV line. Mann-Whitney U analysis was used to identify variables associated with complications of peripheral vasoactive infusion. RESULTS: Seventy-three (6%) of the 1133 patients were treated during transport with vasoactive agents via PIV line. No complications occurred during transport, but 11 (15%) of 73 patients developed intravenous (IV) infiltrates related to vasoactive infusion at a mean of 7 hours after arrival to the receiving facility (range, 2-24 hours). Compared with patients with IV infiltrations, those without IV infiltrates had significantly lower median duration of vasoactive infusion and median maximum medication dose (256 vs 810 minutes and 10 vs 15 microg/kg per minute, respectively; P < 0.05). There were no significant differences between any other variables tested, and all infiltrates resolved without significant intervention or lasting injury. CONCLUSIONS: Results from our series suggest that administration of vasoactive medications via PIV line during transport of critically ill infants and children is safe. The risk for complications increased with higher infusion rates and longer duration of therapy. Prompt transitioning of vasoactive infusions to a CVL may lead to fewer complications but does not seem to be necessary before transport. Retrieved to Boston Children’s Results from our series suggest that administration of vasoactive medications via PIV line during transport of critically ill infants and children is safe. The risk for complications increased with higher infusion rates and longer duration of therapy. Prompt transitioning of vasoactive infusions to a CVL may lead to fewer complications but does not seem to be necessary before transport. Recommendations (grade 2C): Initial: dopamine For cold shock: epinepherine For warm shock: norepinepherine Special circumstances: Low CO/ high SVR: dobutamine / phosphodiesterase inhibitor Low SVR despite norepinepherine: vasopressin (NB- trend towards incr mortality in Choong Am J Resp Crit Care Med 2009) In those in whom infiltrates developed infusions were running on average for longer (1069±235mins V 600±132mins) and were carrying a higher dose of inotrope (median 15 Vs 10µg/kg/min Dopamine)
- Solutions: Recognise the physiology. Not rely on concensus based dogma about fixed physiological limits across many ages
- Solutions: Recognise the physiology. Not rely on concensus based dogma about fixed physiological limits across many ages