PICU Doc On Call is the podcast for current and aspiring Intensivists. This podcast will provide protocols that any Critical Care Physician would use to treat common emergencies and the sudden onset of acute symptoms. Brought to you by Emory University School of Medicine, in conjunction with Dr. Rahul Damania and under the supervision of Dr. Pradip Kamat.
12: Acute Management of Hyperkalemia
Today’s episode is dedicated to acute management of hyperkalemia in the PICU. Join us as we discuss the patient case, symptoms, and treatment.
We are delighted to be joined by Dr. Roshan George, Associate Professor of Pediatrics, a practicing Pediatric Nephrologist at Children’s Healthcare of Atlanta, and the Program Director of Pediatric Nephrology Fellowship at Emory University School of Medicine.
Our case, symptoms, and diagnosis: A two-year-old male with a history of focal segmental glomerulosclerosis controlled on chronic prednisone therapy presents to the PICU for respiratory failure. The patient is noted to be hypotensive and tachycardic. Potassium is elevated at 6.4 with no hemolysis noted. The EKG is notable for peak T waves, and the patient is also noted to be anuric.
Definition of hyperkalemia: a potassium serum level higher than 5.5 (Be sure to correlate your lab sample with clinical and telemetry changes to rule out pseudohyperkalemia)
Common causes of hyperkalemia:
Increased intake of potassium
Decreased renal excretion
Inborn error of metabolism, especially adrenal problems
Why it’s important to be vigilant about hyperkalemia in patients with chronic kidney disease, end-stage renal disease, acute kidney injury, and those with a transplanted kidney
Clinical manifestations of hyperkalemia:
The risk is for cardiac conduction abnormalities and muscle weakness/paralysis.
Adverse events can occur with levels > 5.5mEq/L, and the risk increases as levels rise.
Any serum K level > 6mEq/L is significant, regardless of EKG changes.
Two hallmarks that can drive effective management of hyperkalemia are EKG findings and laboratory confirmation of elevated serum potassium.
Other important labs for patients with hyperkalemia include a basic electrolyte panel to assess kidney function, CBC, and serum blood gas to assess acid/base balance. (A medication check for K supplements or ACE inhibitors should also be done.)
Steps in the management of hyperkalemia:
First, caution should be exercised that any K level > 5.5 is a medical emergency and should be addressed immediately without finding the etiology.
Stabilize the cardiac membrane.
Shift potassium with insulin and glucose, bicarbonate, and B2 adrenergic agents.
The long-term goal should be to improve excretion with Kayexalate or Furosemide (Remember the mnemonic: “Loops lose K.”)
General considerations about dialysis are:
CVVH vs. HD
Severe hyperkalemia is a key indication for RRT in acutely ill patients.
Hemodialysis can be used in an emergency.
Takeaway clinical pearls regarding hyperkalemia:
Make sure the potassium level is accurate.
Consider the next steps in potassium removal.
Remember that etiology is the last step.
11: Management of High Risk Intubations in the PICU
Today’s episode is dedicated to the intubation of the critically ill pediatric patient. Join us as we discuss the patient case, symptoms, and treatment.
We are delighted to be joined by Dr. Heather Viamonte. Dr. Viamonte is an Assistant Professor of Pediatrics at Emory University School of Medicine. She is a Pediatric Cardiac Intensivist at the Children’s Heart Center and the Director of Cardiac ECMO. The Children’s Heart Center is a 30-bed, dedicated cardiac intensive care unit at the Children’s Healthcare of Atlanta at Egleston. She is a newly published author whose book, Wilde Type, has already been released, and a second novel is on its way to publication. Dr. Viamonte is on Twitter as @hk_jacobs.
Our case, symptoms, and diagnosis: A four-month-old patient is admitted to the PICU from the emergency department for acute respiratory failure on high-flow nasal cannula. The child’s condition has slowly deteriorated over the last few hours and now requires intubation. An echo is performed pre-intubation due to enlarged cardiac silhouette on chest radiograph demonstrating left ventricular dysfunction with ejection fraction in the low 40s. The patient’s saturations are dipping to the mid-80s despite being on maximal HFNC support.
Common indications for intubation in the PICU or CICU include acute respiratory failure, upper airway obstruction, hemodynamic instability, management of increased ICP, mediastinal masses, protection of the airway, as well as for procedures and safe transport.
Patient conditions with a high risk prior to endotracheal intubation include congenital or acquired heart disease, an infant or child with hemodynamic instability, pulmonary hypertension, upper airway obstruction, increased ICP, and mediastinal masses.
Factors in infants and children with congenital heart disease that make them high risk for intubation include anatomical or physiologic issues that could lead to cardiac arrests, such as systemic ventricular dysfunction, single ventricle physiology, arrhythmias, pulmonary hypertension, and coronary artery anomalies.
Why an understanding of the patient’s past medical history and overall physiology are important for risk stratification
Anatomical concerns that should be assessed in infants and children prior to intubation include genetic syndrome heart defects that could interfere with bag-mask ventilation, airway visualization, or laryngoscopy. These could include morbid obesity and abnormalities of the face, mouth, and teeth.
In conceptualizing congenital heart defects prior to intubation, the overriding concern is blood flow to the heart and lungs. Three factors to consider are volume overload, pressure overload, and systemic hypoxemia.
Patients can have anatomical and physiological difficulties with regards to airway management, especially in those who are critically ill and those with cardiac disease.
Four important clinical scenarios for physiologic derangements are hypoxemia, hypotension, metabolic acidosis, and congenital heart lesion pathophysiology.
Remember that infants and children have a higher fragility factor and are at a higher risk for rapid desaturation, hypoxic brain injury, and cardiac arrest.
Key factors for the intensivist are fine attention to detail, optimizing your monitoring equipment, and anticipating risk factors for peri-intubation cardiac arrest.
Special considerations with intubation for the patient with severe metabolic acidosis are necessary to prevent cardiovascular collapse and pulmonary hypertension.
How systolic dysfunction from either ventricle plays into the process of intubation
Factors to consider to mitigate risk in intubation include preparation, a multidisciplinary approach, intubation equipment nearby, and management of the post-intubation period.
Dr. Viamonte shares her perspectives on sedation and other medication
10: Anterior Mediastinal Mass
Today’s episode is dedicated to the acute management of anterior mediastinal mass in the PICU. Join us as we discuss the patient case, symptoms, and treatment. We are delighted to be joined by Dr. Lisa Lima and Dr. Tom Austin.
Dr. Tom Austin is the Director of General Pediatric Anesthesiology at Children’s Healthcare of Atlanta-Egleston. He is also an Associate Professor of Anesthesiology and Pediatrics at Emory University School of Medicine.
Dr. Lisa Lima is a Fourth Year Advanced Technology Fellow in the Division of Critical Care at Children’s Healthcare of Atlanta. She’s also the Senior Associate in the Department of Pediatrics at Emory University School of Medicine. She’s one of the only pediatric-trained ECMO Fellows in the country.
Our case, symptoms, and diagnosis: A 17-year-old female has facial swelling and shortness of breath. She recently went to her primary care physician and received a steroid burst and Benadryl for the facial swelling. On the day of admission, her mother noticed that the patient had a deep voice and a “funny” inspiratory sound. The patient presented to the ER and was noted to have a widened mediastinum on a chest x-ray, bringing up concern for an anterior mediastinal mass.
Key presentation features for mediastinal masses
What defines a widened mediastinum?
Important differentials to consider with mediastinal masses:
Take the patient’s history and presentation into context, like if there was a high-impact motor vehicle collision, history of congestive heart failure, lupus, transplant, leukemia, or lymphoma
Pay attention to the Four T’s: thymoma, teratoma, ATLL(lymphoma), and thyroid masses
Key principles that might put pediatric patients with mediastinal masses at risk for anesthetic agents
Important pathophysiologic issues for patients with mediastinal mass include compressed trachea, blocked access to lungs, and right ventricular failure; these effects can be magnified under general anesthesia
Why we need to have great appreciation of the risk of cardiovascular collapse in patients in a tenuous physiological state
General management strategies for those patients who are unable to lie flat or may not tolerate a diagnostic scan: patient history, personal physical exam, determining a rescue position
Key considerations for the patient in the PICU:
Keep the patient spontaneously breathing
Have adequate access with large-bore IVs in sites with no anatomic compression
Have a rescue position
Have a backup plan for rapid deterioration
Communicate with others on the patient care team
Why the Chamberlain procedure is used to obtain a tissue biopsy when there isn’t another primary biopsy site
Key anesthesia principles for patients needing intrathoracic biopsies:
Have clear role assignments in the multidisciplinary team approach
Keep the patient spontaneously breathing
Manage the patient’s pain
Employ liberal use of local anesthetics
Avoid intubation if possible
If necessary, use fiber optic intubation
Keep large-bore IVs in extremities
Why it’s important to stress interdisciplinary involvement early in management
Key factors to consider in patients headed to the OR about airway compression and vascular compression
Takeaway clinical pearls regarding anterior mediastinal masses:
Remember the Four T’s
The pathophysiology of local compression
Emphasize a streamlined multidisciplinary approach with important considerations for contingency planning
09: Tumor Lysis Syndrome in the Pediatric Intensive Care Unit
Today’s episode is dedicated to Tumor Lysis Syndrome management in the PICU. Join us as we discuss the patient case, symptoms, and treatment.
We are delighted to be joined by Dr. Himalee Sabnis, Assistant Professor of Pediatrics at Emory University School of Medicine. She is also a pediatric hematologist/oncologist and the Co-Director of the High-Risk Leukemia Team at the AFLAC Cancer and Blood Disorders Center at Children’s Healthcare of Atlanta.
Our case, symptoms, and diagnosis: A three-year-old female with pre-B ALL presents on Day 2 of chemotherapy to the PICU. She is admitted with telemetry findings of arrhythmia, decreased urine output, and an EKG notable for peaked T waves. Her labs are notable for elevated WBC, hyperkalemia, hyperphosphatemia, and low ionized calcium.
Tumor Lysis Syndrome is a life-threatening medical emergency stemming from rapid tumor cell destruction that overwhelms the usual metabolic and excretory pathways.
Why TLS is the most common pediatric oncologic emergency for pediatric cancer patients
When the tumor cells die or lyse, what’s inside those cells comes out into the blood
Key metabolic abnormalities that affect organ function are too much potassium and phosphorus, low calcium, and uric acid buildup.
Those metabolic abnormalities can result in cardiac arrhythmia and kidney failure.
Certain patient populations have an increased risk for TLS:
Hematological cancers have a higher risk than solid tumors
Patients with fast-growing tumors, like lymphoma and leukemia, are at high risk
Key pathophysiologic principles that drive TLS:
The imbalance of electrolytes can impact heart function
TLS is characterized by hyperkalemia, hyperphosphatemia, hypocalcemia, and uric acid, which is a by-product of DNA breakdown
If untreated, the uric acid can lead to acute kidney injury and renal failure
Electrolyte and metabolic disturbances can progress to renal insufficiency, cardiac arrhythmias, seizures, and death
TLS releases cytokines that can cause a systemic inflammatory response and multi-organ failure
Other lab markers in patients with TLS include uric acid, LDH, CBC, DIC panel, and daily blood gas (these are typically trended every 4-6 hours).
Key factors in TLS management are to understand the risk and know your resources.
Steps taken would be continuous cardiac monitoring, uric acid control, administering Allopurinol to combat uric acid formation, and managing electrolyte disturbances in conjunction with an intensivist.
Chemotherapy would not be delayed due to TLS because the patient’s condition won’t improve until the cancer is treated.
How the complications of TLS are treated:
Hyperphosphatemia should be treated by using oral phosphate binders such as aluminum hydroxide.
Hypocalcemia does not require therapy unless cardiac function is affected.
How renal replacement therapy might be required and indications are similar to other forms of acute kidney injury.
Besides Allopurinol being given at the initiation of chemotherapy, patients at high risk for TLS may receive low-intensity initial therapy to prevent rapid cell lysis.
Takeaway clinical pearls regarding TLS:
Know what you’re dealing with because every cancer is different.
Fluid management is important and will vary from patient to patient.
Be proactive in monitoring. Intervene early and quickly.
08: Acute Management of the Post-operative Renal Transplant
Today’s episode is dedicated to post-operative management in the PICU of the pediatric renal transplant patient. Join us as we discuss the patient case, symptoms, and treatment.
Joining the conversation is Dr. Rouba Garro, Associate Professor of Pediatrics at Emory University School of Medicine and the Medical Director of the Kidney Transplant Program at Children’s Healthcare of Atlanta. Children’s Healthcare of Atlanta has one of the largest kidney transplant programs in the country and is the largest in the Southeast US with excellent patient and graft survival.
Our case, symptoms, and diagnosis: a five-year-old is transferred to the PICU after a related living kidney transplant for end-stage renal disease due to obstructive uropathy. The patient has a history of post-urethral valves and is on room air, IV fluids, an arterial line, and a Foley catheter is in place.
The top indicators for renal transplant in pediatrics vary according to age, but congenital anomalies are the most common in children younger than six.
The criteria for being considered for kidney transplantation include several factors, including when kidney function drops below 20%.
The keys for successful transplantation:
An experienced pre-transplant team
A robust and experienced team for perioperative care and graft outcome
A comprehensive and multidisciplinary post-transplant team
The process of organ procurement for cadaveric and living donor renal transplants includes the following:
Multiple factors determine the points a patient receives toward transplant priority
Deceased donor kidneys are classified using the KDPI (kidney donor profile index)
A thorough evaluation is performed for living donors
Advantages to living donation include a shorter time on dialysis and waitlists, improved graft survival, and shorter ischemia time than from a deceased donor
Information from the operating team that is vital for the PICU team to know for post-op success includes patient history, transplant details, ischemia time, and transplant complications.
Red flags for the critical care post-op team are in the three categories of blood pressure, urine output, and kidney function/electrolytes.
The need to watch for signs of infection in the post-op phase
How immunosuppressive medications might be used for the pediatric renal transplant patient
Why the post-op transplant patient might need dialysis
Clinical pearls for post-op care of the pediatric renal transplant patient in the PICU:
Teamwork and collaboration are key elements for success.
The most important task is to monitor blood pressure, urine output, and electrolytes.
07: Acute Management of Post Op Liver Transplant
Today’s episode is dedicated to post-operative management of liver transplant patients in PICU. Join us as we discuss the patient case, symptoms, and treatment.
Joining us is Dr. Joe Magliocca, Associate Professor of Surgery in the Department of Surgery at Emory University School of Medicine. He is also the Surgical Director of Adult and Pediatric Liver Transplantation at Children’s Healthcare of Atlanta.
Also joining the conversation is Dr. Rene Romero, Professor of Pediatrics at Emory University School of Medicine and Medical Director of the Liver Transplant Program at Children’s Healthcare of Atlanta, which is one of the largest liver transplant programs in the country with over 600 pediatric liver transplants to date.
https://www.dropbox.com/s/bktel3qza7y50j4/Post%20Op%20Liver%20Transplant.jpg?dl=1 (>>Click here to download the PICU card for this episode)
Our patient, symptoms, and treatment: An 18-month-old with a history of biliary atresia is admitted to PICU after an orthotopic whole liver transplant. The patient is intubated, and Doppler ultrasound shows vascular patency post-operatively. AST and ALT are pending.
Common indications for pediatric liver transplantation:
500-700 pediatric liver transplants are performed annually in the US
40% of the transplants are done on children born with biliary atresia
10-15% of the transplants are due to acute liver failure
5% of the transplants are due to malignancies
The rest of the transplants are due to different childhood diseases and metabolic diseases
How the PELD (Pediatric End-Stage Liver Disease in children under 12) score relates to prioritization for liver transplant
Criteria for the PELD score are bilirubin, albumin, age, growth parameters, and INR
The major differences between whole organ vs. split liver transplantation (long-term outcomes are similar and good for both situations)
Why liver transplantation requires less immunosuppression than other organ transplants
Three phases of the liver transplant process are the hepatectomy phase, anhepatic phase, and reperfusion phase
Specifics of the time intervals during the transplant process, where the major risk is for primary non-function during cold ischemia and warm ischemia times
Major red flags to look for during the immediate post-operative period
Acute post-op management includes extubation in the OR, CV monitoring, pain management, checking urine and electrolyte levels, and communication with the transplant surgeon and liver team
How treatment and management have evolved over time with standardized post-op management, protocols, and parameters
Two important aspects of post-op management are nutrition and immunosuppression
Clinical pearls of wisdom:
The need for organ donors is great.
Teamwork and collaboration are essential for good patient outcomes.
The transformation in the field of liver transplantation has saved many children’s lives.