BIG problems, little people: lessons learned from paediatric retrieval

Dr Fran Lockiefranlockie@gmail.com

Sydney Based Health practitionerPassion for female weight loss‘www.hotfatchicks.com’

Sydney Based Health practitionerPassion for female weight loss‘www.hotfatchicks.com’

Recurring Themes….Recurring Themes…..

CaseIssues

Solutions

15 month old male with fever

• NVD at term, BW 2.7kg• Previously fit and well• No meds, NKDA• Immunisations UTD• Family all coryzal

Country Hospital

• At triage – Alert and playful– Temp 39, Hr 160, Rr 40– Good central perfusion– Mottled peripherally

4hrs later Seen by RMO

• Given panadol with resolution of fever, HR never < 170 since triage

• Bloods sent• Urine NAD

4 hrs after that…

• Given panadol with resolution of fever, HR never < 170 since triage

• Bloods• Urine NAD

• 2 small vomits in waiting room, then a small area of petechiae

Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes

VBG pH 7.15, BE -10, B/C 10, lact 5, CO2 25, BSL 6

22:00

• A BVM with high flow O2• B RR 60, marked increased resp effort• C peripheral CRT: absent, central >5 secs

• Multiple attempts at iv access unsuccessful• D alert, talking to mum

Rapid deterioration

– AVPU– Increasing respiratory distress– HR >200, Only femoral pulse palpable

– IO sited – Aggressive filling– DA started

Ketamine, sux, adrenaline bolus

Courtesy: Stefan Mazur

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

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

Recurring Themes….

• Oxygen delivery• Vascular access• Fluid, antibiotic administration

Recurring Themes….

• Oxygen delivery• Vascular access• Fluid, antibiotic administration

• Teamwork, leadership and communication• Recognition of paediatric critical illness

Recurring Themes…..At audit

• 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

shockArch Dis Child 2009

Pediatrics 2009

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

Resuscitation 2014

Resuscitation 2014

Train together daily!

• One Base• Adult teams

– ED– Intensivists– Anaesthetists

• Paediatric and neonatal teams

• Special operations paramedics

McDonalds approach to ‘out of theatre’ anaesthesia

Courtesy: Stefan Mazur

PREPARATION PHASE

Courtesy: Matt Hooper

PREPARATION PHASE

ELM

PREPARATION PHASE

PREPARATION PHASE

PREPARATION PHASE

PREPARATION PHASE

PREPARATION PHASE

INTUBATION PHASE

POST - INTUBATION PHASE

Patients intubated by MedSTAR:

Date LocationWt(kg) Indication Ket Sux Prop Roc Fent View

ETT size

ETT depth ETCO2 ILS Adjuncts Cricoid Comment Seniority

02/01/14 Yorketown Hospital 100 Cardiac 40 200 I 8 24 Calorimetric No None No Adrenaline Infusion +

Fluid 1000mLED Registrar

>100

08/01/14 Stansbury 70 Head Injury – threatened airway

100 200 I 8 23 Calorimetric Yes Bougie No Anaesthesia Reg> 100

12/1/14 Whyalla 45 Gastrointestinal 25 100 II 7 22 No None Yes N. Saline 200mL Para > 100

14/1/14 Moonta 120 Combative / Agitated

200 200 II 8 24 Waveform Yes Bougie No Fluid 500mL Anaesthesia Reg >100

16/01/14 Balaklava 80 Neurological 100 100 50 I 7 22 Waveform No Bougie Yes Fluid 1000mL Anaesthesia Reg > 100

17/01/14 115

Head Injury – threatened

Airway; Chest trauma

150 200 IV 8 23 Yes Bougie No Anaesthesia Reg >100

17/01/14 Mt. Compass Head injury- threatened

100 100 I 8 24 Waveform Yes Bougie No Anaesthesia Reg > 100

18/01/14 Pt. Broughton 100 Neurological 50 150 10mL / hr III 8 24 Calorimetric No Bougie No Pancuronium + N.

Saline 1000mLICU Reg

> 100

18/01/14Head Injury –

Threatened airway

I 7 23 Calorimetric Yes Bougie Yes In car – difficult access; no induction meds.

Para 10-100

19/01/14 Victor 65 Respiratory 50 100 40 III 7 23 Yes No Nil / Bougie No

2 attempts – nurse then MD, unexpected

Gr IIINurse <10 ;

Consultant > 100

28/01/14 Berri Combative / Agitated

100 100 30None then

IIWaveform Yes Nil /

Bougie Yes 2 Attempts – same MD; desat <92%

Anaesthesia Reg > 100

smaller FRCGreater VO2 than adults

How can we overcome rapid desaturation after apnoea?

Ann Emerg Med. 2012

Ann Emerg Med. 2012

BMJ 2007

• Mapleson circuit– Significantly easier to

breath through – More effective

Ann Emerg Med. 2012

Kids have smaller FRCGreater VO2 than adultsRapid desaturation (with stress and apnoea)

10 days, pCO2 100, pH 7.00

• He’s Tired Doctor:• 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

• 95 patients• Mean age 5.5• 95% success• 10 seconds or less• Pain score 2.3

Pediatr Ermerg Care 2008

• 95 patients• Mean age 5.5• 95% success• 10 seconds or less• Pain score 2.3

• Fluids, ABx, DA

Pediatr Emerg Care 2008

Lancet 2011; 377: 1011–18

• Listen to the physiology!• Don’t rely on consensus based dogma with

fixed physiological limits a cross many ages

Lancet 2011; 377: 1011–18

Is lactate really the ‘Holy Grail’ of sepsis biomarkers?

Intensive Care Med 1997

Is lactate really the ‘Holy Grail’ of sepsis biomarkers?

Intensive Care Med 1997

No, but sepsis often masquerades as respiratory disease in kids

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…

Just before Christmas..

Just before Christmas..

Lessons learned…

• Collaborate / cross-pollinate

• Drills, teamwork• Evaluate practice• Attention to detail, keep

it simple

Thanks to:A/Prof Stefan MazurA/Prof Matt Hooper