picu audit

PICU AUDIT

Objectives

• To present a new approach of management of dengue fever

General Data

• LN• 2 year old• Female• 15.2 kg• February 27, 2012• Malaysian• Hindhu• Lives in Malaysia• Admitted last May 16, 2014

Chief Complaint

• Fever

History of Present Illness

11 days PTA

• Undocumented fever– Paracetamol – 1 day

• No other symptoms• No consult done


10 days PTA

• Fever resolved• Good appetite• Good activity


7 days PTA

• Fever Tmax 39• Consult in Malaysia– Serial CBCPC

LaboratoriesHg Hc WBC Neu Lym Mon

oEo Baso Plt

5/9 13.5 40 2.8 19 70 8 2 121 Atyp lym 1

5/10 12.9 39 2.1 28 58 10 3 1 137

5/11 10.9 35 2.7 18 68 10 3 1 106

5/12 13.2 41 3.6 14 70 11 4 1 139

Na K Cl Phos Ca Corrected Ca

5/9 134 4.2 99 1.69 2.23 2.27

LaboratoriesUrea Uric

acidGlucose

Crea

5/9 4.8 0.21 4.8 30 EGFR >90

TP A G A/G

5/9 65 38 27 1.41

Total bil

Total chol

ALP GGT AST ALT

5/9 2.8 3.9 181 16 47 33

DNS1 DB Mycoplasma Pneumonia antibody

5/9 Neg Neg 1:40 <1:40


4 days PTA

• Patient discharged• A> Viral Infection• Given Azithromycin


3 days PTA

• Afebrile• Playful• Active


Morningof admission

• Febrile– Paracetamol

• Poor oral intake• Decreased activity• Weak looking• Vomiting episodes• Consult TMC ER

ADMITTED

Past Medical History

• No asthma, allergies• No previous surgeries nor hospitalizations

Family History

• Hypertension• DM

Birth History

• Full term via NSD to a 42 year old G1P1 (1001)

Immunizations

• Complete for age• With booster doses

Feeding History

• Eats a regular diet• No food allergies

Review of Systems• General: No weight loss, poor appetite• Skin: Flushed, no rashes• Head: No migraines, dizziness and head injuries• Eyes: No blurring of vision• Ears: Good hearing, no tinnitus, earaches, infection, vertigo, no

discharges• Nose: No nasal stuffiness, discharge, and itching, nosebleeds,

and sinus trouble• Throat (Mouth/Pharynx): No sore tongue, dry mouth, sore

throat, hoarseness, and ache in the teeth and gums• Neck: No lumps, swollen glands, goiter, pain/stiffness of neck

Review of Systems• Cardiovascular: No palpitations, orthopnea, easy

fatigability• Respiratory: No cough, sputum, hemoptysis• Gastrointestinal: No diarrhea, constipation, nausea,

(+) vomiting, no abdominal pain• Genital: No genital infections, lesions.• Renal: No polyuria, dysuria, normal urine color• Neurologic: No fainting spells, seizures, paralysis,

numbness, and tremors• Psychiatric: No anxiety, tension, depression, and

memory change. He has never had suicidal attempts.

Physical Examination (ER)

• General Survey: Awake, ambulatory, not in cardiorespiratory distress

• Vital Signs: BP 90/60 HR 120 RR 25 T 38.6Height: 93 cm Weight: 15.2 kg

BMI 17.6 IBW 12 kg Pain scale 0/10

Physical Examination

• Skin: Flushed, good turgor

• HEENT: Normocephalic, pink palpebral conjunctiva, anicteric sclerae, nasal septum midline, hyperemic posterior pharyngeal wall

• Neck: Supple neck, Non palpable cervical lymph nodes, thyroid not enlarged

Physical Examination• Respiratory: Symmetrical chest expansion, no

retractions, clear breath sounds

• Cardiac: Adynamic precordium, normal rate, regular rhythm, no murmur

• Abdomen: Normoactive bowel sounds, Soft, non tender, no hepatomegaly

• Extremities: No cyanosis, swelling, full and equal pulses

Neurologic Examination

• Mental Status: GCS 15, conversant, active, irritable• Cranial Nerves: • Cranial nerves:

I – not assessedII – pupils 2-3mm ERTLIII, IV, VI – extraocular muscles intactV – intact corneal reflex V1, V2, V3 intactVII – no facial asymmetryVIII – intact gross hearingIX, X – good gag reflexXI – can shrug shouldersXII – tongue midline

Neurologic Examination

• Motor: 5/5• Cerebellar: No dysmmetria, dysdiadokinesia• Sensory: No sensory deficit• Reflex: +2 on all extremities• No babinski, meningeal signs

SYSTEMIC VIRAL ILLNESS

INITIAL IMPRESSION

Admitting Orders

Diagnostics• CBC• Urinalysis

Therapeutics• IVF: D5NM at Maintainance

+ 10 or 3.8 ml/kg• Paracetamol at 13 mkdose

q4 for T≥37.8

LaboratoriesHg Hc WBC Band Neu Lym Mon

oEo Plt

5/16 124 37 8 1 84 9 6 223

1st hospital stay

Day 2 of illness

No complaints

Poor oral intake

Urine output 1 ml/kg in 8 hours

PLANSUBJECTIVE OBJECTIVE ASSESSMENT

BP 100/60 HR 126 RR 26 T 39.2-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec

SVI r/o Dengue fever

Repeat CBCDengue Ns1Dengue blotDengue PCRBCS


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

Dengue Ns1: positiveDengue blot: negativeDengue PCR: Type 1

1st hospital stay

Day 1 of Illness

No complaints

Poor oral intake

Urine output 1.4ml/kg


BP 100/60 HR 126 RR 26 T 38-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT>2sec

Dengue fever

IVF increased 3.8 ml/kgDaily cbc monitoring

2nd hospital stay

Day 2 of Illness

Loose stools + particles x 1

Urine output 2 ml/kg


BP 90/60 HR 112 RR 24 T 38.4-39.6FlushedPuffy eyelids, bilateralDry lipsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec

Dengue fever

Decreased IVF to 3 ml/kgDaily cbc monitoring


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

5/18 119 36 3.1 47 46 6 1 125

3rd hospital stay

Day 3 of Illness

Loose stools x 2

Still with puffy eyes

Urine output 1.3 ml/kg


BP 90/60 HR 118 RR 26 T 38.1-40.2FlushedDecreased eye puffinessClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec

Dengue fever

Decreased IVF to 2.7ml/kgProbioticsDaily cbc monitoring


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

5/18 119 36 3.1 47 46 6 1 125

5/19 127 38 2.3 34 59 7 115 RL

4th hospital stay

Day 4 of IllnessOccasional

coughAbdominal

painNo recurrence

of loos stools

Urine ouput 1.7 ml/kg


BP 100/60 HR 110 RR 28 T 37.5-39.1FlushedMaculopapular rashes on faceOral soresClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses

Dengue fever

Fluid is maintainedDaily cbc monitoring


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

5/18 119 36 3.1 47 46 6 1 125

5/19 127 38 2.3 34 59 7 115 RL

5/20 127 38 1.9 22 73 5 92 RL

5th hospital stay

Day 5 of Illness

Persistence of abdominal pain

Urine ouput 2.9 ml/kg


BP 100/60 HR 110 RR 28 T 37.3-38.7FlushedMaculopapular rashes on facePuffy eyesOral soresClear breath soundsRegular rhythmAbdominal distentionFull pulsesNonpitting bipedal edema

Dengue fever with warning signs

Cardiac, liver enzymesKidney functionBleeding parametersElectrolytesAlbuminGastro referralCardiac referral


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

5/18 119 36 3.1 47 46 6 1 125

5/19 127 38 2.3 34 59 7 115 RL

5/20 127 38 1.9 22 73 5 92 RL

5/21 123 36 2.7 24 70 6 72 RL

Laboratories

CK total CK MB CKMM

5/21 662 84 578

Na K Ical

5/21 142 3.8 1.22

SGPT SGOT Alb BUN Crea

5/21 61 192 2.9 4.48 0.37

Gastro

• A> Dengue Hepatitis

5/21 Control Patient % Act INR

PT 12.4 11.4 1 0.95

PTT 29.6 48.7

Cardio

Cardio

• 2d echo– Small pericardial

effusion, pleural effusion, normal intracardiac structure

• A> Dengue Myocarditis

5th hospital stay (2 hrs prior to transfer)

DOB


BP 90/60 HR 120 RR 41 T 36

Decreased breath sounds on right base

Dengue fever with warning signsDengue HepatitisDengue Myocarditis

Transfer to PICUHGT 91Chest xray

AT PICU

Day 5 of IllnessNo abdominal

painNo recurrence

of loose stools



BP 105/52 HR 112 RR 69 T 36.9Flusheddecreased breath sounds right baseRegular rhythmSoft, nontender abdomen, no hepatomegalyFull pulses, CRT < 2 sec, warm extremities


Serial cbc monitoring


oEo Plt

5/16 124 37 8 1 84 9 6 223

5/17 119 35 4.5 59 34 7 185

5/18 119 36 3.1 47 46 6 1 125

5/19 127 38 2.3 34 59 7 115 RL

5/20 127 38 1.9 22 73 5 92 RL

5/21 123 36 2.7 24 70 6 72 RL

5/21 6pm

120 36 3.3 17 75 8 60 RL

5/21 11:30pm

106 31 3.8 24 69 7 52 RL

WBC vs Platelet

1 2 3 4 5 6 70

50

100

150

200

250

0

1

2

3

4

5

6

7

8

9

WBCPlatelet

Chest Xray

• Pleural effusion right

• Intercurrent Pneumonia not ruled out

AT PICU

No complaints


Albumin 2.0Hct 31 from 36 (14% decreased)


pRBC transfusion (5ml/kg)Albumin infusion (1g/kg)

1st PICU stay

Day 6 of IllnessGoing Day 1

afebrileMinimal

abdominal pain

Better well being



BP 118/70 HR 125 RR 34 T 37.3Flusheddecreased breath sounds right baseShallow subcostal retractionsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities


Serial cbc monitoring q6ElectrolytesAlbuminChest xrayFurosemide 0.4mg/kg/dose given 2 doses


oEo Plt

5/21 123 36 2.7 24 70 6 72 RL

5/21 120 36 3.3 17 75 8 60 RL

5/21 106 31 3.8 24 69 7 52 RL

5/22 6am

121 36 2.9 30 61 8 1 50

5/22 12pm

123 37 2.9 33 62 5 56 RL

5/22 6pm

117 35 3.2 30 63 6 1 56 RL

Laboratories

Na K Ical

5/21 142 3.8 1.22

5/22 140 3.8 1.13


5/21 61 192 2.9 4.48 0.37

5/22 3.3

Chest Xray

• Regressing pleural effusion right

• Intercurrent Pneumonia cannot be totally ruled out

2nd PICU stay

• Day 7 of Illness

• Going Day 2 afebrile

• No complaints

• Better well being

• Urine output 2 ml/kg


BP 107/60 HR 88 RR 24 T afebrileFlushedHarsh breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities

Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis

Serial cbc monitoring q12ElectrolytesAlbuminCardiac enzymesPTCreatinine


oEo Plt

5/21 123 36 2.7 24 70 6 72 RL

5/21 120 36 3.3 17 75 8 60 RL

5/21 106 31 3.8 24 69 7 52 RL

5/22 121 36 2.9 30 61 8 1 50

5/22 123 37 2.9 33 62 5 56 RL

5/22 117 35 3.2 30 63 6 1 56 RL

5/236am

118 35 3.3 28 67 2 3 88

5/23 6pm

112 33 3.3 18 72 7 3 116 RL

LaboratoriesNa K Ical

5/21 142 3.8 1.22

5/22 140 3.8 1.13

5/23 138 4.1 1.1


5/21 61 192 2.9 4.48 0.37

5/22 3.3

5/23 3.4 0.42

CK total CK MB CKMM

5/21 662 84 578

5/23 268 76 192

3rd PICU stay

Day 8 of illnessGoing Day 3

afebrileBetter well

beingImproving

appetiteUrine output

1.3 ml/kg


BP 100/70 HR 88 RR 22 T 36.7PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities


Transfer to regular room

8th hospital stay

Day 8 of illness

Going Day 3 afebrile

Noisy breathing

DysuriaUrine output

1 ml/kg




UrinalysisSalinase

5/25Color Dark yellow RBC 2

Transpency Slightly cloudy WBC 7

pH 7.0 Epithelial cells 15

Specific gravity 1.010 Casts 0

Blood + Bacteria 24

Protein +

Glucose -

Leucocytes +

Ketones +

Urobilinogen +

Bilirubin +

Nitrites -

Laboratories

9th hospital stay

Day 9 of illness

Going Day 4 afebrile



Dengue hemorrhagic feverDengue HepatitisDengue MyocarditisUTI

May go home


oEo Plt

5/21 123 36 2.7 24 70 6 72 RL

5/21 120 36 3.3 17 75 8 60 RL

5/21 106 31 3.8 24 69 7 52 RL

5/22 121 36 2.9 30 61 8 1 50

5/22 123 37 2.9 33 62 5 56 RL

5/22 117 35 3.2 30 63 6 1 56 RL

5/23 118 35 3.3 28 67 2 3 88

5/23 112 33 3.3 18 72 7 3 116 RL

5/26 136 41 5.8 24 66 8 2 164 RL

Laboratories


5/21 61 192 2.9 4.48 0.37

5/22 3.3

5/23 3.4 0.42

5/26 91

Discharge

• Discharged on the 8th Hospital stay• Home medications– Cefuroxime (dose) for UTI

• Follow up prior to going back to Malaysia

DENGUE HEMORRHAGIC FEVERDENGUE HEPATITISDENGUE MYOCARDITIS

Final Diagnosis

picu audit

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