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PICU I Joseph M. LaRochelle, Pharm.D. Xavier University of Louisiana College of Pharmacy/ Louisiana State University Health Sciences Center School of Medicine New Orleans, Louisiana

PICU I

PICU I Joseph M. LaRochelle, Pharm.D. Xavier University of Louisiana College of Pharmacy/ Louisiana State University Health Sciences Center School of Medicine New Orleans, Louisiana

ACCP Updates in Therapeutics® 2015: Pediatric Pharmacy Preparatory Review Course 1-177

PICU I

Learning Objectives 1. Identify the signs and symptoms of the different classifications of sepsis. 2. Develop an appropriate treatment plan for patients with sepsis. 3. Identify common sedation strategies. 4. Describe techniques to prevent withdrawal from sedative agents. 5. Describe the pharmacokinetic changes that occur during extracorporeal membrane oxygenation (ECMO). 6. Modify drug therapy while a patient is deployed on ECMO. 7. Choose an appropriate algorithm to follow according to the specific rhythms in cardiac arrest. 8. Given a patient’s clinical situation, differentiate between various therapeutic options for cardiac arrest and explain when to use each therapy. 9. Compare and contrast various modalities for optimizing mean arterial pressure in patients with traumatic brain injury (TBI). 10. Given a patient scenario, select appropriate agents for increased intracranial pressure management caused by TBI. 11. Devise a fluid replacement plan for patients with severe burns. 12. Describe therapies to decrease the secondary responses to burns. 13. Describe some of the basic principles of pediatric sedation. 14. Choose appropriate agents for sedation in critical care patients.

Self-Assessment Questions Answers and explanations to these questions can be found at the end of this chapter. 1. A 5-year-old boy presents in septic shock with a temperature of 102.5°F (39.2°C). His blood pressure (BP) is 60/40 mm Hg, his heart rate (HR) is 100 beats/minute, and he is cool to the touch. Which is the most appropriate vasopressor to initiate first? A. Dopamine. B. Norepinephrine. C. Milrinone. D. Epinephrine.

2. An 8-year-old boy (weight 30 kg) sustained burns to 40% of his body after accidentally pulling boiling water off the stove. Which is the most appropriate way to replace his fluids? A. 300 mL/hour for 24 hours. B. 450 mL/hour for 8 hours; then 225 mL/hour for 16 hours. C. 225 mL/hour for 8 hours; then 450 mL/hour for 16 hours. D. 225 mL/hour for 8 hours; then 112 mL/hour for 16 hours. 3. A 7-year-old patient is currently on a fentanyl infusion at 1 mcg/kg/hour and is in the process of being deployed on extracorporeal membrane oxygenation (ECMO). Which best describes the pharmacokinetic change that is expected to occur with fentanyl while the patient is on ECMO? A. Decreased volume of distribution. B. Adsorption to the circuit. C. Increased clearance. D. No changes to fentanyl pharmacokinetics. 4. A 4-month-old child with no significant past medical history presents with respiratory failure secondary to respiratory syncytial virus. Mechanical ventilation has been maximized, with little improvement in the patient’s clinical status. The decision is made to start ECMO. Which is the most appropriate anticoagulant to use during ECMO? A. Heparin. B. Warfarin. C. Enoxaparin. D. Aspirin. 5. A 6-year-old girl presents in shock. She has a past medical history significant for a dilated viral cardiomyopathy with a baseline ejection fraction of 45%. Her current ejection fraction is 35%. Her current systemic vascular resistance (SVR) is 130/80. Which is the most appropriate agent to use in this child for cardiac support? A. Norepinephrine. B. Milrinone. C. Dopamine. D. Phenylephrine.


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6. A 9-year-old mechanically ventilated child goes into cardiac arrest in the intensive care unit (ICU). Earlier that day, the child lost intravenous access, and the team is unable to obtain a new line. Which drug would be most appropriate to give endotracheally to this child? A. Calcium chloride. B. Lidocaine. C. Amiodarone. D. Vasopressin. 7. A 3-year-old is in supraventricular tachycardia (SVT). Which is the most appropriate way to administer adenosine? A. Intravenous push over 2–5 minutes, followed by a saline flush over 2–5 minutes. B. Diluted infusion over 30 minutes. C. Rapid intravenous push, followed by a saline flush over 2–5 minutes. D. Rapid intravenous push, followed by a rapid saline flush. 8. Cardiac arrest is called on a 4-year-old girl on the floor. The team begins cardiopulmonary resuscitation (CPR), and the monitor reveals ventricular fibrillation (VF). The team does three cycles of CPR, defibrillation, and epinephrine with no return to spontaneous circulation. Which drug would be best to consider next? A. Atropine. B. Adenosine. C. Amiodarone. D. Procainamide. 9. E.G. is a 3-year-old girl who presents to the emergency department with lethargy, increased respiratory rate, hypotension, weak pulses, and poor capillary refill. Her HR is 200 beats/minute. She has a past medical history significant for tuberous sclerosis with a large rhabdomyoma on the left ventricular septum. An electrocardiogram (ECG) shows monomorphic wide QRS complexes (greater than 0.09 second) with absent P waves. Which would be best for treating E.G.? A. Amiodarone. B. Synchronized cardioversion. C. Lidocaine. D. Magnesium.

10. After initial intervention, E.G.’s ECG now shows wide, polymorphic QRS complexes with a QRS axis shifting back and forth around the isoelectric baseline (i.e., torsades de pointes). Which would be best for treating E.G.? A. Amiodarone. B. Synchronized cardioversion. C. Lidocaine. D. Magnesium. 11. A 3-year-old involved in a motor vehicle collision sustained a severe traumatic brain injury (TBI). Mannitol is used to help control the patient’s intracranial pressure (ICP). Which best matches the mechanism of action of ICP reduction with mannitol’s duration or onset? A. Blood viscosity reduction lasts 6 hours. B. Blood viscosity reduction lasts 1 hour. C. Osmolar agent starts working within 2 minutes. D. Osmolar agent lasts 1 hour. 12. A 5-kg patient is receiving adequate sedation with fentanyl and midazolam, scheduled mannitol 5 g every 6 hours, and 3% saline continuous infusion at 5 mL/hour for ICP management. Osmolarity is 350 mOsm/L, and serum sodium is 175 mEq/L. Which is the next most appropriate agent for management of an increased ICP? A. A 7-mL/kg bolus of 3% saline. B. Mannitol 0.5 g/kg x 1 now (regardless of timing of previous mannitol). C. Pentobarbital bolus, followed by continuous infusion. D. Phenytoin every 8–12 hours. 13. A 2-year-old is 5 days post–severe scald injury burn to 45% of her body. Which most accurately describes how propranolol would help? A. Increase HR. B. Increase resting energy expenditure. C. Decrease resting energy expenditure. D. Decrease lean body mass.


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Abbreviations AV Atrioventricular CPP Cerebral perfusion pressure CPR Cardiopulmonary resuscitation ECMO Extracorporeal membrane oxygenation ET Endotracheal ICP Intracranial pressure ICU Intensive care unit MAP Mean arterial pressure PALS Pediatric advanced life support PEA Pulseless electrical activity PICU Pediatric intensive care unit SIRS Systemic inflammatory response syndrome SVR Systemic vascular resistance SVT Supraventricular tachycardia TBI Traumatic brain injury TBSA Total body surface area VF Ventricular fibrillation VT Ventricular tachycardia


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I. SHOCK A. Types of Shock 1. Hypovolemic a. Dehydration, hemorrhage b. Tachycardia, sodium and water retention through the renin angiotensin aldosterone system, antidiuretic hormone c. Covered in the Fluids, Electrolytes, and Nutrition chapter 2. Cardiogenic shock a. Acid-base imbalance, severe electrolyte disorders, poor myocardial function, heart failure, etc. b. Usually fluid overload states (see Cardiology chapter) 3. Distributive shock: Septic, anaphylactic, neurogenic, spinal 4. Obstructive shock: Tamponade, aortic stenosis, etc. B. Septic Shock: Definitions 1. Systemic response to infection 2. Mortality rate 2%–10% 3. Decreased perfusion to tissues 4. Spectrum of severity: See Figure 1. a. Systemic inflammatory response syndrome (SIRS) b. Sepsis c. Severe sepsis d. Septic shock 5. Cardiovascular dysfunction: a. Hypotension or need for vasopressor OR b. Two of the following: Metabolic acidosis, ↑ lactate, ↓ urine output, ↑ capillary refill, gap in core to peripheral temperature c. Children can maintain BP longer than can adults; if hypotensive, then decompensated shock 6. Respiratory dysfunction (just one criterion must be met): a. ↓ Pao2/fraction of inspired oxygen (Fio2) ratio (less than 300) b. ↑ Paco2 c. Fio2 greater than 50% d. Mechanical ventilation 7. Must meet two criteria of the organ systems below (a–d) for severe sepsis: a. Neurologic: Glasgow Coma Scale score of 11 or less or a change of 3 points with a mental status change b. Hematologic: i. Platelet count less than 80,000/mm3 or a 50% drop OR ii. INR (international normalized ratio) greater than 2 c. Renal: Serum creatinine (SCr) 2 x normal (or ↑ from baseline) d. Hepatic: Total bilirubin 4 mg/dL or greater or ALT (alanine aminotransferase) 2 x normal


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Systemic Inflammatory Response Syndrome (SIRS): >38.5°C or