PICU Doc On Call

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. 

Show Highlights:

• 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

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 & Blood Disorders Center at Children’s Healthcare of Atlanta. 

Show Highlights:

• 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.

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. 

Show Highlights: 

• 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. 

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. 

>>Click here to download the PICU card for this episode<<

Show Highlights:

• 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.

Today’s episode is dedicated to pediatric acute liver failure. Join us as we discuss the patient case, symptoms, and treatment. 

 Joining the conversation is Dr. Rene Romero, Professor of Pediatrics at Emory University School of Medicine and the Medical Director of the Liver Transplant Program at Children’s Healthcare of Atlanta. 

>>Click here to download the PICU card for this episode<<

Show Highlights: 

• Our case, symptoms, and diagnosis: a three-year-old child presents in the PICU with decreased arousal; the patient is hypoglycemic. The coagulation panel is significant for increased PTT and INR, and AST and ALT are significantly elevated. The patient is hyperammonemic, and the acetaminophen level is normal. The diagnosis is acute liver failure.
• Basic functions of the liver, the “workhorse of the body” that plays major roles in interactions with other organs
• Why pediatric acute liver failure is more difficult to diagnose than in adults; key indicators are coagulopathy along with biochemical disruptions
• The most important contributing factors to pediatric acute liver failure, and why most pediatric cases are children under four years of age
• Causes of pediatric acute liver failure in the US include HSV, adenovirus, enterovirus, metabolic causes, and acetaminophen, especially in older children
• The diagnostic approach considers infectious etiologies, toxins, vascular issues, and immune dysregulation
• In treatment, care should be given to the correction of abnormal lab values and possible renal replacement therapy
• Why the use of prophylactic antifungal antibiotics is controversial and varies from institution to institution
• How to discern hyperammonemia and neurologic status
• The role of intracranial pressure monitoring for cerebral edema, which is the mode of death for these patients
• Key Clinical Pearls: acute liver failure is a systemic disease that requires a broad diagnostic approach, and the need for standardized approaches still exists.

Today’s episode is dedicated to acute metabolic emergencies. Join us as we discuss the patient case, symptoms, and treatment. 

Joining us is Dr. Lori-Anne Schillaci, trained in clinical pediatric genetics with additional training in metabolism. She had a dual appointment in the Department of Pediatric Emergency Medicine at Rainbow Babies and Children’s Hospital, as well as an appointment in the Department of Genetics and Metabolism. Dr. Schillaci is currently embarking on a fellowship in Pediatric Emergency Medicine at Wake Forest Brenner Children’s Hospital. 

>>Click here to download the PICU card for this episode<<

Show Highlights:

• Our case: A three-month-old infant presents with seizures and decreased oral intake
• History, symptoms, and treatment: The child is hypothermic and tachypneic. Blood gas is notable for anion-gap metabolic acidosis. Blood cultures are drawn, and antibiotics are started. Urine organic acids and serum ammonia are both pending. 
• A metabolic emergency is defined as a defect in the breakdown or storage of the body’s energy sources (sugar, fat, and protein) at the cellular level
• Why metabolic conditions can be inherited or result from a spontaneous mutation
• How the toxic products form in the body and can affect children in three categories (protein, fat, and sugar metabolism)
• Common lab tests would be for ammonia, gas, and blood sugar
• Why the physician should save a purple top tube before any transfusion
• General management should include treatment of the underlying acute issues, early dextrose fluids, normal saline fluid boluses, IV lipid emulsion (except in patients with known fatty acid oxidation defects)
• Advice to colleagues in managing a patient with inborn error:
• Keep in mind that the presentation can occur in older kids
• Get early labs when they are sick
• Start high dextrose fluids
• Keep the patient NPO
• Treat fever, hypoglycemia, seizures, infection, etc. 
• The goal is to prevent catabolism and be aggressive early in treatment
• Dr. Schillaci’s final thoughts: “Be vigilant. Assume an inborn error of metabolism unless proven otherwise. Be aware of late presentations of inborn errors of metabolism.”

Today’s episode is dedicated to PICU applications of lipid emulsion therapy. Join us as we discuss the patient case, symptoms, and treatment. 

Joining us is Dr. Ziad N. Kazzi, Associate Professor of Emergency Medicine at Emory University School of Medicine, Director of the International Toxicology Fellowship Program at Emory, and Assistant Medical Director of the Georgia Poison Center. Dr. Kazzi is also a board member of the American College of Medical Toxicology and current president of the Middle East North Africa Toxicology Association. 

>>Click here to download the PICU card for this episode<<

Show Highlights:

• Our case: a 14-year-old girl has been admitted to PICU after acute ingestion of the calcium channel blocker Amlodipine in a suicide attempt
• Symptoms: profound hypotension
• Acute management: After fluid resuscitation, norepinephrine infusion, and high-dose insulin therapy, lipid emulsion therapy is considered
• How lipid emulsion therapy began
• How lipids work in the toxicology realm
• Applications in PICU for indicators and efficient doses of lipid emulsion therapy
• Examples of cases that call for lipid emulsion therapy
• Considerations of propofol as a substitute for lipid emulsion therapy
• To minimize complications from lipid emulsion therapy, pay attention to dosing guidelines, limit the duration of the infusion, and focus on systemic toxicities
• Final thoughts: Know when to use (and when not to use) antidotes and be aware of publication bias with any studies

Resources:

Download the PICU Card for this episode here

www.lipidrescue.org  

Today’s episode is dedicated to the acute management of pediatric stroke. Join us as we discuss the patient case, symptoms, and treatment. 

Joining us is Dr. Elissa Ortolani, Assistant Professor of Pediatrics in the Division of Child Neurology and Assistant Professor of Neurology at Emory University School of Medicine. Dr. Ortolani has a strong clinical interest in pediatric vascular disease and is one of the few pediatric neurologists who has completed a formal adult stroke fellowship. She is actively helping to develop a pediatric stroke program at Children’s Healthcare of Atlanta.

>>Click here to download the PICU card for this episode<<

Show Highlights:

• Our case: a five-year-old male, previously healthy, has had cold symptoms for two days; he presents to the ER with possible stroke symptoms
• Symptoms: the patient has had left arm and left leg weakness during the past day, and his mother noticed a subtle left side lip droop with drooling
• Acute management: In the ER, a CT revealed a subtle hypodensity in the right basal ganglia region; the patient was admitted to PICU for further monitoring and workup
• Causes of an acute pediatric vascular event can include stroke, seizure, migraine, and toxidrome
• Definition of stroke: an acute neurologic change identified by advanced imaging
• Practical tools in evaluating stroke include F-facial droop, A-arm weakness, S-speech difficulty, T-time. (Now, amended to FASTER to include stability and eyes/vision)
• Risk factors for pediatric stroke include vascular issues like sickle cell disease, congenital heart problems, thrombophilia, and mitochondrial, inflammatory, or connective tissue disease
• In pinpointing pediatric stroke or stroke mimic, which is very common, MRI is the preferred imaging method 
• Important considerations in the diagnosis of pediatric stroke are that mild sedation is sufficient for the 10-12 minutes needed for MRI
• In the management of pediatric stroke, TPA should be administered within 4.5 hours, and endovascular therapy (if needed) should be administered within 24 hours
• Why the diagnosis and management of pediatric stroke is delayed, and how ER and ICU physicians can change that
• Developing a pediatric stroke program is a collaborative effort among emergency care providers, radiologists, pharmacists, adult neuro interventionalists, ICU team, neurosurgeons, hematologists, and rehab physicians
• A key in the diagnosis of pediatric stroke is recognizing altered mental status

Today’s episode is dedicated to acute management of laryngospasm. Join us as we discuss the patient case, symptoms, and treatment. 

Joining us is Dr. Tom Austin, director of General Pediatric Anesthesiology at Children’s Healthcare of Atlanta-Egleston. He’s also an associate professor of anesthesia and pediatrics at Emory University School of Medicine. 

>>Click here to download the PICU card for this episode<<

Show Highlights:

• Our case: a two-year-old male with a history of Wilms’ tumor presents in a sedation suite for post-surveillance MRI
• History, symptoms, and treatment: One-week history of nasal congestion with no active nasal discharge and clear lung sounds. Patient was placed on continuous pulse ox symmetry and CO2 monitoring. With sedation for the MRI, the patient had a sudden cough, which progressed to perioral cyanosis and loss of end-tidal CO2.
• How this case illustrates laryngospasm
• Definition of laryngospasm: complete or partial closure of the larynx due to some manner of external stimulation
• Why laryngospasm leads to acute respiratory failure in children
• How laryngospasm differs from airway obstruction
• Characteristic breathing pattern with laryngospasm
• Acute management of laryngospasm includes a bag-mask and positive pressure ventilation, followed by deepened sedation, and a breathing tube
• Why early recognition of laryngospasm is the key

Welcome to the first episode of our podcast for current and aspiring intensivists. Our panel of medical professionals and students will examine specific patient cases, symptoms, and treatments. Today’s episode focuses on anaphylaxis. Join us!

>>Click here to download the PICU card for this episode<<

Show Highlights:

• Our case: a four-year-old is admitted to PICU, and TPN has been administered.
• Symptoms: dyspnea, wheezing, strider, and urticaria
• Vitals: hypotensive, tachycardic, with stats dropping rapidly
• What is anaphylaxis? An acute, life-threatening, systemic allergic reaction that can lead to death by airway obstruction or cardiovascular collapse.
• Anaphylaxis symptoms include skin, mucosal, respiratory, cardiovascular, and gastrointestinal symptoms that develop within one hour of exposure to the allergen.
• Anaphylaxis triggers can include allergens, biologics, immunotherapy, and radio-contrast media.
• The anaphylaxis reaction ends with distributive shock, manifested by low cardiovascular output, low systemic vascular resistance, and high pulmonary vascular resistance.
• Acute management of an anaphylaxis reaction includes airway, circulation, and breathing management, and epinephrine (the dosing is different from code dose).
• Watch out for hypotension and lower airway obstruction as possible complications, which can be managed with fluids and nebulized albuterol.
• Adjunctive therapies include histamine blockers and steroids.
• Post-anaphylaxis care:
• Focus on observation of the patient for 10-24 hours.
• Watch for a biphasic reaction.
• At discharge, provide two prescriptions for epinephrine, education for the patient and family, and a medical alert bracelet for the patient to wear.