- Typically, stable children with a tracheostomy and no additional respiratory support or supplemental oxygen do not require hyperinflation or hyperoxygenation. (CHOP's nursing protocol)

- Who might need preoxygenation: If the patient is on more than 40% oxygen or has been clinically unwell and needed oxygen during or after suction on previous occasions. In these situations, oxygenation should commence a minute before the suction procedure and should continue until the procedure is complete and the child has reached his or her baseline heart rate and oxygen saturations.

- Careful with cardiac population: may be contraindicated due to the abnormal physiology

- Ireton, J. (2007). Tracheostomy suction: A protocol for practice. Paediatric Nursing, 19(10), 14-18.

- Nursing procedures (7:1:b): Artificial airway suctioning

- Right patient, right tube, right cuff, right length, right manufacture/type, patency

- Recapitulation of equipment readiness to ensure problems are worked out before they arise

- Needs to be done every time you do a tracheostomy change

- In collaboration with a respiratory therapist

- Fill the data collection paper every time (QI project)

You are floating to the PICU and find yourself taking care of a ventilated patient. You notice that the patient has a non-invasive CO₂ monitor.

What are the two most frequent non-invasive devices used and what are its advantages?

The 2 non-invasive CO₂ monitoring devices are:

- Transcutaneous carbon dioxide (TC-CO₂)

- End-tidal carbon dioxide (ET-CO₂)

Advantages:

- Real time CO₂ monitoring

- Accurate

- Decreased number of blood draws (ABG)

Tobias, J. D. (2009). Transcutaneous carbon dioxide monitoring in infants and children. Paediatric Anaesthesia, 19(5), 434-444.

- Also known as chronic lung disease (CLD)

- The current definition of BPD is based upon the need for oxygen supplementation, gestational age of the infant, and the severity of disease.

- Pathophysiology: Disruption of lung development (fewer and larger alveoli = reduction of surface exchange area for gas exchange) and reduced number of capillaries

- Risk factors: low birth weight, prematurity, mechanical ventilation, oxygen toxicity, sepsis, PDA

http://www.uptodate.com/contents/pathogenesis-and-clinical-features-of-bronchopulmonary-dysplasia?source=search_result&search=bronchopulmonary+dysplasia&selectedTitle=1%7E87

- Tachypneic

- Retractions (depends on the degree of pulmonary edema and/or atelectasis)

- Intermittent wheezing from scarring, constriction, mucus retention, collapse and/or edema

http://www.uptodate.com/contents/pathogenesis-and-clinical-features-of-bronchopulmonary-dysplasia?source=search_result&search=bronchopulmonary+dysplasia&selectedTitle=1%7E87

Elevated pulmonary arterial pressure and secondary right ventricular failure. It is a life-threatening condition with a poor prognosis if untreated.

Etiology: Numerous causes, but the PCU often from bronchopulmonary dysplasia (premies) or congenital heart disease. 

- Patient family education manual (21:B:12): Pulmonary hypertension

- Up to date

- http://intranet.chop.edu/sites/cardiac_nursing/resource-binder.html#ph

Sildenafil: phosphodiesterase Type-5 inhibitor (oral)

- PDE5 is the major subtype present in the pulmonary vasculature and is more abundant in the lung that in other tissues (little systemic hypotension). Therefore, it decreases pulmonary artery pressure.

Remodulin: prostacyclin analogs

- vasodilator of pulmonary and systemic arterial vascular beds, also inhibits platelet aggregation

- Decreases exercise-associated symptoms of PAH

- continuous iv, sc infusion (preferred) or inhalation

http://intranet.chop.edu/sites/cardiac_nursing/resource-binder.html#ph

Lexicomp

- Reflex: subconscious, relatively consistent responses to a particular stimulation, confirms the integrity of the spinal cord, diagnose the presence and location of a spinal cord injury or neuromuscular disease

- 7 deep tendon reflexes

- Biceps - musculocutaneous nerve and mainly C6

- Triceps - radial nerve and mainly C7

- Brachioradial - radial nerve and mainly C6

- Finger flexor -  musculocutaneous nerve and mainly C7-8

- Patellar - femoral nerve and mainly L3-L4

- Achilles's reflex (ankel jerk)- tibial nerve and mainly S1

- Jaw jerk - trigeminal

- Voluntary movement: purposeful, goal-directed movement, often learned movements which improve with practice and requires less attention

http://vanat.cvm.umn.edu/NeuroLectPDFs/LectSpReflexNeuronInteg.pdf

http://www.uvm.edu/~biology/Classes/261/Ch14Supplemental.pdf

http://www.dartmouth.edu/~dons/part_1/chapter_8.html

The response should be symmetric

Definition: Increase activity of sympathetic nervous system; dissociation or loss of balance between the sympathetic and parasympathetic nervous system. 

Look at the table from the article.

Lemke, D. M. (2007). Sympathetic storming after severe traumatic brain injury. Critical Care Nurse, 27(1), 30-37. Retrieved from www.scopus.com

Clinical presentation: state of agitation, extreme posturing/dystonia, tachycardia, tachypnea, hypertension, diffuse diaphoresis, and hyperthermia within seconds.

- Signs and symptoms vary from episode to episode and from individual to individual.

Lemke, D. M. (2007). Sympathetic storming after severe traumatic brain injury. Critical Care Nurse, 27(1), 30-37. Retrieved from www.scopus.com

Triggers:  frequently unprovoked, suctioning, repositioning, environmental

sensory stimulation, fever

Treatment: treat signs and symptoms

Potential adverse effects: Decrease cerebral tissue oxygenation = brain injury

Lemke, D. M. (2007). Sympathetic storming after severe traumatic brain injury. Critical Care Nurse, 27(1), 30-37. Retrieved from www.scopus.com

Watch the you tube video done by CHOP. 

http://www.youtube.com/watch?v=JA0Wb3gc4mE&feature=results_main&playnext=1&list=PLBF51A9998F68ACBC

- Tetralogy of Fallot
- Total anomalous pulmonary venous connection
- Hypoplastic left heart syndrome
- Transposition of the great arteries
- Persistent truncus arteriosus
- Tricuspid atresia (closed or absent)
- Pulmonary atresia
- Pulmonary stenosis (narrowing)
- Patent ductus arteriosus may cause cyanosis in late stage

    Look in the patient family education manual for diagrams and information

Expect lower oxygen saturation at baseline

http://en.wikipedia.org/wiki/Cyanotic_heart_defect

- Definition: Supraventricular tachycardia (SVT) ia a rapid rhythm arrhythmia that origninates from the atria and excludes all ventricular arrhythmias. The HR usually exceeds 180 beats/min and may occasionnaly be as rapid as 300 beats/min. This rapid HR does not allow the ventricules to fill with an adequate amount of blood. 

 - Part 14: Pediatric Advanced Life Support: 2012 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. http://circ.ahajournals.org/content/122/18_suppl_3/S876.full.pdf+html

  -  Marx: Rosen's Emergency Medicine, 7th ed., Chapter 169: Cardiac Disorders

Clinical manifestations are related to decreased cardiac output:

- Initially stable and becomes unstable as blood pressure drops

- Chest pressure or pain

- Altered mental status

- Syncope or near syncope

- Lightheadedness or dizsiness

- Palpitation which can be skipping, fluttering or pounding in the chest

- Shortness of breath

- Decreased perfusion

- Fatigue

- Part 14: Pediatric Advanced Life Support: 2012 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. http://circ.ahajournals.org/content/122/18_suppl_3/S876.full.pdf+html

-       -  Marx: Rosen's Emergency Medicine, 7th ed., Chapter 169: Cardiac Disorders

Your patient is having an episode of SVT. After calling for help, the physician  tries the vasalva maneuver with ice, without any success.

What will be the next step?

Pharmacologic cardioversion: 0.1 mg/kg IV or IO (maximum 6 mg)

Use two syringes connected to a T-connector or stopcock; give adenosine rapidly with one syringe and immediately fluch with greater than 5 mL of normal saline (rapid onset of action and very brief duration)

Monitoring parameters: HR and rhythm throughout therapy

 - Part 14: Pediatric Advanced Life Support: 2012 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. http://circ.ahajournals.org/content/122/18_suppl_3/S876.full.pdf+html

  -  Marx: Rosen's Emergency Medicine, 7th ed., Chapter 169: Cardiac Disorders

- Maintain patent airway, assist with breathing as necessary

- Oxygen

- Cardiac monitor to identify rhythm

- Monitor blood pressure and oxymettry

- 12 lead ECG

-

Part 14: Pediatric Advanced Life Support: 2012 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. http://circ.ahajournals.org/content/122/18_suppl_3/S876.full.pdf+html

-       -  Marx: Rosen's Emergency Medicine, 7th ed., Chapter 169: Cardiac Disorders

A ex-premie is transferred from the NICU to the PCU for tracheostomy teaching. The baby desaturates, you run into the room and the baby picks up quickly. After the event, the mom asks you why you came running like it was an emergency.

What would explain the difference in practices between the NICU and the PCU?

In utero, the baby's saturation is about 60%. Premies don't need high oxygen saturation to develop and it is even toxic to them. High administration of oxygen often leads to the development of bronchopulmonary dysplasia or retinopathy of prematurity. The NICU's practice is to accept lower oxygen saturation levels to prevent these disorders. However, when the baby comes to the PCU, lower oxygen saturation are no longer accepted.

Gien, J., & Kinsella, J. P. (2011). Pathogenesis and treatment of bronchopulmonary dysplasia. Current Opinion in Pediatrics, 23(3), 305-313. Retrieved from www.scopus.com

MAP= 2/3 DP + 1/3 SP

- With a MAP of 40, there is ow tissue perfusion and organs will become ischemic, will require fluid ressuscitation

- Age dependent: look at the normals

http://proxy.library.upenn.edu:2066/books/page.do?eid=4-u1.0-B978-1-4160-3623-4..00072-9--s0020&isbn=978-1-4160-3623-4&sid=1329885295&uniqId=344402766-3#4-u1.0-B978-1-4160-3623-4..00072-9--s0020

Calf and arm BPs are not interchangeable in acutely ill children, ages 1-8 years, with the difference being most pronounced in the 2-5 year age group. In general, calf BP’s are higher than arm BP’s. Knowing this information informs nursing practice. There will still be circumstances where BP measurements will need to be obtained using the calf. However, noting the location where the measurement was obtained, as well as following for trends wil help the care team interpret the value in the context of the child’s overall picture, resulting in toughtful and appropriate care.

- Briening, E., & Lebet, R. (2012). Measuring blood pressure in infants an children: Points to ponder. DNA Reporter, 37(1), 9.                  

- Nursing procedures (4:1:c): Non-Invasive Blood Pressure Monitoring

- Do not reconnect the tubing

- Call the respiratory therapist fo a new "Y" connector

- Manually ventilate the patient until a new tubing is available

Rule: Only items in a sterile package can be used if dropped on the floor.

Why: Infection prevention, think of what is on the floor...

Physiological effects of Trendelenburg positioning in hypotensive patients
Cardiovascular
- Slight increase in mean arterial pressure, no increased preload, dilated right ventricle, decreased right ventricular ejection fraction, decreased cardiac output, increase in systemic vascular resistance
Pulmonary
- Reduced vital capacity, increased work of breathing, decreases in PaO₂, increases in mechanical impedance of lung and chest wall, decreased tidal volume, decreased lung compliance, increases in PaCO_2, tissue perfusion, no change in oxygen delivery, no change in oxygen extraction, no change in oxygen consumption
Gastrointestinal
- Cephalad shift of abdominal contents, increased abdominal pressure, impaired diaphragmatic function, impeded lung expansion
Neurological
- Possible increase in intracranial pressure associated with increase in central venous pressure, distention of internal jugular vein

Makic, M. B. F., VonRueden, K. T., Rauen, C. A., & Chadwick, J. (2011). Evidence-based practice habits: Putting more sacred cows out to pasture. Critical Care Nurse, 31(2), 38-62.

You come in the morning and the off coming nurse says that the patient is not doing very well, but does not know why. Immediately after report, you go into the room to assess the patient.

What tool could be helpful in determining the patient's status?

- Can use the Modified Pediatric Early Warning Score (MPEWS) as an assessment tool: neurologic, cardiovascular and respiratory assessment

- Can look at trends over hours and ask someone who knows the patient

Your patient is having increased work of breathing of unknown origin. The physician or nurse practitioner orders a BNP.

What is the rationale behind this diagnostic test?

Both systolic and diastolic heart failure are accompanied by increased ventricular and atrial wall tension leading to release of natriuretic peptides types A and B (secreted by atrias)

This test is used to identify patients with dyspnea and pulmonary infiltrates who have heart failure from those with primary pulmonary disorders.

- Increased B-type Natriuretic Peptide: Systolic and diastolic right and left ventricular failure. Will not be increased in pulmonary edema

- Normal Concentration: less than 100

http://proxy.library.upenn.edu:2198/content.aspx?aID=3658337&searchStr=brain+natriuretic+peptide#3658337

- Phosphodiesterase enzyme inhibitor

- Positive inotropic and vasodilatory activity, with minimal chronotropic activity

- Use: short-term iv therapy of congestive heart failure; adjunctive therapy for low cardiac output syndrome after cardiac surgery

Up to date and lexicomp

http://proxy.library.upenn.edu:2066/das/pharm/body/344420941-4/0/full/406

Digoxin is an appropriate medication for hypertension.

True or False?

False

- Positive inotropic effect ( increases force and velocity of myocardial contraction): congestive heart failure

- Negative chronotropic response (slows the AV node conduction): atrial fibrillation, atrial flutter, atrial tachycardia

http://proxy.library.upenn.edu:2066/das/pharm/body/344420941-7/0/full/190