Paediatric intensive care

Question 1

what do you think when a kid comes in with bradycardia?

Answer 1

hypoxia

Question 2

what are some causes of a widened pulse pressure?

Answer 2

Sepsis 
anaphylaxis
patent ductus arteriosus
anaemia
aortic regurgitation

Question 3

what are some causes of a narrow pulse pressure?

Answer 3

aortic stenosis/coarctation
hypovolaemia (due to peripheral vasoconstriction)
pump failure (e.g. myocarditis/tamponade)
untreated sepsis

Question 4

describe kussmaul breathing

Answer 4

effortless tachypnoea

Question 5

why would you not intubate a patient with septic shock immediately to protect his airway?

Answer 5

because giving anaesthetic drugs will shut down his circulatory system

Question 6

if you get to 40mls/kg fluid resuscitation to a shocked child and they are still in shock, what do you do?

Answer 6

call intensive care unit for advice!

give inotrope or vasopressor

Question 7

what do we use as fluid maintenance therapy for a child?

Answer 7

Plasma-lyte

Question 8

what is the most commonest cause of iron deficiency in kids

Answer 8

poor nutrition

Question 9

how can cow’s milk cause iron deficiency?

Answer 9

poorly bioavailable iron
occult blood loss if there is an allergy to cow’s milk
often associated with poor diet

Question 10

why do premature babies need iron supplements?

Answer 10

premature babies are at higher risk of iron deficiency because most of the hb transferred from the mother occurs during late gestation.

Question 11

what is the issue with interpreting iron studies in an anaemic child?

Answer 11

ferritin may be normal or raised

so need to order a reticulocyte count along with full iron studies

Question 12

how do you give iron supplementation and what advice do you give?

Answer 12

oral iron- take it with orange juice and on a full stomach; keep it safe and out of reach; brush teeth after giving iron to prevent staining of teeth

IV iron is now making a comeback

Question 13

what are the acute effects of iron overdose in a child?

Answer 13

inflammation of the gastrointestinal tract- mucosal irritation

Question 14

how can we tell if an iron deficient child is responding to iron supplementation?

Answer 14

increased reticulocytes within 72 hours

Question 15

why might a child with beta thalassemia major present with concurrent haemosiderosis?

Answer 15

Blood transfusions are the mainstay treatment of beta thalassaemia major. In some countries, additional chelating agents are not available and so the excess iron from each transfusion accumulates

Question 16

what are the indications for a blood transfusion?

Answer 16

when the patient is symptomatic for anaemia

• has co-morbidities
• decompensated deficit in oxygen delivery
• progressive anaemia/blood loss

Question 17

What are the ways we can provide respiratory support to a sick child?

Answer 17

Low flow O2
High flow O2 (flow rate > respiratory flow rate)
CPAP
BiPAP
Mechanical ventilation

Question 18

what is the main difference between mechanical ventilation and bipap?

Answer 18

Bipap= spontaneous breathing

Mechanical ventilation= ventilator takes over breathing; requires a level of sedation; can use higher pressures than bipap as high pressures in bipap will cause gastric dilation as air goes down the oesophagus

Question 19

what is the main mechanism by which CPAP helps respiratory failure?

Answer 19

increased recruitment of alveoli (functional residual capacity), enables greater oxygenation and hence reduced work of breathing

Question 20

how might you tell if a CXR is over-exposed?

Answer 20

If you can see the intervertebral discs well on x-ray then over-exposed

Question 21

what does ECMO stand for and what is the indication for its use?

Answer 21

extra-corporeal membrane oxygenation

for life-threatening reversible causes of cardiac/respiratory failure unresponsive to conventional management

think of it like an artificial lung/heart outside the body

Question 22

when might we order a cranial ultrasound?

Answer 22

exclusively for preterm babies/neonates only.

looking through the fontanelle for signs of haemorrhage, leukomalacia, tumours, structural abnormalities, hydrocephalus

Question 23

what is the flow rate of high flow oxygen therapy?

Answer 23

2L/kg/min for first 10kg, then additional 0.5L/kg/min for over kg > 12kg

Question 24

what does FiO2 stand for?

Answer 24

fraction of inspired oxygen

Question 25

what is the normal range for ICP?

Answer 25

0-15mmHg, upper limit= 20

Question 26

what are some causes of hyponatremia in children?

Answer 26

Common:
GIT losses (diarrhoea)
Inappropriate fluid resus
Increased ADH states e.g. meningitis, sepsis, bronchiolitis etc

Less common:
Psychogenic polydipsia
Adrenal insufficiency
Renal tubular acidosis

Question 27

what are the components of high flow oxygen therapy?

Answer 27

clinicians can titrate FiO2 and deliver O2 at a faster rate. But with faster rate of O2 delivery you need humidification. Thus humidification is an essential component of HF therapy

Question 28

what is the most accurate way to obtain a temperature in a fever?

Answer 28

Rectal temperature

Question 29

what is the main cation of intracellular fluid?

Answer 29

K+

Question 30

what is the main cation of extracellular fluid?

Answer 30

Na+

Question 31

what do we mean by fluid resuscitation?

Answer 31

fluid that replaces ongoing losses and existing deficit

Question 32

what do we mean by fluid maintenance?

Answer 32

fluid that replaces insensible losses

Question 33

what are the normal values of Na+ in the body?

Answer 33

135-145mmol/L

Question 34

what are the normal values of K+ in the body?

Answer 34

3.5-5mmol/L

Question 35

why are children at risk of hyponatremia?

Answer 35

children have larger brains and may have impaired adaptive mechanisms due to Na/K ATPase

Question 36

what are the high risk groups for hyponatremia we need to consider when we are commencing IV fluid therapy in a child?

Answer 36

HIGH RISK GROUPS for hyponatremia:
• Neurological disease= meningitis
• Craniofacial/neurosurgical patients
• Neonates- have their own special fluids
Seriously unwell children with full maintenance fluids bc of stress response

these patients will need LESS maintenance fluids- so think 2/1/1 instead of 4/2/1 rule

Question 37

why do we put dextrose in fluids for children?

Answer 37

prevents hypoglycaemia and ketosis
prevents haemolysis (original role when hypotonic fluids were used, but now that we use isotonic fluids, it is mainly to prevent hypoglycaemia)

Question 38

how do we manage hyponatremia in an otherwise ASYMPTOMATIC child?

Answer 38

careful fluid restriction and avoidance of hypotonic fluids

Question 39

how do we manage hyponatremia in a SYMPTOMATIC child?

Answer 39

Notify ICU
ABC + resuscitation
Give 3% NaCL fluid boluses carefully, regularly monitor UEC

make sure to not correct the sodium too quickly!

Question 40

How do we calculate the corrected (ie. Actual sodium) in the setting of hyperglycemia?

Answer 40

Corrected na = na + 0.3 (glucose - 5.5) mmol / litre