PICU Doc On Call

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 patientsWhen the tumor cells die or lyse, what’s inside those cells comes out into the bloodKey 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 tumorsPatients with fast-growing tumors, like lymphoma and leukemia, are at high riskKey pathophysiologic principles that drive TLS:The imbalance of electrolytes can impact heart functionTLS is characterized by hyperkalemia, hyperphosphatemia, hypocalcemia, and uric acid, which is a by-product of DNA breakdownIf untreated, the uric acid can lead to acute kidney injury and renal failureElectrolyte and metabolic disturbances can progress to renal insufficiency, cardiac arrhythmias, seizures, and deathTLS releases cytokines that can cause a systemic inflammatory response and multi-organ failureOther 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 teamA robust and experienced team for perioperative care and graft outcomeA comprehensive and multidisciplinary post-transplant teamThe process of organ procurement for cadaveric and living donor renal transplants includes the following:Multiple factors determine the points a patient receives toward transplant priorityDeceased donor kidneys are classified using the KDPI (kidney donor profile index)A thorough evaluation is performed for living donorsAdvantages to living donation include a shorter time on dialysis and waitlists, improved graft survival, and shorter ischemia time than from a deceased donorInformation 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 phaseHow immunosuppressive medications might be used for the pediatric renal transplant patientWhy the post-op transplant patient might need dialysisClinical 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 US40% of the transplants are done on children born with biliary atresia10-15% of the transplants are due to acute liver failure5% of the transplants are due to malignanciesThe rest of the transplants are due to different childhood diseases and metabolic diseasesHow the PELD (Pediatric End-Stage Liver Disease in children under 12) score relates to prioritization for liver transplantCriteria for the PELD score are bilirubin, albumin, age, growth parameters, and INRThe 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 transplantsThree phases of the liver transplant process are the hepatectomy phase, anhepatic phase, and reperfusion phaseSpecifics of the time intervals during the transplant process, where the major risk is for primary non-function during cold ischemia and warm ischemia timesMajor red flags to look for during the immediate post-operative periodAcute 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 teamHow treatment and management have evolved over time with standardized post-op management, protocols, and parametersTwo important aspects of post-op management are nutrition and immunosuppressionClinical 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 organsWhy pediatric acute liver failure is more difficult to diagnose than in adults; key indicators are coagulopathy along with biochemical disruptionsThe most important contributing factors to pediatric acute liver failure, and why most pediatric cases are children under four years of ageCauses of pediatric acute liver failure in the US include HSV, adenovirus, enterovirus, metabolic causes, and acetaminophen, especially in older childrenThe diagnostic approach considers infectious etiologies, toxins, vascular issues, and immune dysregulationIn treatment, care should be given to the correction of abnormal lab values and possible renal replacement therapyWhy the use of prophylactic antifungal antibiotics is controversial and varies from institution to institutionHow to discern hyperammonemia and neurologic statusThe role of intracranial pressure monitoring for cerebral edema, which is the mode of death for these patientsKey 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 intakeHistory, 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 levelWhy metabolic conditions can be inherited or result from a spontaneous mutationHow 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 sugarWhy the physician should save a purple top tube before any transfusionGeneral 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 kidsGet early labs when they are sickStart high dextrose fluidsKeep the patient NPOTreat fever, hypoglycemia, seizures, infection, etc. The goal is to prevent catabolism and be aggressive early in treatmentDr. 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.”

Dr. Ziad N. Kazzi discusses the application of lipid emulsion therapy in the PICU setting, focusing on a case of calcium channel blocker ingestion. Topics include lipid emulsion therapy origins, mechanisms, and doses, with examples of cases needing this treatment. Considerations for propofol as a substitute and minimizing complications are highlighted.

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 symptomsSymptoms: 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 droolingAcute 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 workupCauses of an acute pediatric vascular event can include stroke, seizure, migraine, and toxidromeDefinition of stroke: an acute neurologic change identified by advanced imagingPractical 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 diseaseIn 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 MRIIn the management of pediatric stroke, TPA should be administered within 4.5 hours, and endovascular therapy (if needed) should be administered within 24 hoursWhy the diagnosis and management of pediatric stroke is delayed, and how ER and ICU physicians can change thatDeveloping a pediatric stroke program is a collaborative effort among emergency care providers, radiologists, pharmacists, adult neuro interventionalists, ICU team, neurosurgeons, hematologists, and rehab physiciansA 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 MRIHistory, 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 laryngospasmDefinition of laryngospasm: complete or partial closure of the larynx due to some manner of external stimulationWhy laryngospasm leads to acute respiratory failure in childrenHow laryngospasm differs from airway obstructionCharacteristic breathing pattern with laryngospasmAcute management of laryngospasm includes a bag-mask and positive pressure ventilation, followed by deepened sedation, and a breathing tubeWhy 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 urticariaVitals: hypotensive, tachycardic, with stats dropping rapidlyWhat 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.