PediatricMorbidity and Mortality

Cases from Aug 2014

Ryan Padrez & Patrick Peebles9/10/14

Discussion of Cases

Status Asthmaticus

What is Asthma?

1. Airway obstruction Bronchoconstriction Inflammation

2. Reversible Improves in response

to bronchodilators

3. Recurrent Triggers: Infection,

stress, allergens, exercise, cold, foods, smells, etc

Inhaled beta-agonists: Albuterol

Safe and well-tolerated in kids HR up to 200 commonly seen

Intermittent albuterol (MDI and nebulizer) Peak activity at 30 minutes Dosing: 0.15mg/kg/dose– titrate to effect

Continuous albuterol Starting dose: 0.5mg/kg/hour (or 5-15 mg/hour) May go up as tolerated

Ipratropium bromide (Atrovent)

Anticholinergic Bronchodilation and decreased secretions

No cardiovascular side effects, very cheap RCT’s of albuterol/atrovent vs albuterol alone

Clinical improvement Decreased hospitalization Especially most severe

Dosing: 3 doses initially, q6h after that No evidence for continued benefit after first 3

doses

Steroids

Systemic: short burst (3-5 days) Prevent hospitalization, reduce duration of

symptoms Most effective when given early in exacerbation IV/IM equivalent to PO Options

Solumedrol/prednisone 1-2mg/kg/dose (max 60mg) Dexamethasone 0.6mg/kg/day

Of note: no established role of inhaled steroids in acute exacerbation

Management of Status Asthmaticusin

ED (or 6M Urgent Care)

Case #1

CC: 18mo boy with history of RAD with viral illnesses

presents to ER with increased work of breathing

HPI: 1 day viral URI symptoms, tactile fevers, stuffy nose; difficulty breathing overnight, fussy and poor PO intake in the morning, parents brought into ER at 8am on 8/31

Meds: none All: NKDA PMH: as noted, immunizations up to date until 1yo Social History: intact family Family History: mom +allergies/asthma

Case #1: 18mo with RAD

Initial Exam in ER:

T: 37.1, P 170, RR 50-60, O2 sat 85% on RA. Gen: nasal flaring, obvious respiratory distress,

somnolent Lungs: Supra-clavicular, intercostal, subcostal

retractions, scattered expiratory wheezes

Brought to Zone 1, Bed 4 and a Zone 1 ED resident assigned to case

Case #1: 18mo with RAD

8:28am: Neb x1 (albuterol + ipratropium bromide) 8:47am: Neb x2 (albuterol + ipratropium bromide) 9am re-assessment by nurse :

T 37.1, P 178, RR 48, O2 sat 98% RA VBG: 7.18/49/32/-10 and Lactate 2.5

~9am: IV Dexamethasone x1 + IV fluids 20ml/kg NS bolus ~9:30: Neb x3 (albuterol + ipratropium bromide) 10am: repeat labs and CXR

VBG: 7.27/35/70/-10 CBC: 9.9>38.3<234 Chem: 143/4.0/113/12/11/0.22 CXR: no abnormalities

Peds Chief Resident assessment at ~10am: Reactive to exam but not crying and not verbally interactive, sleepy, obvious respiratory

distress, nasal flaring, retractions with faint wheezing

What was done well and what could be different at this point in time?

Case #1: ED Management

Asthma Algorithm

Case#1: Continued

To Recap: ~1 hr 20 min the team gave albuterol/atrovent X3, IV

dexamethasone, IV fluid bolus RR 40-50, HR180s, O2 sat 98% on facemask Gen: looks sleepy, tachypnea with flaring and retractions,

not very verbal Lungs: faint wheezing

What does this child have?Status Asthmaticus

ED team asks peds team if next steps are to give: More IV fluids and IV Mag

Discussion Question: What could be done to optimize management if we think child has status asthmaticus?

Status Asthmaticus

Status Asthmaticus definition: “unresponsive to inhaled bronchodilators”

Next steps if concerned for status asthmaticus: Maximize O2 delivery Move to continuous

bronchodilator Get IV access Consider dose of IV steroids

What if none of these things work???

Magnesium Epinephrine Terbutaline

2nd Line Medications

Evidence: Magnesium

Bronchodilation via SM relaxation Single IV dose:

RCT data in children has established safety and efficacy

Most beneficial in severe asthmaticus Repeated doses: utility unclear

Must be infused over 20 minutes Adverse effects: flushing, nausea, hypotension

Epinephrine

Easily available! Found on code cart, easy to dose

Fastest absorption when IM, in lateral thigh Previously standard of therapy, now less

favorable due to cardiac effects

Evidence: Terbutaline

IV beta-agonist, Less B2-selective than albuterol

Efficacy: no consistent decrease in symptoms or length of stay shown Recent trials: trend toward improvement?

Minor side effects common Can be given SC or IV

Loading dose of 10 mcg/kg SC or IV Infusion of 0.4mcg/kg/min

Recommendations: Systemic Bronchodilators

Magnesium first-line systemic bronchodilator, for pediatric status asthmaticus

Consider terbutaline as second-line agents IM Epinephrine if no others available

In ED Peds Team Ordered:

Continuous Albuterol at 20mg/hr IV solumedrol IV magnesium sulfate 40mg/kg x1 IV bolus of fluids #3 followed by 1x

maintenance Admit to 4E

(after mag, patient began to look better, crying, better air movement, more prominent wheezing)

Back to Case

For ED Management of Severe Asthma

Ensure systemic steroids given <1 hour consider IV route if severe presentation

Duo-nebs x3 with poor response move to continuous nebulized albuterol and can start 5-15mg/hr and titrate up to effect

Get IV access early IV magnesium the most effective systemic

bronchodilator for status asthmaticus

Key Points for Case #1

Management of Status Asthmaticusin

4E ICU

Case #2

ID: 11yo M with history of asthma on Qvar with very poor

compliance presents to ED with significant increased work of breathing.

HPI: normal state of health, but recently moved in with father in SF x1 week with cats and cigarette smoke in home; coupled with poor compliance with Qvar (ICS controller). Brought to ER by ambulance. In route received two albuterol nebs by EMS.

Meds: Qvar, singulair, albuterol PRN All: NKDA PMH: multiple admissions for asthma, no intubations,

immunizations UTD Family History: 2 family members with asthma

Case #2: 11yo M with Severe Asthma

Exam (s/p 2 nebs in ambulance)

Vitals: RR 40-50, O2 sats 92% room air Gen: tripod position, significant respiratory distress, 2-3 word

sentences Lungs: retractions prominent, decreased air movement

ED Management: Continuous albuterol 10mg/hr with 100% O2 face mask IM Epi x1 IV solumedrol IV Mag x1 Repeat IM Epi VBG: 7.3/52/-0.8 CXR: no focal infiltrate Admitted to 4E ICU with “status asthmaticus”

Case #2: In ED

Pediatric Team Management:

Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance

Case #2: In ICU

Respiratory Therapy Teaching

• Different devices to provide O2 support on 4E vs 6A vs 6M

• Different ways to deliver continuous albuterol • Optimal flow rate when giving albuterol with HFNC

Pediatric Team Management:

Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance

Case #2: In ICU

Continuous albuterol neb ran out in early

morning hours for uncertain amount of time Significant respiratory distress resulting in:

Epi #3 IM given IV Mag #2 given Continuous Albuterol 20mg/hr neb with HFNC

Discussion Question: What system issues that

may have lead to this error?

Case #2: In ICU

Hospital Night #2:

Overnight peds team weaned from 20mg/hr continuous albuterol to 15mg/hr

In AM worsening respiratory distress and increased expiratory wheezes

Team elected to increase albuterol back to 20mg/hr

Discussion Question: Was this patient weaned too quickly? What resources or

metrics can we use to guide our weaning management?

Back to Case#2: In ICU

Review of Key Points

Inhaled bronchodilators are first line agent in mild, mod and severe asthma Use aggressively, including moving to

continuous early Start steroids early <1 hr Magnesium is the most beneficial systemic

bronchodilator in status asthmaticus Consider systematic approach to weaning