Peds Clinical Cases (Egypt) 3-09 (Final Version)

8/14/2019 Peds Clinical Cases (Egypt) 3-09 (Final Version)

1/57

Interesting PediatricRespiratory Cases:

An Interactive Discussion

Interesting PediatricRespiratory Cases:

An Interactive Discussion

Ira M. Cheifetz, MD, FCCM, FAARCProfessor of PediatricsChief, Pediatric Critical Care

Medical Director, PICUDuke Childrens Hospital

Ira M. Cheifetz, MD, FCCM, FAARCIra M. Cheifetz, MD, FCCM, FAARC

Professor of PediatricsProfessor of PediatricsChief, Pediatric Critical CareChief, Pediatric Critical Care

Medical Director, PICUMedical Director, PICUDuke ChildrenDuke Childrens Hospitals Hospital


2/57

Case 1: PneumoniaCase 1: Pneumonia Previously healthy 4 yo (18 kg) girl presents

with a 5 day h/o URI symptoms, cough, & fever Admitted to the pediatric ward with RLL

pneumonia

Over 48 hours, she develops worseningtachypnea, progressive bilateral infiltrates, and

hypoxia

HR 152, RR 42, SpO2 89% (2 lpm), T 39.5C

Diffuse rales, mod subcostal retractions

Previously healthy 4 yo (18 kg) girl presents

with a 5 day h/o URI symptoms, cough, & fever

Admitted to the pediatric ward with RLL

pneumonia

Over 48 hours, she develops worseningtachypnea, progressive bilateral infiltrates, and

hypoxia

HR 152, RR 42, SpOHR 152, RR 42, SpO22 89% (2 lpm), T 39.589% (2 lpm), T 39.5CC

Diffuse rales, mod subcostal retractionsDiffuse rales, mod subcostal retractions


3/57


4/57

Your AssessmentYour Assessment Moderate subcostal retractions, no

supraclavicular retractions, good air exchange

except at R base

Significant crackles on right, minimal crackles

on left, no wheezing

SpO2 85% on 2 lpm via nasal cannulae

CV normal pulses and capillary refill Exam otherwise unremarkable

Moderate subcostal retractions, no

supraclavicular retractions, good air exchange

except at R base

Significant crackles on right, minimal crackles

on left, no wheezing

SpOSpO22 85% on 2 lpm via nasal cannulae85% on 2 lpm via nasal cannulae

CV normal pulses and capillary refill Exam otherwise unremarkable


5/57

Case ProgressionCase Progression Patient is transported to the Pediatric ICU

Worsening respiratory distress

Increased work of breathing

RR 50s, SpO2 92% on 5 lpm

Patient is transported to the Pediatric ICUPatient is transported to the Pediatric ICU

Worsening respiratory distress

Increased work of breathing

RR 50s, SpO2 92% on 5 lpm


6/57

Question #1

What would be your management?

Question #1

What would be your management?

A. Observe closely

B. CPAP

C. Bilevel non-invasive ventilation (i.e., BiPAP)

D. IntubateE. Hope that help arrives soon

A.A. Observe closelyObserve closely

B.B. CPAPCPAP

C. Bilevel non-invasive ventilation (i.e., BiPAP)

D.D. IntubateIntubateE.E. Hope that help arrives soonHope that help arrives soon


7/57

Non-invasive VentilationNon-invasive Ventilation Use of NIV for acute, hypoxic respiratory failureremains controversial

intubation rate, ICU LOS, & ICU mortality Keenan, CCM, 2004 (meta-analysis)

nosocomial pneumonia risk Hess, Respir Care, 2005 (meta-analysis)

Use of NIV for acute, hypoxic respiratory failureUse of NIV for acute, hypoxic respiratory failure

remains controversialremains controversial

intubation rate, ICU LOS, & ICUintubation rate, ICU LOS, & ICU mortalitymortality Keenan, CCM, 2004 (metaKeenan, CCM, 2004 (meta--analysis)analysis)

nosocomial pneumonia risknosocomial pneumonia risk Hess, Respir Care, 2005 (metaHess, Respir Care, 2005 (meta--analysis)analysis)


8/57

Case ProgressionCase Progression Patient is intubated the next morning for

progressive hypoxia.

PC/PS: rate 24 PIP 30 PEEP 12 FiO2 0.60

ABG pH 7.3 PaCO2 55 PaO2 65

PaO2 / FiO2 108

Oxygenation index = 15

OI = (MAP x FiO2) / PaO2

Patient is intubated the next morning forPatient is intubated the next morning for

progressive hypoxia.progressive hypoxia.

PC/PS: rate 24 PIP 30 PEEP 12 FiOPC/PS: rate 24 PIP 30 PEEP 12 FiO22 0.600.60

ABG pH 7.3 PaCO2 55 PaO2 65ABG pH 7.3 PaCO2 55 PaO2 65

PaOPaO22 / FiO/ FiO22 108108 Oxygenation index = 15Oxygenation index = 15

OI = (MAP x FiO2) / PaO2


9/57

Question #2

What delivered tidal volume wouldyou choose?

Question #2

What delivered tidal volume wouldyou choose?

A. 4 ml/kg

B. 6 ml/kg

C. 8 m/kg

D. 10 ml/kg

A. 4 ml/kg

B. 6 ml/kg

C. 8 m/kg

D. 10 ml/kg


10/57

Low Tidal Volume Ventilation

The appropriate Vt for pediatric acute lung

injury has never been formally studied.

Thus, the best we can do is extrapolate

from data in the adult ARDS population.

The appropriate Vt for pediatric acute lung

injury has never been formally studied.

Thus, the best we can do is extrapolate

from data in the adult ARDS population.

Volume 342(18) 4 May 2000 pp 1301-1308

Ventilation with Lower Tidal Volumes as Compared with

Traditional Tidal Volumes for Acute Lung Injury and theAcute Respiratory Distress Syndrome


11/57

13 Experts

Yes: 5

No: 8

13 Experts

Yes: 5

No: 8


12/57

ARDS WorsensARDS Worsens Patient is transitioned to HFOV.

MAP 28, Amp 59, 33% insp time, FiO2 0.70 pH 7.25, PaCO2 67, PaO2 65, SaO2 90%

PaO2 / FiO2 93

Oxygenation index = 30

Patient is transitioned to HFOV.Patient is transitioned to HFOV.

MAP 28, Amp 59, 33% insp time, FiOMAP 28, Amp 59, 33% insp time, FiO22 0.700.70 pH 7.25, PaCOpH 7.25, PaCO22 67, PaO67, PaO22 65, SaO65, SaO22 90%90%

PaOPaO22 / FiO/ FiO22 9393

Oxygenation index = 30Oxygenation index = 30


13/57

Question #3

What should be the maximumacceptable PaCO2?

Question #3

What should be the maximumacceptable PaCO2?

A. 55 torrB. 75 torr

C. 95 torr

D. Any PaCO2 as long as the pH is

acceptable

A.A. 55 torr55 torrB.B. 75 torr75 torr

C.C. 95 torr95 torr

D. Any PaCO2 as long as the pH is

acceptable


14/57

Permissive HypercapniaPermissive Hypercapnia Available data support permissive hypercapnia to

minimize vent settings and secondary lung injury

Goal: maintain acceptable pH regardless of PaCO2

Contraindications

increased intracranial pressure reactive pulmonary hypertension

Acute lung injury model (Laffey, AJRCCM, 2000)

hypercapnic acidosis is protective

buffering attenuates its protective effects

Available data support permissive hypercapnia to

minimize vent settings and secondary lung injury

Goal: maintain acceptable pH regardless of PaCO2

Contraindications

increased intracranial pressure reactive pulmonary hypertension

Acute lung injury model (Laffey, AJRCCM, 2000)

hypercapnic acidosis is protectivehypercapnic acidosis is protective

buffering attenuates its protective effectsbuffering attenuates its protective effects


15/57

Question #4

What is the goal SaO2 for yourpatient?

Question #4

What is the goal SaO2 for yourpatient?

A. 95%B. 90 94%

C. 85 89%

D. 80 84%

E. < 80%

A.A.

95%95%B.B. 9090 94%94%

C.C. 8585 89%89%

D.D. 8080 84%84%

E.E. < 80%< 80%


16/57

Permissive HypoxemiaPermissive Hypoxemia Definitive data are lacking in the medical

literature!

Goal maintain a safe level of oxygenation

Maintain adequate O2 delivery

optimize cardiac output measure ABG / MVO2 / serum lactate

Assess end-organ function

mental status (difficult 2 sedation)

renal function / urine output

cardiac function

Definitive data are lacking in the medical

literature!

Goal maintain a safe level of oxygenation

Maintain adequate O2 delivery

optimize cardiac output measure ABG / MVO2 / serum lactate

Assess end-organ function

mental status (difficult 2 sedation)

renal function / urine output

cardiac function


17/57

Question #5

Do you routinely use recruitmentmaneuvers (i.e., sustained inflation)

for pediatric ALI / ARDS?

Question #5

Do you routinely use recruitmentmaneuvers (i.e., sustained inflation)

for pediatric ALI / ARDS?A. Yes

B. No

A.A. YesYes

B.B. NoNo


18/57

Recruitment ManeuversRecruitment Maneuvers Use of RMs remains controversial.

Bring lung to TLC to maximize recruitment,then move down the deflation limb of the

pressure-volume curve to an appropriate

PEEP to prevent de-recruitment No adult outcome data

No pediatric data

Use of RMs remains controversial.Use of RMs remains controversial.

Bring lung to TLC to maximize recruitment,Bring lung to TLC to maximize recruitment,

then move down the deflation limb of thethen move down the deflation limb of the

pressurepressure--volume curve to anvolume curve to an appropriateappropriate

PEEP to prevent dePEEP to prevent de

--recruitmentrecruitment

No adult outcome data

No pediatric data


19/57

Should RMs be routinely performed foradult ARDS pts?

12 Experts

Yes 3

No 9

Abstain 1

Should RMs be routinely performed foradult ARDS pts?

12 Experts

Yes 3

No 9

Abstain 1


20/57


21/57

Case 2: TraumaCase 2: Trauma 3 year old unrestrained passenger ejected

from car

Intubated for loss of consciousness

Transported to ED

GCS 5, poorly perfused bruising noted over left chest wall

SpO2 83%; FiO2 1.0

ABG pH 7.25 PaCO2 32 PaO2 43 BE -9

Trauma eval and stabilization in

Emergency Department then to PICU

3 year old unrestrained passenger ejected3 year old unrestrained passenger ejected

from carfrom car

Intubated for loss of consciousnessIntubated for loss of consciousness

Transported to EDTransported to ED

GCS 5GCS 5, poorly perfused, poorly perfused bruising noted over left chest wallbruising noted over left chest wall

SpOSpO22 83%; FiO83%; FiO22 1.01.0

ABG pH 7.25 PaCOABG pH 7.25 PaCO22 32 PaO32 PaO22 43 BE43 BE --99

Trauma eval and stabilization inTrauma eval and stabilization in

Emergency Department then to PICUEmergency Department then to PICU


22/57

Pulm ContusionPulm Contusion

Patient placed on ventilator in PRVC mode

Vt 7 ml/kg rate 20 PIP 31 PEEP 8

FiO2 0.70

ABG pH 7.34 PaCO2 41 PaO2 43

Patient placed on ventilator in PRVC modePatient placed on ventilator in PRVC mode

Vt 7 ml/kg rate 20 PIP 31 PEEP 8Vt 7 ml/kg rate 20 PIP 31 PEEP 8

FiOFiO22 0.700.70

ABG pH 7.34 PaCOABG pH 7.34 PaCO22 41 PaO41 PaO22 4343


23/57

Question #6

Would you administer exogenoussurfactant?

Question #6

Would you administer exogenoussurfactant?

A. Within the first 48 hours

B. If no improvement after 48 hours

C. If no improvement after 7 daysD. Not for this patient

A.A. Within the first 48 hoursWithin the first 48 hours

B.B. If no improvement after 48 hoursIf no improvement after 48 hours

C.C. If no improvement after 7 daysIf no improvement after 7 daysD.D. Not for this patientNot for this patient


24/57

Exogenous SurfactantExogenous Surfactant Exogenous surfactant administration is the

only adjunct therapy that has been shown to

be beneficial for the pediatric ALI / ARDS pt.

Willson, JAMA, 2005

Surfactant was shown to be beneficial whenadministered within 48 hours of onset of ALI.

Exogenous surfactant administration is the

only adjunct therapy that has been shown to

be beneficial for the pediatric ALI / ARDS pt.

Willson, JAMA, 2005

Surfactant was shown to be beneficial whenadministered within 48 hours of onset of ALI.


25/57

Question #7

Would you offer a trial of inhalednitric oxide?

Question #7

Would you offer a trial of inhalednitric oxide?

A. Within the first 48 hoursB. If no improvement after 48 hours


A.A. Within the first 48 hoursWithin the first 48 hoursB.B. If no improvement after 48 hoursIf no improvement after 48 hours



26/57

Question #8

When would you consider a trialof prone positioning?

Question #8

When would you consider a trialof prone positioning?

A. Within the first 48 hoursB. If no improvement after 48 hours


A.A. Within the first 48 hoursWithin the first 48 hoursB.B. If no improvement after 48 hoursIf no improvement after 48 hours



27/57

Inhaled NO / Prone PositionInhaled NO / Prone Position Multiple studies have demonstrated improved

oxygenation for adult and pediatric patients

with the administration of inhaled nitric oxideand prone positioning for acute lung injury.

But, no study has demonstrated improvedsurvival with either therapy for acute lung

injury.

Multiple studies have demonstrated improved

oxygenation for adult and pediatric patients

with the administration of inhaled nitric oxideand prone positioning for acute lung injury.

But, no study has demonstrated improvedsurvival with either therapy for acute lung

injury.

Inhaled Nitric OxideDobyns, Pediatr, 1999

Dellinger, Crit Care Med, 1998

Inhaled Nitric Oxide

Dobyns, Pediatr, 1999

Dellinger, Crit Care Med, 1998

Prone PositioningCurley, JAMA, 2005

Guerin, JAMA, 2004

Gattinoni, NEJM, 2001

Prone Positioning

Curley, JAMA, 2005

Guerin, JAMA, 2004

Gattinoni, NEJM, 2001


28/57

Question #9

At what settings would you initiateHFOV?

Question #9

At what settings would you initiateHFOV?

A. OI 17, MAP 18, PIP 30, FiO2 50%B. OI 22, MAP 22, PIP 32, FiO2 65%

C. OI 38, MAP 27, PIP 37, FiO2 80%

D. Would not use HFOV

A.A. OI 17, MAP 18, PIP 30, FiOOI 17, MAP 18, PIP 30, FiO22 50%50%B.B. OI 22, MAP 22, PIP 32, FiOOI 22, MAP 22, PIP 32, FiO22 65%65%

C.C. OI 38, MAP 27, PIP 37, FiOOI 38, MAP 27, PIP 37, FiO22 80%80%

D.D. Would not use HFOVWould not use HFOV


29/57

Pediatric HFOVPediatric HFOV

Arnold, Crit Care Med, 1994.Arnold, Crit Care Med, 1994.


30/57

DISCUSSIONDISCUSSION


31/57

Case 3: Status AsthmaticusCase 3: Status Asthmaticus 12 year old female with known history of asthma

PMHx: 2 prior PICU admits; never intubated

On ED arrival

obvious respiratory distress

SpO2 84% (RA); BP 110/57; HR 142; RR 48

Triage nurses rushes patient to a room and

STAT pages you

12 year old female with known history of asthma12 year old female with known history of asthma

PMHx: 2 prior PICU admits; never intubatedPMHx: 2 prior PICU admits; never intubated

On ED arrivalOn ED arrival

obvious respiratory distressobvious respiratory distress

SpOSpO22 84% (RA); BP 110/57; HR 142; RR 4884% (RA); BP 110/57; HR 142; RR 48

Triage nurses rushes patient to a room andTriage nurses rushes patient to a room and

STAT pages youSTAT pages you


32/57

Initial ManagementInitial Management Your initial assessment

SpO2 85% (RA); HR 151; RR 54

distant wheezing

poor air exchange

moderate subcostal & intercostal retractions

FiO2 via face mask started at 0.60

Solumedrol (1 mg/kg) IV ordered

Your initial assessmentYour initial assessment

SpOSpO22 85% (RA); HR 151; RR 5485% (RA); HR 151; RR 54

distant wheezingdistant wheezing

poor air exchangepoor air exchange

moderate subcostal & intercostal retractionsmoderate subcostal & intercostal retractions

FiOFiO22 via face mask started at 0.60via face mask started at 0.60

Solumedrol (1 mg/kg) IV orderedSolumedrol (1 mg/kg) IV ordered


33/57

Question #10

Which of the following would youdo next?

Question #10

Which of the following would youdo next?

A. Obtain an ABG

B. Start continuous albuterol at 20 mg/hr

C. Start continuous albuterol at 40 mg/hr

D. Start non-invasive ventilation

E. Emergently intubate

A.A. Obtain an ABGObtain an ABG

B.B. Start continuous albuterol at 20 mg/hrStart continuous albuterol at 20 mg/hr

C.C. Start continuous albuterol at 40 mg/hrStart continuous albuterol at 40 mg/hr

D.D. Start nonStart non--invasive ventilationinvasive ventilation

E.E. Emergently intubateEmergently intubate


34/57

Status AsthmaticusStatus Asthmaticus

Continuous albuterol started at 40 mg/hr

Patient initially with improved air exchange on

auscultation

Continues to have increased WOB but slightly

improved Intern sends med student to obtain ABG

obviously unsuccessful

Patient now complains that she cannot

breathe

Continuous albuterol started at 40 mg/hrContinuous albuterol started at 40 mg/hr

Patient initially with improved air exchange onPatient initially with improved air exchange on

auscultationauscultation

Continues to have increased WOB but slightlyContinues to have increased WOB but slightly

improvedimproved Intern sends med student to obtain ABGIntern sends med student to obtain ABG

obviously unsuccessfulobviously unsuccessful

Patient now complains that she cannot

breathe


35/57

Question #11

Would you offer a trial of heliox beforeintubation?

Question #11

Would you offer a trial of heliox beforeintubation?

A. Yes

B. No

A.A. YesYes

B.B. NoNo


36/57

Gas DensitiesGas Densities

Relative density of He-O2 and N2-O2

mixtures compared with 100% O2.

Relative density of He-O2 and N2-O2

mixtures compared with 100% O2.

Oppenheim-Eden, Chest, 2001.Oppenheim-Eden, Chest, 2001.


37/57

Principles of Gas FlowPrinciples of Gas Flow

Because of its lower density than N2 or O2,

heliox would be predicted to improve gas

flow through a narrowed orifice.

Reynolds number (Re = VD / )

Re > 4000 = turbulent flow Re < 2100 = laminar flow

Because of its lower density than N2 or O2,

heliox would be predicted to improve gas

flow through a narrowed orifice.

Reynolds number (Re = VD / )

Re > 4000 = turbulent flow Re < 2100 = laminar flow


38/57

Turbulent Gas FlowTurbulent Gas Flow

Occurs in constricted passages

Flow rate = k P

gas density yields gas flow.

Thus, heliox improves turbulent gas

flow.

Occurs in constricted passages

Flow rate = k P

gas density yields gas flow.

Thus, heliox improves turbulent gas

flow.


39/57

Asthma and HelioxAsthma and Heliox

Both groups received methylprednisolone 125 mg IV

inhaled albuterol 2.5 mg nebs x 2

After 20 minutes of therapy

Heliox group PEF 58.4% N2-O2 group PEF 10.1%

Both groups received methylprednisolone 125 mg IV

inhaled albuterol 2.5 mg nebs x 2

After 20 minutes of therapy

Heliox group PEF 58.4% N2-O2 group PEF 10.1%

Kass, Chest, 1999.Kass, Chest, 1999.


40/57

Asthma and HelioxAsthma and Heliox

Kass, Chest, 1999.Kass, Chest, 1999.


41/57

A-a GradientA-a Gradient

Schaeffer, CCM, 1999.Schaeffer, CCM, 1999.

0

50

100

150

200

250

300

0

50

100

150

200

250

300

* p= 0.003* p= 0.003

BaselineBaseline 2 hrs2 hrs

**

controlhelioxcontrolheliox


42/57

Asthma and OxygenationAsthma and Oxygenation

FiO2 in the heliox treated group

decreased from 0.810.25 to

0.370.27 after 2 hours of therapy.

(p= 0.0008)

This study rejects the idea that aminimum of 40% helium must be

used to obtain a therapeutic effect.

FiO2 in the heliox treated group

decreased from 0.810.25 to

0.370.27 after 2 hours of therapy.

(p= 0.0008)

This study rejects the idea that aminimum of 40% helium must be

used to obtain a therapeutic effect.

Schaeffer, CCM, 1999.Schaeffer, CCM, 1999.


43/57

The Spiral EffectThe Spiral Effect

some

heliox

some

heliox

improve gas

exchange

improve gas

exchange

decrease

FiO2

decrease

FiO2

increase

heliox

concentration

increase

heliox

concentration


44/57

But.But. What if your patient does not improve with heliox

or if you do not have heliox at your institution?

Then, probably intubate. Patient intubated with 6.5 cuffed ETT without

difficulty (not by the med student)

Patient is being hand ventilated with FiO2 1.0.

Patient is transferred to the PICU.

What if your patient does not improve with heliox

or if you do not have heliox at your institution?

Then, probably intubate.Then, probably intubate. Patient intubated with 6.5 cuffed ETT withoutPatient intubated with 6.5 cuffed ETT without

difficulty (not by the med student)difficulty (not by the med student)

Patient is being hand ventilated with FiOPatient is being hand ventilated with FiO2 1.0.1.0.

Patient is transferred to the PICU.Patient is transferred to the PICU.


45/57

Question #12

What ventilator mode would bemost appropriate?

Question #12

What ventilator mode would bemost appropriate?

A. Volume control with square waveform

B. Pressure control with variable flow

C. PRVC with variable flowD. High frequency ventilation

A.A. Volume control with square waveformVolume control with square waveform

B.B. Pressure control with variable flowPressure control with variable flow

C.C. PRVC with variable flowPRVC with variable flowD.D. High frequency ventilationHigh frequency ventilation


46/57

Pressure ScalarPressure Scalar

Pressure(cm H2O)Pressure(cm H2O)

Constant,

Square Wave

Constant,

Square WaveVariable,

Decelerating Wave

Variable,

Decelerating Wave

00

PIPPIP

PawPaw

Q #13


47/57

Question #13

Which of the following settingswould you use?

Question #13

Which of the following settingswould you use?

A. Vt 12 ml/kg, rate 12, PEEP 5

B. Vt 8 ml/kg, rate 18, PEEP 5

C. Vt 6 ml/kg, rate 24, PEEP 5

A.A. Vt 12 ml/kg, rate 12, PEEP 5Vt 12 ml/kg, rate 12, PEEP 5

B.B. Vt 8 ml/kg, rate 18, PEEP 5Vt 8 ml/kg, rate 18, PEEP 5

C.C. Vt 6 ml/kg, rate 24, PEEP 5Vt 6 ml/kg, rate 24, PEEP 5


48/57

Asthma and Mech VentilationAsthma and Mech Ventilation

6 ml/kg has been shown to be the ideal tidal

volume only for adult ALI / ARDS.

Use long expiratory time ventilation which oftenrequires a larger tidal volume and low set

ventilatory rate.

Goal should be to transition to Pressure SupportVentilation with goal of extubation as soon as

possible.

6 ml/kg has been shown to be the ideal tidal

volume only for adult ALI / ARDS.

Use long expiratory time ventilation which oftenUse long expiratory time ventilation which oftenrequires arequires a largerlarger tidal volume and low settidal volume and low set

ventilatory rate.ventilatory rate.

Goal should be to transition to Pressure SupportGoal should be to transition to Pressure SupportVentilation with goal of extubation as soon asVentilation with goal of extubation as soon as

possible.possible.


49/57


Case 4:Case 4:


50/57

Case 4:

Patient-Ventilator Interactions

Case 4:

Patient-Ventilator Interactions 10 mo old infant; 28 weeks prematurity

Intubated for viral pneumonia

HR 172, RR 65, BP 82/45, afebrile

SIMV / PS rate 24, PIP 28, PEEP 7, FiO2 0.50

ABG: pH 7.25 / PaCO2 64 / PaO2 68

Infant is very agitated

Nurse requests additional sedation/analgesia

10 mo old infant; 28 weeks prematurity10 mo old infant; 28 weeks prematurity

Intubated for viral pneumoniaIntubated for viral pneumonia

HR 172, RR 65, BP 82/45, afebrileHR 172, RR 65, BP 82/45, afebrile

SIMV / PSSIMV / PS rate 24, PIP 28, PEEP 7, FiOrate 24, PIP 28, PEEP 7, FiO22 0.500.50

ABG: pH 7.25 / PaCOABG: pH 7.25 / PaCO22 64 / PaO64 / PaO22 6868

Infant is very agitatedInfant is very agitated

Nurse requests additional sedation/analgesiaNurse requests additional sedation/analgesia


51/57

Question #14Question #14


52/57

Question #14

Why is the patient agitated?

Question #14

Why is the patient agitated?A. Inadequate sedation / analgesia

B. Trigger insensitivityC. Flow dys-synchrony

D. Inadequate PEEP

E. Inadequate tidal volume

A.A. Inadequate sedation / analgesiaInadequate sedation / analgesia

B.B. Trigger insensitivityTrigger insensitivityC.C. Flow dysFlow dys--synchronysynchrony

D.D. Inadequate PEEPInadequate PEEP

E.E. Inadequate tidal volumeInadequate tidal volume


53/57


54/57

Question #15Question #15


55/57

Question #15

Why is the patient agitated?

Question #15

Why is the patient agitated?A. Inadequate sedation / analgesia

B. Trigger insensitivity

C. Flow dys-synchrony

D. Inadequate PEEP

E. Inadequate tidal volume

A.A. Inadequate sedation / analgesiaInadequate sedation / analgesia

B.B. Trigger insensitivityTrigger insensitivity

C.C. Flow dysFlow dys--synchronysynchrony

D.D. Inadequate PEEPInadequate PEEP

E.E. Inadequate tidal volumeInadequate tidal volume


56/57



57/57


Peds Clinical Cases (Egypt) 3-09 (Final Version)

Documents

Transcript of Peds Clinical Cases (Egypt) 3-09 (Final Version)