107/07/27 小兒科聯合病例討論會：兒科加護病房的照護進展

兒科加護病房的照護進展 高雄長庚 兒童加護科主任 兒童心臟科主治醫師 林盈瑞 醫師

案例報告 • • • • • • •

12 y/o, female, BW 45kg Fever upto 39°C 3 days ago Vomiting for 5-6 times this morning No diarrhea Mild epigastric pain Brought to our ER CRP 6.4, AST 217, ALT 98 admission to ward

Physical examination • • • • •

BT 36.3, PR 108, RR 20 BP 115/80mmHg GA: ill-looking, pale-looking BS: coarse HS: RHB, tachycardia Abd: soft and flat no tenderness or rebounding pain BS: hypoactive • Ext: freely, cold

Lab data • WBC 6700 (seg 42.3%, lym 48.5%, mono 8.6%, eosino 0.3%, basao 0.3%) • Hb 13.7 • Plt: 223000

• • • • • •

Sugar: 149 BUN/Cr: 16/0.79 AST/ALT: 217/98 Amylase/lipase: 49/16 Na/K 142/4.9 CRP: 6.4

Impression AGE Dehydration Elevated liver function

Clinical course (3/13) • 14:30 admission • 18:00 Vomiting for 4 times after admitted to ward • Novamine use • 01:15 BP 75/51 mmHg N/S challenge • 03:15 nausea, BP 76/46mmHg -> primperan • 06:00 go on abdominal pain and nausea, BP 71/46mmHg N/S challenge, call CR

3/14 • 07:15 Poor perfusion, persisted hypotension • Dopamine and dobutamine use Transfer to PICU • 8:15 VT => xylocaine use • 9:00 CPR and on ECMO with hypothermia • 15:00 distal perfusion

Lab (3/14 9:00) • • • • • • •

Sugar 140 BUN/CR 34/3.38 AST/ALT 11086/6003 CRP 6.3 CK-MB 187.7 Troponin I 58.51 Lactate 119.8

• • • • • •

PH 7.153 PCO2 32.7 PaO2 37.8 HCO3 11.0 BE -17 Sat 57.7%

Lab (3/15 11:00) • • • • • • • •

Lactate 59.4 BUN/Cr 61/3.50 Bil D/T 1.1/3.1 AST/ALT 9196/3679 CPK 37534 (15-130) CK-MB 365.1 (0.6~6.3) Troponin I 58.13 (<0.5) Myoglobulin 32780

• • • • •

ECMO V gas PH 7.379 PCO2 35.2 HCO3 16.1 Sat 82.6%

Clinical course • • • • •

ECMO duration 3/14~3/18 IABP 3/15~3/21 CVVHD duration 3/15~3/31 Transfer to ordinary ward on 4/11 Fever at ward and discharged on 4/24

Lab • • • • •

4/15 BUN/Cr 36/0.71 Bil D/T 2.4/4.2 AST/ALT 119/97 BNP 206

• • • • •

5/27 BUN/Cr Bil D/T AST/ALT BNP

12/0.55 0.57/1.2 44/61 7

ECMO 經驗

Myocarditis N=11 Survival rate: 100% All return to daily activity

Results Demography Sex (F/M)

6/5

Age (y/o)

11.0

Body weight (kg)

38

Body Height (cm)

143.2

Access (Neck/Femoral)

13~60 100~167

5/6

Distal perfusion (n)

2

IABP (n)

5

Dialysis during ECMO (n)

1

ECMO time (days)

3.3~15.5

5.99

Mortality (n)

0

CNS complications (ICH, CPâ&#x20AC;¦)

0

2.94~12.1

Results Clinical characteristics Presentation (n=11) CNS (dizziness, LOC, seizure)

81.8%

GI (abdominal pain, vomiting)

72.7%

Chest pain

54.5%

Initial ECG Ventricular tachycardia

54.5%

Complete AV block

45.4%

sinus tachycardia with ST-T change

9.0%

Overall ECG presentation Ventricular tachycardia

90.9%

Complete AV block

63.6%

asystole

63.6%

PEA ( agonal rhythm)

72.7%

Results Laboratory data Initial data CRP

28.2

5.8~75.7

Sugar

212.1

128~382

AST

1311.8

108~11086

ALT

681.3

21~6003

Cr

1.22

0.48~3.38

Troponin I

50.8

16.3~104.6

CPK

1315

606~3140

CK-MB

109.5

43.9~229.2

Lactate

45.1

14.3~119.8

AST

2694

168~16008

ALT

1196.7

43~6527

Cr

1.33

0.49~3.6

Troponin I

60.9

25.3~121.2

CPK

10071.6

1024~62958

CK-MB

227.2

45.6~678.6

Highest data

ARDS – 2007/03 • N= 17 • VA/VV: 7/10 • Survival rate : 64.7%

Case 1

Double lumen

Case 2

Case 3

• • • •

Sex: Male Age: 9-year-5-month old BW: 28.4 kg Date of Admission: 2016/02/29

• 9-year-5-month old – Steroid-resistent nephrotic syndrome, 2009/10 • Prednisolone 5mg 6# QOD • cyclosporin 100mg 1# BID

• Urine output ↓ , progressive change of general edema - 7 days, albumine 0.1 g/dL – BW: 25->28.4 kg (2/12-2/29)

• Influenza A (+)

2016-3-10 on ECMO and CVVHD 2016-3-11 blister formation over right leg, pulse + Favor femoral vein occlusion related Change ECMO V tube to neck

# CPCR 10mins # On pericardial tube # Explained to family # Re-on ECMO with heparine-free RV decompression Organ support

# Hypothermia therapy

200ml blood drainage

3/20

3/22

Remove ETT and pericardiac tube Gas: pH:7.469 pCO2: 40.3 mmhg pO2: 90.8 mmHg HCO3:28.6mmol/L SaO2:97.4% Lab: Cr:1.33mg/dL BUN:55 mg/dL

2016-03-28

Lab: CRP: 2.87 mg/L Cr:0.48 mg/dL BUN:14.0mg/dL Gas: pH:7.43 pCO2: 32.8 mmhg pO2: 77.4 mmHg HCO3:21.3mmol/L SaO2:95.9% â&#x2021;&#x2019;Transfer to ordinary ward

4/5 discharge

2016-04-13

2016-05-31

Neonatal ECMO

小兒及新生兒 – – – – –

吸入性胎便肺炎症候群( MAS；Meconium aspiration syndrome) 呼吸窘迫症候群( Hyaline membrane disease) 先天性橫膈膜疝氣(CDH；Congenital diaphragm hernia) 新生兒頑固性肺高壓(PPHN；Persistent pulmonary hypertension of neonate) 上述疾病經傳統治療(含呼吸器)，並合乎下列 呼吸衰竭指數 • • •

Oxygenation Index ≧ 40; OI＝ MAP X FiO2 X 100/PaO2 AaDO2＝(Patm–47) x FiO2–PaO2–PaCO2 ＞610 for 8Hrs or ＞600 for 12Hrs PaO2＜ 40 mmHg for 2hrs

Newborn • HFOV – 1990 HFOV appears in commercial products • iNO – 1997 FDA approval of nitric oxide for pulmonary hypertension in the newborn

Newborn ECMO 的困難 • 血管細，管路難固定– IV and ECMO line set • 心臟小 – tube position • 血量少 – ECMO priming, fluid control, electrolyte balance, 失溫

600~800 CC

200+ CC

Newborn ECMO 200906~201704 Diagnosis

BW (kg)

Age (D/O)

Diagnosis GA

Ventilator setting

ECMO (days)

Cetheter

ECMO syastem

Results

1

CDH

3

1

19

CMV

14

8.5A12V

Metronic

C

2

CDH

2.97

1

22

HFOV+iNO

8

8.5A12V

Metronic

A

3

CDH

3

1

16

PCPPV+iNO

7

10A10V

Terumo

A

4

CDH

2.57

0

29

HFOV+iNO

45

8.5A12V

Terumo

C

5

CDH

3.5

1

25

HFOV+iNO

7

8.5A12V

Terumo

A

6

CDH

3.1

1

birth

HFVO+iNO

2

8.5A12V

Terumo

C

7

ARDS

2.36

1

HFOV+iNO

6

12D

Metronic

A

8

ARDS

2.83

14

PCPPV+iNO

14

10A12V

Metronic

B

9

MAS with PPHN

3.36

2

HFOV+iNO

32

12D

Terumo

A

10

MAS with PPHN

2.68

1

PCPPV+iNO

3

10A14V

Metronic

A

11

Pneumonia PHT

3.19

20

HFOV+iNO

17

8.5A12V

Terumo

C

12

MAS with PPHN

3.66

1

HFOV+iNO

4

14.5D

Metronic

A

Hypothermia

Basic data • Name:王○方 • A 12-year-4-month-old boy.

• Growth: – BW: 27kg(<3rd percentile) – BH: 138cm(3rd-10th percentile)

Chief complaint • Fever up to 40.5°c for 3 days

Present illness • High fever up to 40.5° c for 3 days • no cough, diarrhea, abdominal pain, purulent nasal discharge, sore throat, dyspnea or dysuria.

• His appetite and activity are preserved • Past history : – Asthma and allergic rhinnitis • Fluticasone furoate nasal spray • Seretide 50 evohaler • levocetirizine

Physical examinations • Vital signs:T:38.2/℃ P:110/min R:27/min BP:112/74mmHg • General Appearance:fair looking

• HEENT: – conjunctiva: pink – throat: injected ++

• Neck: – supple, no lymphadenopathy • Chest: – bilateral clear and symmetric breathing sound

• Heart – regular heart beat, no murmur

Physical examinations • Abdomen: – soft and mild distended – normo-active bowel sound

– Hepatosplenomegaly: no

• SKIN: – No rash; no petechiae or ecchymosis; no vesicle; no desquamation

Basic laboratory survey

Leukopenia Thrombocytopenia Bandemia Liver function impairment

Impression • Leukocytopenia and thrombocytopenia, suspect dengue fever • Unspecified septicemia with bandemia • Acute hepatitis

PICU

Inform CDC for r/o dengue fever

Seizure E2VeM4

E1VeM1

Intubation

Inform CDC ,r/o influenza

CSF Abdominal echo: Hepatomegaly, r/o hepatitis

EEG

brain CT

Mycoplasma pnumonia (+)

Brain MRI EEG

EEG monitor

Rapid consciousness change on 1/22->1/23 • E2VeM4 pupil 2-3 symmetric with light reflex • muscle power 4-5 • DTR ++ • barbinski sign : bil dorsiflexion • Gag refles + • no loose anal tone

• E1VeM1 pupil 1-2 symmetric with light reflex • muscle power 3 • DTR +++ • barbinski sign : bil dorsiflexion • Gag refles +/-, • anal tone :decreased

Lab studies

Lab studies

Basic laboratory data survey

Autoantibodies screen Negative findings

1/20

Admission

MEDs

F *3 ds

1/21

1/23

1/25

1/27

1/29

1/31

2/2

PICU

2/4

2/6 2/8 2/10

Teico

vancomyci n Ceftriaxone

Mepem

2/18

Dapto

Teico

Tazocin

Mepem

acyclovir Tamiflu Azithro

PE

MP

AEDs

Dex

IVIg

Midazolam line Levetiracetam Phenobarbital Citosol line 4mg/kg/hr

Seizures

Hypothermia 33â&#x20AC;&#x2122;c

Phenytoin

Valproa te Clobazam

Clinical course Coma scale 15 13 11 9 7 5 3

14 12 10 8 6 4 2 0

IVIg

MP

Hypother mia 33â&#x20AC;&#x2122;c

PE

Seizure frequency

Tentative Diagnosis â&#x20AC;˘ Mycoplasma pneumonia associated encephalitis â&#x20AC;˘ Febrile infection-related epilepsy syndrome (FIRES)

Day 45

Day 60 Plus one course (10 days) HBO !

Hypothermia use • • • • • • • • • •

Neonatal HIE Cardiac arest Traumatic brain injury Status epilepticus IICP control Ischemic stroke Myocardium infarction Drowning Cardio & neurosurgery Hepatic encephalopathy

Dialysis â&#x20AC;&#x201C; CVVHD

Age: 5-month-7-day-old girl Admission date: 2018/5/29 BH: 61 cm (3rd-15th); BW: 5.26 kg (＜3rd ) BMI: 14.1 kg/㎡ (＜3rd) Family history : non-specific Personal history : Vaccination : as scheduled Newborn screen test : normal

Jan. ~Feb. , 2018

02/02, 2018

Admission to our hospital Neonatal hyperbilirubinemia Vomiting and dehydration, favored GERD

3rd time admission: Seizure Episodes Limb rigidity, limb extended, eye gazing for 5 minutes Upward gazing, persistent eye blinking Mouth angle twist 4 limbs twisting movement No fever, no cough, no vomiting, no diarrhea

Initially brought to 四季台安 and then transferred to our hospital Seizure still noted at our ER Subsided after dormicum use Brain CT: non specific finding

Admitted to our PICU

Februar y, 2018 02/03

The day admitted to PICU Suspect meningitis, r/o inborn error Examination Lumbar puncture: unremarkable finding Blood test : respiratory alkalosis with pH â&#x201E;&#x192; 7.425 metabolic compensation, pCO2 mmHg 25.0 pO2 mmHg 4 thrombocytosis HCO3 mmol Toxin/drug screen : negative7.9 /L 16.0 Inborn error survey later TCO2 mmol/L 16.8 ABE

Medication

mmol/L -

6.3

Ampicillin + claforan (meningeal dose) SBE mmol/L Keppra for seizure control 8.4

Other management

SBC

mmol/L 19.1

NPO, check F/S IVF: taita 5

SAT

%

85.6

Patient’s clinical presentation Februar y, 2018 02/03~ 02/16

No fever, seizure, no vomiting Still mild hypertonicity , high-pitch crying, bicycling

Examination EEG: Epileptiform discharges over bifrontal area; Slow awake background over right side Brain sonography : mild subdural fluid collection Lab data : Lactate , improved on follow-up Ammonia 460 ug/dL 473-> 472->489 still elevated

Send tandem mass and UOA to 台大 Medication Ampicillin + claforan (2/2~2/8) Sodium benzonate 自費使用

Other management Milk formula: cyclinex-1

Hyperammonemia Februar y, 2018 02/17~ 03/01

Urea cycle disorder highly suspected Start CVVH (2-17/2-24) since ammonia level up to 733 ug/dl despite of titrating up sodium benzonate dose Contact Dr.胡 at 台大 OTCD or CPS1D was suspected Suggest stop dialysis earlier and keep diet control

Medication Sodium benzonate Sodium Phenylbutyrate (from 林口) Carbaglu (from 罕病物流中心) Zinc , carnitine

Nutrition Milk : Cyclinex-1 + PFD (protien free) IVF : high glucose fluid + low dose insulin

Cardiac output 運用

Hemodynamic Evaluation • BP = Cardiac output X T.P.R. • Cardiac output = Stroke volume X HR • Stroke volume – Preload – Afterload – contractility

Cardiac output O Swan-Ganz : thermodilution O PICCO and Flotrac: pulse pressure method O Fick principle : SpO2, O2 consumption O Non-invasive : O Doppler O Electrical cardiometery

Thermodilution

Fick principle VO2 = (CO X Ca)-(CO XCv) CO = VO2 / (Ca-Cv) O2 content = Hb (g/dl) X 1.36 (cc O2 /g of Hb) X SpO2 + 0.0032 X PO2 (torr)

Doppler

USCOM

Electrical cardiometery

Parameters

高雄長庚PICU 轉診專線成立了

兒童內科加護病房接聽轉診專線流程 高長跨山越海 LINE群組

轉診專線

W1-5 08:00~17:00----專人接聽 假日或夜間--當班組長接聽 使用「兒童內科加護病房接受轉診 前評估表」詢問接件 評分

電話聯絡控床總住院醫師

兒童內科加護病房接聽轉診專線流程 電話聯絡控床總住院醫師

控床總醫師聯絡兒科ER醫師

評分> 3分 病童到達本院急診時，啟 動快速通關流程，辦理住 院手續後不需等待，立即 轉送至兒童內科加護病 房。

評分<3分

急診兒科醫師進一步評 估診治後決定

兒童內科加護病房轉診APP

感謝各位先進細心聆聽