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