RENAL SYSTEM
A. CRRT B. Hemodialysis
C. Peritoneal dialysis
Case Study 5.2
A 6-month-old girl is admitted to the PICU with a 3-day history of nausea and vomiting. Her physical exam and laboratory results are consistent with moderate to severe dehydration. While providing adequate fluid resuscitation, the physician orders a Foley catheter to be placed. Your institution has a CAUTI bundle in place to prevent infection.
1. The most appropriate actions in this bundle include:
A. Refuse to place the catheter as this patient does not meet criteria for a Foley according to the guidelines.
B. Place the Foley with clean technique.
C. Allow the medical assistant who is not trained on Foley placement to give it a try.
D. As the RN caring for the child, place the Foley with sterile technique and maintain a closed drainage system with no dependent loops.
Case Study 5.3
You are caring for a 5-year-old boy who has sustained third-degree burns over 50% of his body. He is critically ill and has acute renal failure with a BUN of 98 mg/dL and Cr of 3.4 mg/dL. He is on CRRT with citrate as the anticoagulant. This hour, the labs results are as follows:
ABG: pH 7.59, pCO2 34 mmHg, PO2 99 mmHg, oxygen saturation 100%, HCO3 41 mmol/L, Ionized calcium 0.9 mmol/L, serum calcium 11 mg/dL.
1. Your first actions should be:
A. Redraw labs in 1 hour.
B. Notify the medical staff, stop the citrate infusion, and anticipate redrawing labs in an hour and restarting citrate at a slower rate when appropriate.
C. Notify the medical staff and anticipate increasing the rate calcium infusion.
D. Notify the medical staff and anticipate decreas- ing the rate on the ventilator for the alkalosis.
TABLE 5.11 Examples of Inappropriate Uses of Indwelling Catheters As a substitute for nursing care of the patient or resident with incontinence
As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void
For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.)
Note: These indications are based primarily on expert consensus.
Source: Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., Pegues, D., & Healthcare Infection Control Practices Advisory Committee (2017, February 15). Guideline for prevention of catheter-associated urinary tract infections 2009. Retrieved from https://www.cdc.gov/infectioncontrol/
pdf/guidelines/cauti-guidelines.pdf
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Case Study 5.4
You are caring for a 12-year old who underwent open-heart surgery for removal of a subaortic membrane.
His postoperative labs show: Na 140 mEq/L, K 2.8 mEq/L, Cl 109 mEq/L, CO2 25 mEq/L, BUN 27 mg/dL, Cr 1.8 mg/dL, Mg 2 mg/dL, Ca 8.5 mg/dL. He is hav- ing occasional premature ventricular contractions that are becoming more frequent. You have standing electro- lyte replacement orders in EMR.
1. You should:
A. Administer IV calcium gluconate at a dose of 100 mg/kg over 1 hour in a central line.
B. Administer IV potassium chloride at a dose of 1 mEq/kg over 5 minutes in a central line.
C. Administer IV potassium chloride at a dose of 1 mEq/kg over 1 hour in a central line.
D. Administer IV potassium chloride at a dose of 1 mEq/kg over 1 hour in a peripheral line.
Answers and Rationales Case Study 5.1
1. A. Her history, physical exam, vital signs, and lab- oratory results are consistent with fluid loss and dehydration. Judicious fluid resuscitation is the first goal of therapy. Neurologic improvement miti- gates the need for neurologic imaging or intubation.
Blood cultures and antibiotics are necessary and would occur after fluid resuscitation is started. The presence of shistocytes on the blood smear is consis- tent with a diagnosis of HUS.
2. C. Peritoneal dialysis is the preferred mode of dialy- sis for this diagnosis at this time.
Case Study 5.2
1. D. Per Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines, this patient meets criteria for indwelling catheter place- ment as she is acutely critically ill and needs accu- rate measurements of urinary output. Foleys must always be placed with sterile technique by staff who have been formally trained.
Case Study 5.3
1. B. These labs are consistent with citrate lock and immediate action needs to be taken. Treatment for citrate lock is to stop the citrate infusion and restart at a lower rate when appropriate. Increasing the calcium infusion is not appropriate as the serum
calcium level is already high. Adjusting the rate on the ventilator is not appropriate as this arterial blood gas shows a metabolic alkalosis with mild respira- tory compensation, not a respiratory alkalosis.
Case Study 5.4
1. C. A potassium level of 2.8 is low. The presence of ectopy is alarming, likely a symptom of the hypo- kalemia. Potassium should always be given in a cen- tral line over 1 hour. Ususal dose is 0.5 to 1 mEq/
kg/dose. The serum calcium level is normal, so this option is not appropriate. Hypocalcemia does not usually manifest with ectopy.
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Two types of endocrine problems are seen in pediatric critical care: (a) specific endocrine abnormalities (diabetes mellitus [DM], panhypopituitarism) and (b) endocrine dysfunction secondary to critical illness (sick euthyroid or syndrome of inappropriate antidi
uretic hormone [SIADH]).
ENDOCRINOLOGY CONCEPTS A. Role of the Endocrine System
1. The endocrine system maintains homeostasis, including fluid and electrolyte balance, blood pres
sure, intravascular volume and maintenance of fat, muscle, and bone.
2. Functions of the endocrine system involve control and regulation of metabolism, maintenance of energy stores, growth and development, reproduction and sex differentiation, growth and coordination of the body’s response to stress (e.g., trauma, critical illness, infection, major surgery) via the secretion of counter
regulatory hormones (Buzby, 2012; Molina, 2013).
3. Integrated functions include central nervous system (CNS) input to the endocrine system via the hypothalamic–pituitary complex. The immune system contributes to endocrine regulation via acti
vation of proinflammatory mediators (interleukin1, tumor necrosis factor; von Saint Andrevon Arnim et al., 2013).
4. Most diseases from the endocrine system occur as a result of hypersecretion, hyposecretion, altered response at the tissue level, or tumors in an endo
crine gland (Buzby, 2012).
5. Many of the most powerful therapies used in the pediatric intensive care unit (PICU) are media
tors of the neuroendocrine system and include epi
nephrine, norepinephrine, vasopressin, insulin, and steroids.