PICUPrimerII - PICU Primer II Kevin M Creamer M.D Pediatric...

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Unformatted text preview: PICU Primer II Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC The Primer Outline ♦ Physiology – Hypoxia / Hypoxemia – ABG’s and Acidosis – Sodium and H 2 O metabolism – Hemodynamics and Cardiopulmonary interactions ♦ ICU Care – Postoperative issues – Mechanical Ventilation ♦ Common Problems – Head trauma – Toxicology Postoperative Issues ♦ Borrowed in part from Akron syllabus ♦ Know the surgery – what can you expect from a posterior spinal fusion is different than a tracheal reconstruction ♦ Know the patient – Age, PMHx, Syndromes ♦ Be there when they get out of the OR Postoperative Evaluation ♦ ABC’s ♦ Look at the breathing pattern ♦ Listen to the chest--breath sounds, stridor? ♦ Listen to the heart--gallop, murmur? ♦ Feel the pulses--strong, weak, thready? – Cap refill?, Extremity warmth? The Anesthesia Report ♦ “History of present illness” for surgical patients – Difficulties with induction or intubation? – Drugs used during case – Regional techniques employed? – Extubation-problems? ♦ Vital signs- BP, HR, RR, SaO2, temp – Patients are frequently cold! The Anesthesia Report ♦ Ventilation parameters/difficulties ♦ Fluids--ins and outs ♦ Any “events”? ♦ Lines and tubes Intraoperative Fluids ♦ Pediatrician : “Why do they always get so much fluid?” ♦ Anesthesiologist : “Because they need it” – maintenance + replacement of “third space” losses • “third space” losses can be 15 cc/kg/hr + replacement of 3 X blood loss Anesthesia and Fluid Balance ♦ General anesthesia produces vasodilation and some decrease in myocardial contractility. ♦ Increased intrathoracic pressure, and stress response to surgical stimulus, may lead to increased ADH production and decreased urine output BLOOD loss and replacement ♦ Blood loss is estimated ♦ Transfusion Criteria - it depends – Check Hct, HR, UOP, pH, ongoing loss, Hemodynamics … ♦ When do you need Component Tx? – after a “massive” transfusion or ( 0.75-3.0 blood volumes) Blood Products - How much? ♦ PRBCs - 4cc/kg of will Hb 1gm/dl ♦ Platelets - 1unit/5kg will ⇑ count by 50000 ♦ FFP - 10 ml/kg round up/down to closest unit ♦ Cryoprecipitate - 1bag/every 5-10kg Surgeons get extremely persnickety if you transfuse THEIR patient without letting them know ahead of time! The Surgical Report ♦ Since we are not surgeons we need to know what they anticipate and worry about – Amount of pain – Third spacing – Possible complications ♦ Their wish list: – Extubate tomorrow, MRI at midnight – Special meds: antibiotic and stress ulcer prophylaxis The Surgical Report ♦ What to touch and not to touch?...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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PICUPrimerII - PICU Primer II Kevin M Creamer M.D Pediatric...

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