PICU rotation

[doopdidoop]

hey guys,

i got a spot to do an away rotation at a top tier peds program next month. (un?)fortunately, it is a picu spot and i haven't had the chance to do picu at my home institution (not enough spots), just my peds clerkship and a peds heme/onc/nephrology sub-I. any advice on books/reading/studying to do this month so i don't look like a complete idiot? ive got a copy of harriet lane, but just wondering if there's any specific advice or resources people have who have done a picu rotation. i'm currently doing peds ER so hoping some of that can be useful as far as what is picu appropriate and what isnt, etc. any advice would be appreciated!! thanks!!

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[jerseytrash]

hey guys,

i got a spot to do an away rotation at a top tier peds program next month. (un?)fortunately, it is a picu spot and i haven't had the chance to do picu at my home institution (not enough spots), just my peds clerkship and a peds heme/onc/nephrology sub-I. any advice on books/reading/studying to do this month so i don't look like a complete idiot? ive got a copy of harriet lane, but just wondering if there's any specific advice or resources people have who have done a picu rotation. i'm currently doing peds ER so hoping some of that can be useful as far as what is picu appropriate and what isnt, etc. any advice would be appreciated!! thanks!!

I imagine it's not super different from the MICU in that you'd see a lot of folks on vents, pressors, etc. I only ever rotated through the NICU as a medical student and as an IM resident my experience with peds is of course limited but I imagine helpful topics would be
- vent management in different diseases (ARDS, status asthmaticus, etc)
- management of DKA
- management of septic shock, hemorrhagic/hypovolemic shock, anaphylactic shock, and cardiogenic shock (I'm not sure which of these would be specifically most applicable to a PICU setting)

 

[link2swim06]

I did 2 weeks in a PICU at a level 1 trauma center as part of my peds rotation.

Most common things I saw:

DKA management
Infectious disease (RDS, any lung infection you can imagine)
Trauma (car accidents, abuse victims, drowning victims)
Problems 2/2 congenital issues (pulmonary hypoplasia, weird heart stuff, etc)
ALL patients
WPW

About 60-70% of our patients were actually between 1-2 years old. Most of the older kids either were DKA or trauma/abuse.

Also "most" of the codes are due to some variation of respiratory failure.

Knowing vents is a plus. My first patient I followed was on a oscillator (lots of learning for me). Look it up if you have never heard of it.

 

[J-Rad]

I imagine it's not super different from the MICU in that you'd see a lot of folks on vents, pressors, etc. I only ever rotated through the NICU as a medical student and as an IM resident my experience with peds is of course limited but I imagine helpful topics would be
- vent management in different diseases (ARDS, status asthmaticus, etc)
- management of DKA
- management of septic shock, hemorrhagic/hypovolemic shock, anaphylactic shock, and cardiogenic shock (I'm not sure which of these would be specifically most applicable to a PICU setting)

I agree with this as well as the post below. As for cardiogenic shock, it's probably going to mostly be left sided obstructive disease and some cardiomyopathies. They may be there prior to development of shock e.g. a pre-op coarctation repair or someone awaiting transplant, but knowing about how they could have presented in extremis would be good. Brushing up on some of Carcillo's papers on management of shock would be manageable. You aren't going to be able to learn all the esoteric congenital heart disease that will seem common in a big referral center, but familiarizing yourself with a few things you probably didn't learn a lot about in med school would be good. Single ventricles and the surgical and cath procedures for palliating this spectrum of defects would probably help. At your level, getting familiar with all the vent management modes would be a big chunk to learn in a month. Reviewing the pulmonary physiology chapters in a book like Costanzo might be higher yield and more practical. DKA: definitely. There was a study by Glasser in NEJM about the risk factors for cerebral edema that would make for a good "bonus" read.

 

[doopdidoop]

thanks so much for the advice guys, i really appreciate it!

 

[epsilonprodigy]

Hey OP, just a lowly MS-2 here, but I was a PICU nurse before I crossed over to the dark side

Disease processes to know:

sepsis, esp. infants/neonates
craniosynostosis repairs
Chiari repairs
diffuse axonal injury/shaken baby syndrome
spinal fusions
DKA
ARDS
near-drowning]
congenital cardiac defects (know cyanotic vs. non-cyanotic, what's going on mechanically and what that causes.) Find out what surgeries your hospital does (for example, not all of them repair hypoplasts) and read up on those procedures.
status epilepticus
splenic lacs
status asthmaticus
RSV
diGeorge
MRCP/anoxic birth injuries
tracheoesophageal fistula repairs
asthma
croup
transplants specific to your hospital
heme/onc: ALL, sickle cell, rhabdomyosarcoma, brain tumors
overdoses/ingestions: very common ones are Tylenol, Benadryl, TCA's (teenagers) BP meds, cardiac meds (as in, toddlers getting into grandma's purse)
smoke inhalation/burns


Interventions:]
-]
-oscillators/HFOV
-ECMO
-placing central lines
-continuous venovenous hemodialysis (CVVH)


etc....

-Know how to manage kids on pressors (when to start them, how to titrate them)
-In PICU, urine output is king... diminished UOP is very often the earliest sign of trouble.
-If a kid needs pressors, they need a central line. You can't put dopa in a PIV in a kid.
-In neuro kids (really, any kid) if the parents say the kid's cry sounds different, listen. You will deal with a lot of terrified and unreasonable parents, but they know their kids. If they say something's off, it warrants a close and critical look.
-Be able to explain everything the kid is attached to in extremely simplistic terms. Dumb things way, way down and don't worry about insulting anyone- remember that these parents are living through their worst nightmare.


Vent-specific stuff:
-When you pre-round, look at the overnight trend of tidal volumes as well as how much and how efficiently the kid breathes over the vent, as well as their MAP.
-If you just started feeding them and now they're breathing fast, scale back on the feedings. If they're fighting or auto-PEEPing, they might need more sedation. (Don't be governed by weight-based dosing, especially in chronic kids and autistic kids- they are impossible to sedate.)
-If their MAP's and UOP stink, ask yourself about the PEEP being too high if there doesn't seem to be another explanation.
-Don't be too heavy-handed with the FiO2 in the kids with cyanotic defects- even if they're sats are below baseline, you don't want to over-oxygenate them and flood their pulmonary circulation.

*phewph* That's a jumble of stuff straight from the top of my head, composed of common situations and common things I saw residents get yelled at for. PM me if you have questions and I'll try to help!

 

[jerseytrash]

That post above me is awesome. Hope that helps OP!

Incidentally they do use oscillators with adults sometimes at my institution. Not sure what the data is for use in adults

 

[epsilonprodigy]

Thanks jerseytrash. I love, love, love ICU. Ultimately, what I didn't like (and what caused me to switch to ED) was thumping on the chests of dead kids who should have gone to heaven a long time ago.

This was/is my spiel about HFOV for students, when trying to teach them when to call the resident and suggest the oscillator. My summer research has to do with ventilation of diseased lungs in adults, and as far as I can tell, it still holds true:

Oscillators are good for anybody who you can't oxygenate without running into ridiculously high vent settings, putting them at risk for barotrauma, pneumo's, and compromised venous return. Our institution reserved them for the sickest of the sick, but I've been told that in many places, they are standard for "moderately sick" ICU patients who are just hard to oxygenate, for whatever reason. Think of it this way: so your patient has lung damage/pathophysiology. This takes a bunch of alveoli out of the running for gas exchange. Air they inspire (be it from the vent or their own breaths) will preferentially go to the functional alveoli. This is a good thing, except when you reach a point where each alveolus is receiving sooo much pressure and volume that it's causing overinflation, trauma and inflammation. Each healthy-ish alveolus has to take on an extra workload to make sufficient gas exchange happen. If this can happen on the vent, great- sedate the heck out of them and paralyze them if needed- they can NOT be fighting the vent on high settings because it will tire them out and defeat the whole purpose. If this increased "workload" means ultimately damaging those last few healthy alveoli or compromising venous return, it's time to think about the oscillator.

 

[mvenus929]

I did my PICU rotation in March as a fourth year. I imagine most programs are similar, but I wanted to note that there were no interns rotating through--only second or third year residents who did 28 hour call. As a student, I worked days only, which meant that I had a better feel for all the patients than the residents, who would go home right after they admitted a patient. YMMV, but you should use the experience to at least see all the kids in the PICU.

You should find out what sort of PICU you're rotating in, though. Ours is a combined PICU, but a lot of the larger institutions have separate cardiac PICU and general PICU.

If you're rotating in a combined PICU, you should definitely look up some basic congenital heart defects and when they get fixed. The ones I saw most frequently were Tetrology repairs and hypoplastic left heart/double outlet right ventricle kids. Saw a couple coarcs and truncus babies as well.

DKA is good to know, but you should be prepared for the fact that when the kid is admitted to the PICU, they're generally placed on a protocol, and there is not much deviation from that. And generally, by the time they get to the PICU, they're on the upswing because they spent a fair amount of time either at an outside ED or just waiting for a bed to be readied. Knowing the differences in management of adult DKA and peds DKA would be important too--I rotated with some ED folks more recently than PICU, and there's a lot more variation in treating adult DKA (and you can bolus insulin in adults--you shouldn't do that in kids).

Pulmonary HTN was another big diagnosis when I was on. We had a couple of PEs as well. Most everything else was either trauma, overdose, or one-night stays for airway protection after surgery.

Other things to be familiar with, which are similar across the different ICUs if you have other ICU experience:
- Pressors
- Vent settings
- sedation (which is a bit different in kids)
Those were the things that my attendings taught over and over again, so it's reasonable to at least know names and general concepts to start.

 

[BigRedBeta]

Knowing the differences in management of adult DKA and peds DKA would be important too--I rotated with some ED folks more recently than PICU, and there's a lot more variation in treating adult DKA (and you can bolus insulin in adults--you shouldn't do that in kids).

It's nice to know the differences, but you're failing to get the most out of your PICU rotation if you don't take this example to the next step - which is WHY? is this true (it is an extremely important difference). In an exceedingly large portion of medicine you can get by just knowing what to do and having a sense of the high points in pathophys...but in the ICU, the physiology is key and matters to intensivists. Use that knowledge your attendings have to really get deep into what's happening with your patients.

Another recommendation for resources - try the learnicu.org webseries from SCCM: http://learnicu.org/Fundamentals/RICU/Pages/PICUModules.aspx
I believe it's $25 for non-SCCM members to sign up for access but will be well worth it.

 

[doopdidoop]

wow, this is all such great information. thank you everyone!!

 

[jerseytrash]

Thanks jerseytrash. I love, love, love ICU. Ultimately, what I didn't like (and what caused me to switch to ED) was thumping on the chests of dead kids who should have gone to heaven a long time ago.

This was/is my spiel about HFOV for students, when trying to teach them when to call the resident and suggest the oscillator. My summer research has to do with ventilation of diseased lungs in adults, and as far as I can tell, it still holds true:

Oscillators are good for anybody who you can't oxygenate without running into ridiculously high vent settings, putting them at risk for barotrauma, pneumo's, and compromised venous return. Our institution reserved them for the sickest of the sick, but I've been told that in many places, they are standard for "moderately sick" ICU patients who are just hard to oxygenate, for whatever reason. Think of it this way: so your patient has lung damage/pathophysiology. This takes a bunch of alveoli out of the running for gas exchange. Air they inspire (be it from the vent or their own breaths) will preferentially go to the functional alveoli. This is a good thing, except when you reach a point where each alveolus is receiving sooo much pressure and volume that it's causing overinflation, trauma and inflammation. Each healthy-ish alveolus has to take on an extra workload to make sufficient gas exchange happen. If this can happen on the vent, great- sedate the heck out of them and paralyze them if needed- they can NOT be fighting the vent on high settings because it will tire them out and defeat the whole purpose. If this increased "workload" means ultimately damaging those last few healthy alveoli or compromising venous return, it's time to think about the oscillator.

All extremely helpful and interesting info, thanks for the discussion!