Note to myself: This podcast is simply outstanding! When seeing a pediatric patient, the doctor is first trying to decide: sick (worrisome-meaning potentially in immediate danger.) or not sick (meaning not worrisome-not in immediate danger). In this podcast, Dr. Mallick, the pediatric intensivist, goes through an incredibly detailed lecture on her approach [thought process] to this question. It is an awesome review.
The clinical material begins at 11:25.
Today, I reviewed PedsCrit‘s* podcast, Rapid Response Teams with Dr. Nada Mallick and the Cribsiders — Part 1. 01:01:17, NOVEMBER 08, 2023.
*This PedsCrit link is to a complete list of all the topics covered on this wonderful site. At the time of this post, there are 78 pediatric critical care topics covered.
The show notes are here on the Cribsiders at #97: Rapid Responses – What Can the PICU Do For You? (Part 1)
November 8, 2023 | By Sam Masur
Dr. Nada Mallick is a pediatric intensivist at Children’s National Hospital in Washington, DC.
Learning Objectives:
By the end of this series, listeners should be able to:
1) Describe techniques for diagnosis of historically oppressed groups
2) Describe acute stabilization of impending hypoxemic respiratory failure from a complicated pneumonia.
3) Discuss workup for a patient with undifferentiated shock.
4) Describe options for ICU support for a patient who does not meet ICU criteria.If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
Here are the show notes from The Cribsiders‘ Rapid Responses – What Can the PICU Do For You? (Part 1). Season 5, Episode 97, Nov 8, 3:00 AM
Summary:
Rapid heart rate at a rapid response? Not to worry, this collaboration with PedsCrit will give you the confidence you need to take step right in. Join Dr. Nada Mallick as she takes us through Part 1 of our Rapid Response Series, highlighting calls for both respiratory distress and hypotension!
Rapid Response Show Notes
What happens at a rapid response?
A rapid response team is a designated team of clinicians who can be assembled quickly to bring critical care expertise to a deteriorating patient’s bedside. In a rapid response, this team formally evaluates the patient to provide necessary emergency medical treatment and determine if they need escalation of care. In most children’s hospitals, a rapid response team consists of an experienced nurse, a respiratory therapist, and a representative from the PICU.2,3 This PICU representative can be a fellow, attending physician, advanced practice provider, or charge RN.
When Dr. Mallick attends a rapid response, she first examines the patient to make sure that they do not need emergent medical intervention. After examining the patient, Dr. Mallick asks the primary team for the story. Usually, the patient’s front-line provider will be tasked with presenting the patient to the ICU.
After hearing the patient story, Dr. Mallick and her team will decide if the patient needs transfer to the intensive care unit or not. If the patient is being transferred to the ICU, a member of the rapid response team will often stay to assist the floor nurse while an ICU room is being prepared and help transport the patient to the ICU. Front line providers are crucial during this time to help the rapid response team order and provide emergent diagnostic procedures and treatments.
If a patient does not require transfer to the ICU, Dr. Mallick will often plan with the primary team for interventions to help diagnose or treat the patient and set a time interval to re-evaluate the patient. Common diagnostic interventions include x-rays, labs, and cultures. Common treatments include chest physiotherapy and suction, antibiotics, and fluid boluses. After an intervention is planned, Dr. Mallick will set a time interval to re-evaluate the patient and determine if they need ICU transfer. Each hospital has their own protocol for who re-evaluates a patient after a rapid response and when, but the presence of the primary team is often crucial to provide continuity and ownership of the patient.
Presentation & Key Interventions
How should I present my patient to the PICU?
Many intensivists believe that a good rapid response presentation starts with the sentence: ‘we called this rapid response for: _____,’ and is followed by a brief presentation in the SBAR format.4
SBAR is an abbreviation that stands for ‘Situation, Background, Assessment, and Recommendation.’ After you state the situation, you provide the relevant medical background, your assessment of the situation, and finish the presentation with your recommendation.
For example, if you were calling a rapid response for escalation of a patient on continuous albuterol for status asthmaticus with worsening hypoxemia, you would say:
- Situation – “We are calling this rapid response for hypoxemia and respiratory distress.”
- Background – “This is a 13yo with moderate persistent asthma who has been admitted for 3 days for status asthmaticus. She is experiencing worsening hypoxemia requiring 60% FiO2 on continuous albuterol for the past hour. We have given magnesium and intramuscular epinephrine. A chest x-ray from 30 minutes ago is hyperexpanded wedge-shaped atelectasis of her left lower lob, and she is experiencing one-word dyspnea and worsening retractions.”
- Assessment – “Continuous albuterol is insufficient respiratory support at this time…”
- Recommendation – “…and I think she would benefit from BiPAP.”
This presentation structure allows the PICU to focus on pertinent details and focuses the team on the potential ICU therapy.
Case #1: Hypoxemia and Increased Work of Breathing
It’s 3am in peak respiratory season. Your pager beeps- it’s a rapid response on the acute care floor. While you’re putting on your PPE, the acute care charge RN tells you it’s an infant with bronchiolitis who is experiencing increased work of breathing.
You enter the room, the monitor shows a heart rate of 164, a saturation of 92% and a respiratory rate of 70. A well-nourished infant about 6 months old, sitting up in the bed supported by a parent on a nasal cannula; the flow rate is set to about 4L/min. A pediatric intern stands at the bedside, holding their patient list.
You ask for the patient presentation, and the team says: ‘this is a rapid response for increased work of breathing. This is a 6-month-old ex-36-week girl with bronchiolitis on day 8 of illness. Currently requiring 4L NC to maintain saturations above 90%. Also having decreased PO intake, decreased urine output, and fevers.’
Respiratory exam shows scattered crackles and diminished air movement on the right-hand side. Last temp was 39.5. Cap refill is ~2s, and the child is crying without tears. Abdomen is soft, without hepatomegaly.
In this case, Dr. Mallick notes the increased work of breathing and tachycardia and recommends escalating respiratory support. In some children’s hospitals, it is possible to ask a respiratory therapist to set up non-invasive respiratory support (high-flow nasal cannula or BiPAP), during a rapid response.
Dr. Mallick also notes that fevers, tachycardia, and worsening respiratory distress are not typical after 8 days of illness in bronchiolitis. She broadens her differential by asking for labs and a chest x-ray. Many intensivists believe that if a rapid response is called for respiratory failure, a chest x-ray should be obtained prior to the RRT to help the PICU team diagnose and risk-stratify the underlying lung disease.5 Dr. Mallick also states that if hypovolemia is expected, a fluid bolus should be given prior to the RRT, because this can both treat and risk-stratify the patient.
The team discussed obtaining a blood gas at a rapid response, and Dr. Mallick stated that she prefers to use her physical exam to risk-stratify respiratory failure in this age group.
Someone needs to do the chart review.
Fever and tachycardia? Is this sepsis? Think of that possibility and request Ceftriaxone sent up from the pharmacy so that the Rapid Response Team can give it quickly if they decide it is indicated.
Every patient with respiratory distress requires a chest x-ray while the Rapid Response Team is on the way. And now perhaps the hospitalist team should be doing a lung and cardiac pocus while awaiting the RRT.
Case #2: Post-Op Hypotension
Your pager beeps for a rapid response on the Surgical Care Unit and you look at the chart: a 14-year-old girl with neuromuscular scoliosis and stage 5 chronic kidney disease who is post-op day 1 from a posterior spinal fusion. Her last charted blood pressure is 84/47 with a MAP of 59mmHg.
The surgery was complicated by about 700mLs of blood loss, for which she received an intra-operative transfusion. A JP drain is in place. Analgesia is provided via scheduled acetaminophen and PRN morphine. The patient is experiencing decreased urine output and has not had any fevers.
Pre-op electrolytes showed a creatinine of 1.2 and a BUN of 16. A post-op CBC showed a hemoglobin of 6.8, for which another blood transfusion was given. Electrolytes have not been drawn since before the surgery.
This is a clinical case of uncompensated shock presenting as hypotension. Drs. Mallick, Hodges, and Shanklin, discussed the potential causes of her presentation:6
- Distributive shock
- This patient could have an untreated infection leading to systemic vasodilation and distributive shock.
- This patient has chronic kidney disease. If she is metabolizing opioids incorrectly,
- Hypovolemic or hemorrhagic shock
- This patient could be hypovolemic from unrecognized blood or fluid loss, resulting in tachycardia and hypotension.
- Cardiogenic shock
- This patient could have unrecognized cardiac dysfunction or myocardial depression.
- Obstructive shock
- This patient could have a pulmonary embolism leading to tachycardia or hypotension. [And of course a tension pneumothorax or pleural effusion could lead to obstructive shock.
And so every patient with undifferentiated shock should have a chest x-ray and a POCUS evaluation as we are awaiting the Rapid Response Team. In this patient with hypotension we need to consider the above four causes of shock. And be ready to give a fluid bolus. And prepare a push-dose pressor if needed and prepare a continuous pressor drip to be ready if she needs it.
And of course, she needs surgery cosult stat to see if she needs to immediately go back to the operating room or if she is stable enough for imaging studies (CT) before operative therapy.
